Repeated attempts to make hospital care less expensive and more accessible have been frustrated by bureaucratic rivalries and a failure to take on monopolistic hospitals and train more doctors, the report said. The result, it said, is that “seeing a doctor has become even more difficult.”

China’s hundreds of millions of migrant workers, who leave their farms and villages for jobs in the cities, usually don’t qualify for urban benefits like health care or education for their children. Experts have called on China to ease up on the limits in order to help turn migrant workers into bigger consumers. But many cities have created point systems that still exclude them, the report said.

State companies — many of which suffer from overcapacity and heavy debt, burdening the broader economy — have resisted plans to rein them in while rival agencies have bickered over the direction of change.

“Over all, progress in every reform of state-owned firms has been quite sluggish,” it said.

Above all, the report said, local officials have been besieged by conflicting demands to be both cautious and courageous, and have become allergic to taking risks that could end their careers or even land them in detention on charges of violating party discipline.

“It’s an inescapable objective fact that the enthusiasm of many local governments to get things done has fallen greatly,” said the report. “The lack of vigor in implementing reform plans has become the most pressing difficulty in our country’s efforts to comprehensively deepen reform across the board.”

But the authors do not blame the sluggishness just on foot-dragging cadres and state executives, an impression sometimes left by state-run news media reports.