Table 1 shows the comparison of core features in public hospital support policies among major global economies and China. The United States has developed a mixed healthcare system centered on private insurance with public insurance as a supplement (1). Private health insurance serves as the core system, encompassing for-profit commercial insurance and non-profit private insurance. The public healthcare system includes multiple components such as Social Security Medicare, Medicaid, and the National Health Service model, each providing coverage for distinct populations (2). As a federal nation, healthcare policy in the United States is jointly managed by the federal and state governments, with local governments bearing significant responsibilities for implementation and funding allocation.

The U.S. Affordable Care Act (ACA) provides the legal framework for establishing the federal healthcare programs Medicare and Medicaid. Medicare provides health insurance for individuals aged 65 and older and certain disabled groups, while Medicaid offers coverage for low-income populations. Together, they constitute the primary funding sources for public hospitals. However, significant variations in Medicaid implementation across U.S. states have led to disparities in payment standards and coverage scope, creating financial pressures for public hospitals in some states. Furthermore, as the U.S. population ages and healthcare demands increase, Medicare and Medicaid face sustainability challenges that may impact public hospitals' revenue and operational stability. Beyond relying on traditional programs like Medicare and Medicaid, the federal government has also advanced healthcare expansion and optimized payment methods through reforms such as the ACA, encouraging public hospitals to enhance service quality and operational efficiency. In recent years, public hospitals have also faced transformation pressures, shifting from traditional fee-for-service models to payment systems based on health outcomes. This requires hospitals to deliver more efficient, patient-centered care. Overall, U.S. public hospitals remain dependent on federal-state collaboration, seeking to ensure their critical role in serving vulnerable populations through the support of the healthcare system.

In 1965, the Medicare and Medicaid Act, enacted during President Johnson's administration, established the first federal public health insurance programs for the older adults (Medicare) and low-income individuals (Medicaid). This legislation provided public hospitals with a stable channel to serve these two major groups and receive corresponding compensation. During the 1970s, the U.S. economy faced the “stagflation” dilemma of sluggish technological innovation, slowing foreign trade growth, and economic stagnation, leading to persistently rising healthcare costs. Against this backdrop, the U.S. government sought to alleviate fiscal pressures through systemic adjustments. In 1982, the Reagan administration enacted the Deficit Reduction Act, followed by the nationwide implementation of a DRGs-based prepaid payment system in 1984. By establishing a standardized disease classification system, this reform enabled the Centers for Medicare and Medicaid Services (CMS) to precisely control reimbursement standards for healthcare services. Under this mechanism, healthcare providers' revenues became directly linked to treatment costs, compelling them to achieve budgetary balance through enhanced operational efficiency and optimized resource allocation.

The reform reduced Medicare inpatient costs by approximately 20% over 6 years (3), while significantly improving overall hospital service efficiency. The U.S. government has long sought to balance expanding healthcare accessibility with controlling medical costs. However, the 2008 global financial crisis plunged the U.S. economy into crisis once more. Widening income inequality, rising unemployment, and declining incomes triggered a series of social issues. The shortage of market-based public goods became more severe, leading to inadequate health insurance coverage. By 2010, nearly 50 million Americans remained uninsured. Facing social pressures stemming from healthcare accessibility, the Obama administration advanced healthcare reform by strengthening the government's role, aiming to alleviate social hardships and consolidate the foundation for social stability (4). The ACA, formally signed into law in March 2010, marked a new phase in U.S. healthcare reform. In 2025, the CMS continued to adjust Medicare hospital payment policy through annual rulemaking, with updates finalized in the Calendar Year 2026 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule fact sheet (5). CMS also strengthened hospital price transparency requirements, requiring hospitals to post actual, consumer-usable prices in standardized formats (6).

The U.S. support policies for public hospitals exhibit distinct characteristics: market mechanisms serve as the primary driver, supplemented by public programs, with adjustments made dynamically in response to socioeconomic conditions. The core of these policies lies not in direct administrative funding or operational management of public institutions, but rather in indirectly providing financial resources and guiding hospital behavior through the establishment and refinement of public healthcare security systems. The federal government provides crucial financial backing to public hospitals through programs like Medicare and Medicaid, ensuring they can deliver essential healthcare to low-income and older adults populations. However, these subsidies offer only limited support. While reliant on public funds, public hospitals must also confront market-driven operational pressures and competitive environments. Against this backdrop, many public hospitals have progressively adopted market-oriented management models, implementing strategies similar to those of private hospitals. This market-oriented transformation helps public hospitals improve operational efficiency, reduce financial dependence, and enhance competitiveness. Overall, U.S. support policies for public hospitals essentially constitute an indirect support model deeply integrating market incentives and government regulation, underpinned by public finances and utilizing insurance payments as tools. This approach ensures the provision of basic healthcare services while enhancing public hospitals' adaptability and sustainability within the healthcare market.

The formation and development of the UK's public hospital system has been profoundly shaped by the National Health Service (NHS), with its core foundation rooted in a tax-funded universal healthcare model. Since the implementation of the NHS in 1948, the UK has established a public healthcare system based on full state funding. The government centrally finances and allocates the overall budget, providing universal free healthcare services. The UK government funds public hospitals through general taxation, ensuring citizens incur no direct medical costs when seeking care and achieving the system's objectives of universal coverage and provision based on need.

Within the NHS framework, public hospitals form the core of the healthcare delivery system, with their operational funding primarily derived from annual government budget allocations. Regarding payment mechanisms, the UK has transitioned from a purely annual budget model toward more efficiency-focused approaches. Examples include implementing a pay-for-performance system with centrally set uniform prices, and actively exploring integrated care and value-based payments to incentivize hospitals to deliver more efficient, patient-centered services. Thus, the UK's public hospital system centers on the NHS. Supported by full state funding, it has established a public healthcare system grounded in principles of fairness and universal access, ensuring basic medical coverage for all citizens. Simultaneously, it undergoes continuous reform to address fiscal pressures and structural shifts in health demands.

The institutional foundation of Britain's modern public hospital system traces back to the 1948 National Health Service Act. This legislation established the basic framework for the NHS, creating a tax-funded, government-managed universal healthcare model. This institutional arrangement made the UK one of the earliest nations to achieve universal free healthcare. Primary care services are delivered by community general practitioners (GPs), while secondary care is provided by regional general hospitals and central specialist hospitals. The patient pathway typically begins with an initial consultation at a GP practice, requiring a referral letter to access specialist care within the hospital system. In the 1990s, the UK government initiated internal market reforms. Under the 1990 National Health Service and Community Care Act, public hospitals were restructured into NHS Trusts with independent legal status, overseen directly by the Department of Health. Under this framework, hospital directors were publicly recruited by boards of trustees. Serving as the highest decision-making bodies, these boards were responsible for strategic planning and management oversight, establishing a governance structure combining government macro-guidance with hospital autonomy. Policies during this phase promoted modernized hospital management, market-oriented operations, and performance-based service delivery, laying the foundation for subsequent performance assessment systems (7).

Entering the early 21st century, the UK government released the landmark NHS Plan and NHS Modernization Strategy, initiating a phase of healthcare service modernization and information technology development. In 2003, the UK government passed the Health and Social Care Act, giving rise to the new Foundation Trust model. These hospitals enjoy greater financial and managerial autonomy and implement social oversight and democratic participation through a governance mechanism involving councils with representatives elected by residents. This move signified the transformation of UK public hospital governance structures from direct state control to delegated autonomy and shared social governance (8). Concurrently, starting in 2004, the NHS implemented the Quality and Outcomes Framework (QOF) for performance evaluation. By directly linking assessment outcomes to financial subsidies, QOF continuously drove improvements in healthcare service quality. Evidence on patient-reported outcomes remains limited, but recent analysis suggests that higher QOF achievement is associated with a small yet statistically significant improvement in health-related quality of life (measured using EQ-5D-5L) among adults with long-term conditions in England. These findings indicate that pay-for-performance incentives may translate into modest gains in patient-perceived health status, although the magnitude appears limited (9).

Since 2010, under dual pressures of fiscal austerity and rising healthcare demand, the UK government has intensified cost control and performance optimization. Concurrently, the 2012 Health and Social Care Act signaled deepened market-oriented reforms by substantially encouraging private healthcare providers to bid for NHS service contracts. UK public hospitals began appropriate collaborations with private entities to alleviate financial strain and enhance system resilience. The policy focus shifted from mere expansion to enhancing quality and efficiency, optimizing governance, and controlling costs, driving public hospitals toward institutionalized, refined, and sustainable development while maintaining their public attributes (10).

The COVID-19 pandemic exposed and exacerbated inherent vulnerabilities within the NHS system, such as an aging population and increasing burdens of chronic diseases. Consequently, the UK government launched the NHS Ten-Year Plan to restructure the healthcare system, focusing on technological upgrades and preventive medicine. The landmark Health and Care Act 2022 promotes the establishment of an integrated care system. This aims to break down barriers between institutions like the NHS, local governments, and social services, replacing past internal competition with collaborative partnerships to more effectively address long-term challenges such as population aging and chronic disease management.

In 2025, NHS England further operationalized elective care reform through a national delivery program that emphasizes pathway redesign, expanded diagnostic access, and productivity-oriented incentives for provider organizations. The framework prioritizes straight-to-test pathways, outpatient reform to reduce low-value follow-ups, and stronger performance oversight across trusts, linking implementation to funding design and system management expectations (11). Concurrently, the Government's 2025 mandate to NHS England reaffirmed a strategic focus on reducing elective waiting times and improving patient experience, highlighting the need to deploy resources more efficiently while maintaining quality and safety. Together, these measures indicate an incremental reform approach centered on operational performance, demand management, and delivery-system accountability rather than large-scale structural reorganization (12).

Consequently, the evolution of supportive policies for UK public hospitals reflects a shift in core policy tools. While maintaining consistent government financial investment and institutional frameworks, the approach has progressively transitioned from direct government management to the introduction of internal market mechanisms, ultimately developing into a hybrid model emphasizing performance evaluation and autonomous governance. Its defining characteristic lies in the government's sustained commitment to public financial responsibility, coupled with ongoing adjustments to governance and payment mechanisms. Through institutional innovation, this approach enhances the healthcare system's efficiency and equity, building a more resilient, effective, and future-ready healthcare infrastructure.

The UK's public hospital system operates under the unified framework of the NHS, primarily tax-funded, establishing a healthcare service model characterized by deep government intervention and clear public financial accountability. The government assumes integrated roles in planning, funding, and oversight, directly allocating resources through the central budget to ensure universal access and national uniformity of healthcare services. This system avoids rigid bureaucracy. Post-1990s reforms introduced mechanisms to enhance resource allocation efficiency, including separation of purchaser and provider, establishment of foundation trusts, and implementation of outcome-based payments and quality performance management. Policy evolution has upheld tax-funded universal free healthcare while adjusting governance and incentive structures to prevent inefficiency, forming a unique model combining planned coordination with market-based allocation.

The core insight from the UK experience lies in demonstrating the long-term dynamic process through which public service systems achieve both equity and efficiency. Even under government leadership, a public hospital development model that balances equity, efficiency, and quality improvement can be constructed through sound governance structures and performance management tools.

German hospital revenues primarily derive from statutory health insurance payments, while capital investments rely on government funding, particularly state budgets, forming a unique healthcare system anchored by social health insurance and coordinated through corporate governance and federalism. This system features clear delineation of responsibilities. Statutory health insurance organizations are primarily responsible for funding, covering an overwhelming majority of insured individuals. Federal legislative bodies take charge of establishing the overarching legal framework and setting quality standards for the healthcare system. Meanwhile, state governments are tasked with bearing the capital expenditures for public hospitals, which include infrastructure construction and the procurement of major medical equipment. Such an arrangement gives rise to a dual governance structure that effectively separates daily operations from capital investment.

Germany's healthcare system operates under a mixed-ownership model with a diverse range of service providers. There are four types of institutions within this system, including private clinics and general hospitals. Based on their sponsoring entities and operational nature, hospitals can be classified into three categories. Firstly, public hospitals are directly invested in and managed by the government (or are affiliated with universities). Secondly, non-profit private hospitals are operated by entities such as churches. Thirdly, for-profit private hospitals are managed by private capital, although they may also receive government investment. Public and non-profit private hospitals play a dominant role in the sector, delivering the bulk of primary healthcare services.

The healthcare security system in Germany is centered around statutory health insurance, which is supplemented by private health insurance. Statutory health insurance is legislated at the national level and administered by non-profit health funds. Insured individuals have the freedom to choose their preferred health fund provider. Private insurance addresses specialized needs beyond statutory coverage. In the first half of 2020, statutory insurance covered 88.2% of Germany's population, maintaining high penetration rates (13). Fiscal compensation employs a dual-track system based on DRGs. Government budgets cover hospitals' long-term investment costs, while statutory insurance pays service fees according to DRG standards. In summary, Germany's healthcare service model primarily relies on public and non-profit hospitals to deliver basic medical services. Through government macro-governance, hospitals operate autonomously while leveraging market incentives for efficient management. This approach lays a solid foundation for the sustainable development of public hospitals and the efficient operation of the overall healthcare system (14).

The development of supportive policies for German public hospitals exhibits distinct phased characteristics. The enactment of the Workers' Sickness Insurance Act in 1883 marked the beginning of over a century of continuous expansion in Germany's health insurance coverage. In the 1970s, the Hospital Financing Act established a “dual-tier system” funding framework, clarifying hospital funding sources: state governments handle capital investments while health insurance funds cover operational costs. This accelerated public hospital development, but later faced challenges due to insufficient fiscal investment, leading to public hospitals' reliance on government funding, mounting debt, and widening deficits. Although there is no nationally harmonized time series reporting the exact debt ratios of public hospitals under Germany's dual financing regime, empirical studies and industry analyzes indicate that the model has long been associated with persistent investment shortfalls at the state level, leading many hospitals to cover capital expenditure from operating revenues and external financing sources rather than full state subsidies (15). These financing pressures are understood to contribute to increasing financial burdens for public hospitals, particularly in capital-intensive investments.

At the dawn of the 2000s, Germany's healthcare costs soared swiftly, mainly propelled by structural changes on both the demand and supply fronts. On the demand side, universal coverage under statutory health insurance enhanced public access to medical services, stimulating demand for high-quality, comprehensive care. Concurrently, population aging shifted disease patterns toward chronic conditions, with older adults patients' long-term care and integrated treatment needs placing sustained pressure on healthcare expenditures. On the supply side, advances in medical technology and their application improved diagnostic and treatment standards, but their high costs drove up overall healthcare expenditures. Facing rising costs due to chronic diseases, the German government enacted the Digital Healthcare Act in 2019, emphasizing the role of mobile health apps in chronic disease management, particularly diabetes. Additionally, Germany introduced the G-DRG payment system to control cost growth. This system enables precise case grouping through comprehensive analysis of multidimensional data, including disease diagnoses, supporting health insurance payments and hospital management. It marks a shift in hospital compensation models from fee-for-service to a prepaid system.

However, traditional DRG systems incentivized hospitals to prioritize volume over quality. In 2024, the German Bundestag adopted the Hospital Care Improvement Act, which came into force in January 2025. The reform marks a shift away from the traditional DRG-based reimbursement model toward a hospital classification system based on service capacity. Under the new framework, hospitals are grouped according to their clinical capabilities, staffing qualifications, and compliance with defined quality standards. Public funding is increasingly linked to structural capacity and quality requirements rather than service volume alone. The reform aims to limit unnecessary hospital expansion, strengthen regional care coordination, and improve the quality of complex and emergency services. In brief, Germany's public hospital support strategy broadens social health insurance, balances cost and quality, and uses digital healthcare to optimize resources, enhance services, and improve access, showing adaptability and coordination.

The German government's support policies for public hospitals exhibit distinct characteristics. In terms of institutional safeguards, the government clearly delineates the responsibilities of statutory health insurance and public finances: the insurance system covers hospitals' daily operational costs, while governments at all levels handle capital investments. This design ensures the financial stability of public hospital operations, laying a solid foundation for their sustainable development. Regarding the allocation of authority and responsibility, Germany leverages the advantages of its federal system to establish a scientifically structured division of labor. The federal government provides top-level design, legislating clear quality standards and service norms; state governments implement capital investments and allocate resources based on regional needs. This arrangement ensures the uniformity of the national healthcare service system while accommodating local variations, demonstrating the wisdom of tiered governance.

In terms of policy evolution, Germany possesses the capacity for continuous optimization and dynamic adjustment. From establishing a dual governance mechanism to introducing the DRG system for cost control, and then driving the shift from fee-for-service to pay-for-performance, the German government has consistently adjusted its support policies in response to developmental stages and practical needs, demonstrating the resilience of institutional self-improvement. In summary, the German government's support for public hospitals goes beyond mere financial investment; it encompasses a comprehensive support system covering institutional frameworks, responsibilities, operations, and policy optimization, offering significant reference value for deepening healthcare reform in China.

Japan operates under a social insurance-based healthcare model with substantial government involvement. The Ministry of Health, Labor and Welfare (MHLW) formulates national health security policies and guides the implementation of healthcare plans across Japan's 47 prefectures. Hospitals are broadly classified into three categories according to ownership, namely government-operated public hospitals, quasi-public hospitals, and privately-run hospitals (16). Public hospitals, predominantly operated by local governments, handle primary care and emergency services, playing a crucial role in grassroots healthcare and disease prevention. Private hospitals concentrate on high-end medical care, specialized treatments, and innovative technologies, demonstrating strong market competitiveness. Despite competition, both sectors are regulated by policies and laws, complementing each other to promote efficient allocation of medical resources and enhance service quality. Japan implements a universal health insurance system. Since 1961, the government has provided comprehensive medical coverage for all citizens through mandatory health insurance plans, ensuring equitable and universal access to healthcare resources.

Japan's social health insurance system primarily consists of two components: Employee Health Insurance and National Health Insurance. Employee Health Insurance covers industrial workers, civil servants, and their dependents, while National Health Insurance primarily serves agricultural workers, freelancers, and retirees. Funding follows the principle of shared responsibility, with costs borne jointly by national finances, employers, and individuals (17). The universal healthcare system covers ordinary residents, the older adults, low-income groups, and other vulnerable populations, providing essential medical services that effectively reduce the public's healthcare costs and promote universal access to medical care. Overall, within the institutional framework of universal healthcare alongside coexisting public and private hospitals, Japan's public hospital system delivers universal and equitable medical coverage to its citizens, ensuring efficient and sustainable healthcare services.

After the conclusion of the major global conflict in the mid-20th century, Japan faced the dual challenges of reconstruction and scarce medical resources. Insufficient healthcare resources and disparities in medical services between urban and rural areas became pressing issues requiring urgent solutions. To address this, the Japanese government established universal access to healthcare as a long-term development goal and promoted the construction of public hospitals. By building extensive medical infrastructure, it laid the foundation for implementing the universal healthcare system.

In 1956, Japan's Ministry of Health and Welfare formulated the Four-Year Plan for Nationwide Universal National Health Insurance, proposing the goal of establishing a welfare state centered on universal health insurance and universal pension schemes. Subsequently, the government made significant revisions to the Health Insurance Act and the National Health Insurance Act, establishing a system where patients bear a portion of medical costs and mandating enrollment in National Health Insurance. The National Pension Act was enacted in 1959, establishing the welfare pension system. By 1961, Japan's universal healthcare system was largely in place. As the population aged, pressure on medical insurance funds grew. To address this challenge, the Japanese government built upon the existing employee health insurance and resident health insurance systems to create a health insurance system specifically for the older adults, complemented by a long-term care insurance system.

In the 1980s, the coverage of the older adults health insurance expanded, but rising medical costs continued to strain the insurance fund. To address this, Japan enacted the Health and Medical Services for the Older Adults Act in 1982, creating the Older Adults Health Insurance system. This system alleviated financial pressure through cross-fund risk sharing and patient co-payment mechanisms for older adults patients (18). Concurrently, a long-term care insurance system was established, separating long-term care costs from routine medical expenditures for independent management. From the 1980s to the 1990s, confronting dual challenges of fund pressures and rising medical costs, the Japanese government shifted toward policies emphasizing cost control, drug price management, and expenditure restraint. This optimized resource allocation while enhancing healthcare efficiency and quality (19). Concurrently, to address long-term care needs for the older adults, Japan established the Long-Term Care Insurance System in the early 2000s, alleviating pressure on the health insurance fund (20). To curb overmedicalization, Japan formally introduced the Diagnosis Procedure Combination/Payment by Diagnosis Group (DPC/PDPS) system in 2003. By setting daily standard points for specific conditions, this system reduces financial incentives for prolonging hospital stays, effectively curbing overmedicalization and improving healthcare efficiency (21). Evaluations of Japan's DPC/PDPS indicate a sustained reduction in hospital length of stay following its implementation, reflecting improved inpatient efficiency under prospective payment arrangements.

Official assessments by the MHLW report that DPC hospitals consistently exhibit shorter average lengths of stay than fee-for-service hospitals, with a continuing downward trend over time (22, 23). Empirical studies further provide disease-specific evidence of this effect. For acute myocardial infarction, the introduction of DPC/PDPS has been associated with an average reduction in length of stay of approximately 2.3 days, without a corresponding increase in short-term mortality (24). In patients with hip fractures, implementing hospitals reduced average length of stay from 30.1 days to 23.5 days, whereas non-implementing hospitals showed only a marginal decline from 38.5 to 36.4 days over the same period (24). In addition, longitudinal analyzes of surgical cohorts, including patients undergoing cancer-related procedures, have documented a gradual annual decrease of around 0.5 days in length of stay after the adoption of DPC/PDPS, with no significant rise in readmission rates (25). Together, these findings suggest that the DPC/PDPS system has contributed to measurable reductions in inpatient stay across multiple clinical conditions, supporting its role in enhancing hospital efficiency in Japan.

Entering the 21st century, addressing the widespread operational challenges faced by public hospitals, the Japanese government promoted the transformation of public hospitals toward a corporate governance structure. Measures included consolidating redundant institutions, introducing market-oriented operational models, and forming regional medical groups to enhance the management efficiency and market adaptability of public hospitals. Concurrently, internal governance structures were strengthened by implementing a president-responsibility system under board leadership, alongside the introduction of corporate accounting and performance evaluation tools to improve financial transparency and management standards. After 2015, Japan's policy shifted toward restructuring healthcare supply on a regional basis. This emphasized adjusting bed functionality planning according to population trends and disease patterns, promoting networked collaboration among hospitals to enhance system resilience and efficiency. Simultaneously, public hospitals were required to play a central role in medically underserved areas, emergency response systems, and public health crises, ensuring essential medical services during emergencies.

The COVID-19 pandemic further tested the effectiveness of these policies, prompting the government to make corresponding adjustments in short-term financial support, the designated hospital system, and public health preparedness. Japan is advancing regional healthcare restructuring under the Regional Medical Care Vision framework toward the 2025 planning horizon. Prefectural governments are required to align service capacity and hospital bed functions with projected demand (26). The framework reinforces functional differentiation between acute, recovery, and long-term care. Bed function differentiation has become a key implementation mechanism to optimize resource allocation in the context of population aging and to reduce inefficiencies associated with mismatched bed utilization (27). Overall, the reform emphasizes planning-based capacity management and service coordination rather than relying solely on payment incentives. In summary, despite post-war public hospitals' poor performance, Japan quickly adjusted its healthcare model. Through policies like universal health insurance, payment reforms, and hospital restructuring, it has sustained basic healthcare services and medical quality.

A defining feature of Japan's public hospital development lies in the meticulous design of its payment system and the strengthened responsibilities of local governments. The refinement of the payment system is primarily reflected in the deep implementation of the DRG payment system and the DPC/PDPS. Through this series of sophisticated payment mechanisms, Japan has been able to allocate medical resources in a more scientific and precise manner, effectively enhancing the quality and efficiency of healthcare services. Simultaneously, local governments play a pivotal role in the development of Japan's public hospitals. Local governments not only shoulder substantial capital investment responsibilities for public hospitals, covering critical areas such as hospital infrastructure construction and medical equipment procurement, but also actively engage in optimizing hospital governance structures and enhancing operational efficiency. Through initiatives like promoting the incorporation of public hospitals, introducing corporate accounting management systems, and implementing performance evaluation mechanisms, local governments have further strengthened their management responsibilities, laying a solid foundation for ensuring the service quality and economic sustainability of public hospitals. This clear division of responsibilities enables local governments to play an irreplaceable role in ensuring the stable operation and fairness of public hospitals. Facing severe challenges such as market competition and population aging, public hospitals can achieve better responses and long-term sustainable development with the firm support of local governments.

Singapore operates a dual-track healthcare system encompassing both government-run public and private medical institutions, with public hospitals playing a dominant role. The government funds this system through taxation, directly subsidizing the cost of services provided by public institutions. Citizens pay subsidized rates for medical care, with subsidy levels closely tied to their ability to pay, determined through means testing and adjusted based on ward classification. For instance, in Singapore's public hospitals, inpatient ward subsidies are allocated through a means-tested framework administered by the Ministry of Health. Government subsidies apply to subsidized ward classes such as Class C and B2, with eligible Singapore Citizens receiving up to 80% of ward charges depending on per capita household income. By contrast, higher-amenity wards such as Class A (single bed private rooms) do not attract government subsidies, reflecting the policy's progressive distribution of public support according to service level and patient financial capacity (28). This design ensures broad accessibility to essential healthcare services while preventing high-income individuals from disproportionately occupying public medical resources.

Singapore's social security system centers on the Central Provident Fund (CPF) scheme, which mandates employers and employees to contribute a percentage of wages into individual accounts through legislation. This compulsory savings program addresses citizens' long-term expenditure needs for retirement, healthcare, education, and more. Based on this, Singapore has established a 3M healthcare system: First, the MediSave scheme is a mandatory personal medical savings program requiring employed individuals to allocate a portion of their income to the MediSave sub-account within their CPF account. This fund covers hospitalization costs, certain expensive outpatient treatments, and long-term care expenses for the account holder and their immediate family members (29). It emphasizes personal responsibility for health while providing stable funding for the healthcare system; Second, the MediShield Life scheme provides mandatory universal basic coverage against large hospital bills and selected high-cost treatments (30). It mitigates individual financial risks through social mutual aid, with premiums payable from MediSave accounts to ensure both accessibility and compulsory participation. Third, the MediFund serves as the ultimate safety net. Established by the government as a donation fund, its returns subsidize impoverished citizens who remain unable to cover medical expenses after utilizing MediSave and MediShield Life, ensuring no citizen is denied essential healthcare due to financial constraints.

Following the corporatization of Singapore's public hospitals, government regulation of healthcare service pricing triggered competition among hospitals for patient resources, leading to imbalanced healthcare resource allocation and hindering the development of small and medium-sized hospitals. To counteract the negative effects of excessive competition, the government promoted group-based reforms within the public healthcare system. This consolidated national medical institutions into three major regional healthcare groups: the Singapore Health Services (SHS), the National University Health Services (NUHS), and the National Healthcare Group (NHG). This restructuring facilitated resource integration and collaboration, providing more coordinated healthcare services to community residents.

In summary, Singapore's public hospitals operate within a hybrid public-private system characterized by government subsidies and the 3M framework, where responsibilities are shared. Government subsidies ensure equity and accessibility, compulsory savings reinforce personal responsibility and cost awareness, social medical insurance mitigates major illness risks, and medical assistance ultimately fortifies the social safety net. This sophisticated institutional design establishes clear financial rules and incentive mechanisms for efficient hospital operations, forming the foundation for effective policy implementation.

Singapore's public hospital system adopts a model integrating government guidance with market mechanisms. It employs indirect means such as legislative regulation and institutional design to steer hospital development at the macro level, rather than direct administrative intervention in operations (31). This governance philosophy became prominent during the 1980s healthcare reforms, which began by restructuring the financing system. In 1984, Singapore established the Medisave scheme, subsequently refining critical illness insurance (Medishield Life) and medical assistance (Medibond) mechanisms. This formed a healthcare financing framework with clear responsibilities and multi-tiered protections, rationally distributing obligations among stakeholders and laying the groundwork for deepening public hospital reforms. To address public hospitals' inefficiency and sluggish market responsiveness, the Singaporean government implemented corporatization reforms. The restructured public hospitals became autonomous entities, while government subsidies shifted to a demand-oriented approach. This clarified target groups and coverage scope, enhancing the precision and efficiency of subsidies.

Following the completion of hospital organizational restructuring in the 1990s, the Singaporean government focused on refining the 3M healthcare security system, establishing an initial framework for tiered healthcare system and treatment alongside stratified subsidies. Within the refined payment system reforms, subsidies were strictly linked to ward grades, forming a differentiated subsidy matrix ranging from Grade A (0%) to Grade C (80%). This guided patients to select wards based on their payment capacity, achieving cross-subsidization among different income groups. Simultaneously, targeted subsidies for specific demographics were implemented through means testing. Patients bypassing referrals to directly access tertiary hospitals faced lower subsidies and higher out-of-pocket costs, establishing an economic incentive to steer patients toward primary care in communities. This laid the institutional foundation for the tiered healthcare system. Singapore established six Regional Healthcare Systems (RHS) centered on health, forming a horizontally integrated and vertically interconnected healthcare service system to alleviate overmedicalization and hospitalization issues (32).

Since 2020, Singapore's public hospital policy focus has shifted toward system resilience, digital transformation, and comprehensive health management, with further deepening of group-based and tiered healthcare systems. Digital transformation has become central, with upgraded data-sharing platforms within and between healthcare groups providing technological support for integrated care and telemedicine, making tiered healthcare system and two-way referrals more efficient. Under the RHS 2025 strategy, Singapore has accelerated digital integration across regional healthcare systems. The National Electronic Health Record (NEHR) platform now supports real-time data sharing among public hospitals, primary care clinics, and long-term care institutions (33). By 2025, all nine private hospitals in Singapore have committed to sharing patient health records on the national NEHR platform to facilitate continuity of care across providers (34). This digital upgrading enhances referral efficiency, chronic disease management, and population health monitoring, particularly for aging communities.

The Singapore model exemplifies a sophisticated blend of state-led initiatives and market mechanisms, demonstrating exceptional precision in governance through subsidy design and group management. By pursuing three core policy pillars, namely public hospital group and corporate reforms, tiered healthcare system development, and a refined dynamic subsidy matrix, it systematically addresses public hospitals' efficiency, autonomy, resource allocation, and equitable accessibility. For China, currently in a critical phase of deepening healthcare reform, this model offers invaluable reference points and insights on balancing government-market relations, designing precise fiscal subsidies and payment mechanisms, and advancing comprehensive public hospital reforms alongside tiered healthcare implementation.

From a fiscal investment perspective, the financial support mechanisms for public hospitals vary significantly across countries. In the United States, financial support for public hospitals is targeted and limited. Federal direct funding is minimal, with compensation primarily provided indirectly through healthcare security systems. For instance, the Medicaid Act subsidizes hospitals treating low-income or uninsured patients, safeguarding their safety net function, with funds precisely allocated to address shortcomings. The UK's public hospitals operate under a centralized, fiscally dominant system. Within the NHS, funding primarily originates from central general taxation. The central government allocates budgets at the macro level, with funds disbursed down through tiers to local authorities. Local authorities then distribute resources based on hospitals' actual needs and capabilities, ensuring funding stability, optimizing resource allocation, and promoting equity.

China's public hospital financing has undergone significant transformations. From the early years of the People's Republic through the planned economy era, public hospitals relied entirely on government subsidies. Following the reform and opening-up, fiscal support diminished, leading hospitals to operate on a self-financing basis and exacerbating the “drug-subsidized medicine” issue. After the 2009 healthcare reform, the government increased investments to support infrastructure and public health services. The fiscal support models of the United States, the United Kingdom, and China exhibit distinct differences. The U.S. emphasizes precise targeting and responsibility sharing, the UK stresses central government leadership and unified planning to ensure fairness, while China prioritizes universal coverage and government leadership. These approaches directly shape the divergent development models of public hospitals across the three nations.

In governance and responsibility sharing, both Germany and Japan highlight the role of local governments, though their models differ. German hospitals operate under a dual-track system separating investment from operations. State governments bear capital expenditures for hospital infrastructure and major equipment procurement, using fiscal budgets to ensure ongoing hardware upgrades. Routine operational funding primarily relies on statutory health insurance revenues from medical services, creating a government-funded infrastructure, insurance-funded operations framework. This effectively decouples long-term development investments from short-term operational pressures (38). Japan's public hospital financing responsibilities and functional divisions rely on central-local collaboration. Local governments bear core responsibilities in construction and operation, supporting hospital funding needs through taxation and fiscal subsidies. Local governments in remote and financially weak regions face greater pressure, with their public hospitals highly dependent on central government transfer payments and policy support. Within this framework, Japan implements a medical burden-sharing policy where local governments shoulder significant public healthcare responsibilities, while the central government ensures balanced resource allocation and sustainable medical services through fiscal subsidies and policy guidance.

Since implementing the Plan for Deepening the Reform of the Medical and Health System in 2009, China has assigned local governments a crucial role in public hospital construction and operation, with central government support provided through transfer payments and fiscal subsidies (35). However, disparities in local fiscal capacity have led to significant financial pressures in impoverished regions, resulting in uneven distribution of healthcare resources and compromising the equity and accessibility of medical services. Even with central government support, the quality and accessibility of healthcare services in some resource-deprived areas remain affected, limiting the overall efficiency and fairness of the healthcare system (39). In summary, Japan ensures balanced resource allocation through effective central support and policy subsidies, while local governments bear primary fiscal responsibility. China, however, faces resource distribution disparities due to regional fiscal capacity differences, impacting healthcare service quality and accessibility.

Since the 1980s, Singapore has implemented systematic reforms in public hospital management, establishing a healthcare system centered on competition, decentralization, responsiveness, and efficiency. The refinement of subsidy design and the systematization of group management are two key factors in the success of its healthcare system. Singapore's healthcare subsidy system is characterized by “tiered pricing,” which ensures equitable access to basic care while controlling government expenditure. Public hospital wards are categorized into five tiers—A, B1, B2+, B2, and C—receiving subsidies of 0%, 20%, 50%, 65%, and 80%, respectively. High-income individuals pay more for premium wards, while low-income groups receive substantial subsidies for basic care, embodying the equitable principle of cross-subsidization. For financing, Singapore has established a multi-tiered protection system anchored by the 3M Plan. In public hospital management, Singapore implemented group-based and corporate reforms, introducing market competition and decentralized governance to enhance healthcare efficiency and quality. Group-based reforms have optimized resource allocation and service coordination. For instance, Singapore Health integrates multiple hospitals, specialist centers, and polyclinics to enable electronic health record sharing, two-way referrals, and centralized procurement. This significantly reduces operational costs while improving service quality (31).

In summary, Singapore's successful experience in subsidy design and group management demonstrates the government's governance wisdom in enhancing system efficiency through market mechanisms while ensuring equitable access to basic healthcare. Its tiered subsidy system controls government expenditure while guaranteeing fair and accessible healthcare services; the group-based and corporate management model improves resource allocation efficiency and service responsiveness through decentralization, competition, and integration.