Sign up for APARC newsletters to receive our experts' updates.

A Shifting Civil Conflict

Nyantha described the evolution of the anti-coup movement in Myanmar from its beginnings with protests and civil disobedience campaigns by government workers and civil servants to its current state of armed resistance movement aimed at bringing down the military regime. Ethnic Armed Organizations (EAOs) have played a pivotal role in this shift. These non-state actors have fought the Myanmar military for decades in the borderlands and hold parts of the country under de facto control, sheltering and training tens of thousands of young people.

These resistance groups now present a powerful front of grassroots-level insurgency that is hampering operations by the coup regime. In this collection of self-organized groups, some are working with the National Unity Government (NUG) shadow administration, others with more decentralized networks, but all share the conviction that armed struggle is the only option for dealing with the military regime.

The power dynamic between the military and anti-regime resistance forces is now existential for both sides. “We are looking at what will most likely be a protracted civil conflict in Myanmar,” says Nyantha.

What are the paths toward a better future for Myanmar? One possibility is a shift in the military’s calculus, though it would necessitate a leadership change. Another possibility, according to Nyantha, is that the array of opposition actors can come together and use multilateral platforms to facilitate unprecedented forms of cooperation beyond resistance against the military to establish areas of territorial control and self-governance. “If they can emerge from this process with a new political vision and a roadmap for a more tolerant and inclusive Myanmar, then there is a chance the balance may tip against the military.”

These platforms include the National Unity Consultative Council (NUCC), which includes representatives from multiple opposition groups. Depending on how dialogues within the NUCC continue, it could generate a new political dynamic in the country and lay the groundwork for a future federal democratic union, notes Nyantha.

Historical Grievances, Future Visions

But there remains a lot of work to do to build trust among Myanmar’s traditionally fractious ethnic groups, Ambassador Marciel stresses. This mistrust has historical roots in decades of political disunity among Myanmar’s ethnic minorities amidst struggles for autonomy and self-determination, and in their longstanding grievances toward the state that has privileged the majority Burmans (also known as Bamar). Thus, possibly the biggest weakness of the resistance movement is the lack of a unified vision for establishing civilian rule. “I do think that it is hugely important to bring about more unity to the movement that is resisting the military regime,” says Marciel.

The international community should better understand the complexity of the civil conflict in Myanmar and recognize that the spontaneous revolt underway is not only a resistance front against the military but also a movement demanding dramatic social and political change, Marciel emphasizes.

He, therefore, cautions that the traditional tools of conventional diplomatic thinking – ceasefire, peaceful negotiations, and dialogue — do not currently apply to Myanmar. “At this point, there is no realistic scenario of dialogue leading to some compromise deal. As long as the military is in power, Myanmar is not going to enjoy peace or stability.” The people of Myanmar have suffered for far too long at the hands of the military, and the resistance forces are not interested in a compromise deal that would allow the military to maintain substantial political power, Marciel says. At the same time, the military is also not interested in negotiating.

According to Marciel, the international community should focus on supporting the resistance movement efforts. He also expressed this point in a recent interview with The Irrawaddy. “[T]he best possible scenario is for the military to face so much pressure that they then begin to look for a way out […] I think that maximum pressure on the military, both internally and externally, whether it’s by sanctions or other means, is the best chance of achieving progress, though it won’t be easy.”

A Deadly Syndemic

Even before the coup, Myanmar had one of the world’s weakest health systems and one of the least prepared for addressing epidemics and pandemics, according to the 2019 Global Heath Security Index. The devastating effects of the coup have coincided with the COVID-19 pandemic, combining into a perfect storm that has brought the country’s already-fragile health system to collapse.

The coup and the post-coup conflicts interact with the pandemic and Myanmar’s fragmented health system in ways that resemble a syndemic, says Phyu Phyu Thin Zaw, a medical doctor, epidemiologist, and health systems researcher now based at the University of Hong Kong’s School of Public Health. The term syndemic refers to the synergistic nature of health and social problems affecting vulnerable communities and contributing to an excess disease burden. It helps explain the dire crises gripping Myanmar’s health system, explains Dr. Thin Zaw.

Thin Zaw, a former visiting scholar at APARC, spoke at a webinar hosted by the Asia Health Policy Program about the impacts of the devastation caused by the coup and the COVID-19 pandemic on Myanmar’s health system and the current opportunities and challenges for response and recovery. She was joined by Nay-Lin Tun, a medical doctor who manages programs that help vulnerable communities in remote and conflict-affected areas of Myanmar to get access to health services.

Since the coup, hundreds of medical personnel and health care workers have been dismissed and subject to violent attacks. Many have escaped to areas under the control of anti-junta forces, leading to a severe “brain drain” or rather “brain hemorrhage” in the health system, Thin Zaw notes. When the third wave of the coronavirus struck Myanmar in July 2021, it hit like a tsunami. Immunization plans were severely interrupted, no quarantine or contact tracing measures were taken, and with shortages of health workers, medicine, and equipment, the health system was soon overwhelmed, with thousands of infections and rising deaths.

“To fight a pandemic, collective action is needed. Instead, Myanmar has faced a collective trauma,” says Thin Zaw. “The coup destroyed the reciprocal trust both horizontally among people and vertically between people and the government.”

Challenges for Humanitarian Response

Myanmar needs humanitarian assistance in every area, but grueling challenges hamper humanitarian relief delivery. International aid groups grapple with shuttered access, high-cost and high-risk operations, and ethical and political dilemmas: Should they stay or exit? Through which channels should they deliver aid? How can they advocate and work with the military junta? How should their money be spent under the military regime?

Dr. Tun, providing a grassroots medical humanitarian perspective on what is happening in Myanmar, described the multiple problems facing providers and patients on the ground. These include a severe shortage of health workers on the frontline, difficulties getting patients to hospitals, lack of essential medical supplies and equipment, COVID-19 infections, and overall increased mortality and morbidity among IDPs. He presented the results of a mixed-methods survey of health care workers conducted in non-military-controlled areas and conveyed their urgent requests for help. 

A Way Forward

With Myanmar’s health system in collapse, this is a time to focus on strengthening primary health care and leveraging the silver lining of the post-coup softening of ethnic tensions to build a federal health education system for inclusiveness, said Thin Zaw. She pointed to the collaboration between the NUG and EAOs-controlled healthcare groups as an encouraging step towards creating a federal health system.

She urged international actors to be realistic about the limits of their influence over the military junta and to create flexible and politically sensitive aid programs with contingency plans. Yet international organizations must continue all efforts to support the delivery of critical services to the people of Myanmar, especially in areas such as food security, emergency health, and COVID-19 response, she said. “Please don’t forget the people of my country,” she pleaded.

[Subscribe to our newsletters to stay informed on research happening at APARC.]

Oliver Hart and the ‘Proper Scope of Government’

Hart’s seminal economic theory, ‘The Proper Scope of Government,” underpins much of the research into public-private partnerships in healthcare. Hart developed this touchstone framework jointly with Andrei Shleifer and Robert W. Vishny to better evaluate when a government should provide a service itself and when it should contract with a private provider for support and execution of services.

The model outlined in Hart, Shleifer, and Vishny’s original 1996 working paper is designed to help providers and contractors consider the costs and benefits of a proposed contractual service agreement. While this model was originally applied to the case of prison privatization, the framework has served as an invaluable tool for researchers in multiple sectors including health policy and provision.

Reflections and Updates to the Theory

In reflecting on ‘The Proper Scope of Government,’ there are things Hart would like to see more fully incorporated into the theory to enrich its real-world applicability. Chiefly among these is better accounting for contractual incompleteness or the reality that a contract cannot anticipate and outline every possible unforeseen event or area of ambiguity. However, modeling contractual incompleteness is notoriously difficult given the almost-limitless factors of variability.

Some of Hart’s recent work on guiding principles responds to this challenge. Rather than trying to predict every aspect of a contractual relationship within the framing and language of a standard contract model, Hart argues that mutually agreed-upon guiding principles —such as equity, loyalty, and honesty — can serve as a foundation for navigating inevitable areas of ambiguity and potential conflict that a contract does not specifically state or that the original theory does not fully account for.

These guiding principles also help preserve space for renegotiation and innovation, which are necessary in an era of rapid technological advances and explosion of measurable data. In this context, Hart cautions against the mentality of ‘more is more:’

“If you put more and more things into the contract and then something happens that wasn’t in the contract, the fact that you put so much more in may make it more difficult to negotiate about the thing that you didn’t put in.”

 Applying ‘The Proper Scope of Government’

Hart shared a prime example of his theory at work in health systems in a case study of the Vancouver Island Health Authority. Traditionally, family physicians would continue as the primary care provider for their patients even if a patient needed hospitalization. But a change of law in 2006 required all specialized in-hospital care be contracted to hospitalists with little to no crossover with care provided by family practice physicians.

The result was a rise in caseload and stress levels amongst hospital specialists and repeated failed negotiations of the standard contract. The addition of guiding principles to the contract, however, provided avenues where reasonable solutions and additional communications could happen beyond the limits of the formal contract.

This is just one case of innumerable where Hart’s work has helped inform and contextualize how policymakers consider relationships between the public and private spheres of healthcare. Responding to the praise and input from fellow economists presented in a tribute documentary to the impact of his framework, Hart remarked:

“I hadn't realized how many people have been influenced by this paper and how they've been using it in different contexts. I knew some of the applications, but there were others I didn't, and it’s been truly amazing to see that.”

Looking Toward the Future

The tradeoffs between public and private partnerships in healthcare systems across the world will continue to be a dynamic and evolving area of research that will rely on theories such as ‘The Proper Scope of Government’ for framing and application. Looking towards the future, Hart was hopeful but cautious about the vitality of the kind of theoretical tradition which allowed for the development of his original theory. He recognizes that specialties such as contract theory and contractual incompleteness are inherently “messy” and somewhat out of vogue with current trends in economics which tend to favor theories that are “impressive, clever, and non-obvious,” regardless of whether they address important questions.

As he iterated in his Nobel Prize lecture, the incomplete world of contracts nonetheless “underlies numerous significant phenomena, some of which have great policy relevance,” and therefore fully deserving of upcoming economists’ time and efforts.

Further Research into Public-Private Partnerships

The Asia Health Policy Program’s 2020-21 colloquium series focuses on the roles and impacts of public-private partnerships in healthcare and the tradeoffs in equity, accessibility, and cost that come with contracted agreements in health systems. All of the events from the colloquium series are available on our YouTube channel. Click the thumbnails below to start exploring.

Collaborative governance — that is, relationships involving both the private and public sectors in the pursuit of public value — is part of ongoing research by Karen Eggleston. Her forthcoming book, The Dragon, the Eagle, and the Private Sector (Cambridge University Press), co-authored with Harvard’s John D. Donahue and Richard J. Zeckhauser, examines the ways in which collaborative governance works across a wide range of policy arenas in China and the United States, with the goal of empowering public decisionmakers to more wisely engage the private sector. Join us for the book launch event, which will be held jointly with the Harvard Kennedy School on March 5 

 

Image

To celebrate its May Release, the Stanford China Program hosted a virtual book launch event for Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press) on June 2^nd. Joining co-authors Thomas Fingar (Shorenstein APARC Fellow, Stanford University) and Jean C. Oi (Director, Stanford China Program; William Haas Professor of Chinese Politics, Stanford University) were contributors Karen Eggleston (Senior Fellow at FSI; Director of the Asia Health Policy Program, Shorenstein APARC, Stanford University), Barry Naughton (Sokwanlok Chair of Chinese International Affairs, School of Global Policy and Strategy, UC San Diego), and Andrew Walder (Senior Fellow at FSI; Denise O'Leary and Kent Thiry Professor, Stanford University). As Fingar and Oi point out in their volume, despite China’s extraordinary growth over the past 40 years, the country’s future is uncertain. China has enjoyed optimal conditions for development since the 1980s, but new hurdles including an aging populace, the loss of comparative economic advantage, a politically entrenched elite, and a population with rising expectations will test the country’s leaders. With each focusing on a different facet of China’s challenges, the panelists gathered to share their expertise and provide the audience with a glimpse into what the future might hold for this important country.

Available Now: Fateful Decisions: Choices That Will Shape China’s Future

Following an introduction from Professor Jean Oi, the program kicked off with Professor Barry Naughton of University of California, San Diego, who discussed his chapter entitled “Grand Steerage.” Professor Naughton argued that, as it plans for the future, China’s policymaking is becoming increasingly technology-focused, particularly in the realm of economic policy. Naughton further notes that China’s economy is becoming simultaneously more state-guided and more centered around technology. This decision is a gamble, though: China is investing heavily in high-tech industries, advancing massive, centrally steered projects like the Greater Bay Area initiative and the Xiong’an New District. If they are successful, says Naughton, this will indeed be an incredible success. But, if they are not, China’s losses will be major: “There’s not really a middle ground.”

After Professor Naughton was Professor Karen Eggleston, an expert on health policy in Asia. Professor Eggleston’s chapter, “Demographic and Healthcare Challenges,” deals with emerging obstacles for China’s healthcare system, including population aging and the problems that come with it, like chronic diseases and elder care. Although China’s healthcare system has improved dramatically in recent decades, it has done so unevenly, notes Eggleston: life expectancy has greatly increased, but with disparities according to income, region, and urban vs. rural status; universal healthcare is available, but the benefit level is low, effectively limiting the standard of care many can receive. The ratio of health spending to GDP is also increasing, yet it is still modest compared to high-income countries. The COVID-19 crisis has, of course, introduced even more challenges: Will China be able to distribute future vaccines equitably? Will this crisis negatively affect young people’s decisions to choose healthcare as a career? Will telemedicine, which has seen a surge under the pandemic, improve or exacerbate existing disparities? China faces a multitude of constraints and choices going forward if it hopes to meet its population’s healthcare needs.

The audience then had a chance to hear from co-editor Thomas Fingar, speaking on his chapter, “Sources and Shapers of China’s Foreign Policy.” Fingar noted three key takeaways from both his chapter and his talk: Firstly, China’s foreign policy is a fundamental part of its national policy. Secondly, the global political environment plays an important role in shaping both foreign and domestic policy which, thirdly, plays an important role in shaping foreign policy. The conditions that allowed China to flourish over the past 40 years, emphasized Fingar, are very different from those of the present. In the 1970s and 80s, China was able to take advantage of Cold War bipolarity, globalization was in its infancy, and “China was the only significant developing country willing to embark, at that time, on the export-led path of development.” In recent years, though, China’s behavior internationally has alienated other countries; there are many competitors pursuing its style of development; and its needs and aspirations have changed, requiring more raw materials and depending upon multi-national economic agreements. Fingar suggests two potential foreign policy options: China could continue with its wolf warrior diplomacy, which has “alienated essentially all China’s neighbors to some degree,” or it could return to a style more similar to that of the 1980s and 90s Reform and Opening era. It remains to be seen which style will win out.

Finally, Professor Andrew Walder concluded the program with his discussion of China’s political future at large. His chapter, “China’s National Trajectory,” follows China’s remarkable advancement in recent years and “tr[ies] to divine what a lower growth era will mean for China’s political future.” The last 40 years of rapid growth have generated support for China’s political system, more patriotism, the near eradication of democracy movements, and an elite unity not seen in the 1970s and 80s. However, low growth rates could mean a reversal for many of these trends, says Walder. While the aforementioned support for and stability of the Chinese government was maintained by ever-improving living standards and upward mobility, a low growth period (coupled with an aging population) means the government will no longer be able to rely on these trends for popular support. Rather, it will need to improve its provision of public services to address present-day challenges. Regardless, argues Walder, the low growth era will undoubtedly lead to “dynamic changes underneath the façade of stability of Chinese politics….”

For more insights on the modern obstacles China faces and what they mean for the country’s future, check out Fateful Decisions: Choices That Will Shape China's Future, available for purchase now.