China’s recent initiatives to deepen health reform, control antimicrobial resistance, and strengthen primary health services are the topics of ongoing collaborative research by the Asia Health Policy Program (AHPP) at Stanford’s Shorenstein Asia-Pacific Research Center and Chinese counterparts. For example, with generous support from ACON Biotechnology and in partnership with the ACON Biotech Primary Care Research Center in Hangzhou, China, AHPP hosts an annual conference on community health services and primary health care reform in China.

The conference, titled Forum on Community Health Services and Primary Health Care Reform, was held in June at the Stanford Center at Peking University (SCPKU) in Beijing. It featured distinguished policymakers, providers and researchers who discussed a wide-range of topics from China’s emerging “hierarchical medical system” for referring patients to the appropriate level of care (fenji zhenliao), as well as the practice and challenges of innovative approaches to primary care and integrated medical care systems. Yongquan Chen, director of Yong’an City Hospital and representative for the mayor’s office of Sanming, talked about health reforms in Sanming City, Fujian Province, a famous example within China. He discussed the incentives and reasoning behind the reforms, which focus on removing incentives for over-prescription of medications, demonstrating government leadership for comprehensive reforms, consolidating three agencies into one, monitoring implementation and easing tensions between doctors and patients. He pointed out the feasibility and early successes of reform by comparing public hospitals in the city in terms of their revenues and costs, reduced reliance on net revenue from medication sales, and other dimensions of performance. Finally, he addressed reform implementation and future plans on both the hospital's and the government's part.

Xiaofang Han, former director of the Beijing Municipal Development and Reform Commission, shared her personal views on the challenges patients face in navigating China’s health system (kan bing nan) and the need to improve the structure of the delivery system, including a revision to the incentives driving over-prescription in China’s fee-for-service payment system. She emphasized that patients’ distrust of primary care providers can only be overcome by demonstrating improved quality (e.g. with a systematic training program for general practitioners, GPs), and that referral systems should be based on the actual capabilities of the clinicians, not their formal labels. To reach China’s goal of over 80 percent of patients receiving management and first-contact care within their local communities will require improved training and incentive programs for newly-minted MDs, a more flexible physician labor market, and innovations in e-health and patient choice regarding gatekeeping or “contract physician services” (qianyue fuwu).        

Guangde County People's Hospital Director Mingliang Xu spoke about practices and exploration of healthcare alliances and initiatives to provide transparent incentives linking medical staff bonuses to metrics of quality. Ping Zhu from Community Healthcare Service Development and Research Center in Ningbo addressed building solid relationships between doctors and residents and providing more patient-centered services.        

Professor Yingyao Chen from Fudan University School of Public Health discussed performance assessment of community health service agencies based on his research in Shanghai. He introduced the strengths and weaknesses of the incentives embedded in the assessment system for China’s primary care providers, and concluded with suggestions for future research. Dr. Linlin Hu, associate professor at Peking Union Medical College, discussed China's progress and challenges of providing universal coverage of national essential public health services.

Professor Hufeng Wang of Renmin University of China discussed China’s vision for a “hierarchical medical system”– bearing resemblance to “integrated care,” “managed care,” or NHS-like coordination of primary and specialized care – with examples of pilot reforms from Xiamen, Zhenjiang and Dalian cities. Dr. Zuxun Lu, professor of Tongji Medical College of Huazhong University of Science and Technology, also discussed hierarchical medical systems and declared that China currently had a “discounted gatekeeper system.”

Dr. Yaping Du of Zhejiang University presented his research on mobile technology for management of lipid levels and with the help of a volunteer, demonstrated “Dyslipidemia Manager,” a mobile app-based product for both patients and doctors. Innovative strategies for primary prevention of cardiovascular diseases in low- and middle-income countries were the focus of remarks by Dr. Guanyang Zou from the Institute for Global Health and Development at Queen Margaret University, including its connections to international experiences with China’s current efforts in that area.  

In sum, the 2016 Forum elicited lively, evidence-based discussions about the opportunities and challenges in improving primary care and sustaining universal coverage for China.  Plans are underway for convening the third annual ACON Biotech-Stanford AHPP Forum on Community Health Services and Primary Health Care Reform in June 2017 at SCPKU. Anyone with original research or innovative experiences with primary care in China may contact Karen Eggleston regarding participation in next year’s Forum. 

Speaking at the Shorenstein Asia-Pacific Research Center on Tuesday, U.S. Secretary of the Navy Ray Mabus underscored the importance of partnerships in the Asia-Pacific region and need for an adaptable force to meet the rapidly changing security environment around the world.

Mabus began by recognizing William J. Perry, a Stanford emeritus professor and former U.S. secretary of defense, with a Distinguished Public Service Award for his exceptional record of public service and collaboration on alternative energy initiatives, and set the stage for a conversation on innovation in the Navy and Marine Corps.

Throughout his remarks, Mabus highlighted the challenges of preparing for today’s security landscape and offered examples of how the Navy engages them.

The Navy must not be complacent in its ways, he said, especially in a context of eroding trust in multilateral institutions, unpredictable threats, and increasing competition for resources as sea levels rise.

“You’re not going to be able to tell what those next threats are. You never will. But what you can do is make sure that whatever they are you can respond,” he said. “You’ve got to be flexible.”

Mabus, who has led the Navy administration for the past seven years, said four “Ps” – people, platforms, power and partnerships – have guided his approach to improve force capabilities and rapid-response time.

Reviewing his own record as secretary, he cited updates to policies that extend family leave time, boost diversity in the force, and explore alternative energy sources for Navy aircraft and ships, including the earlier launch of the “Great Green Fleet,” a carrier strike group that uses biofuels.

Partnerships in Asia

Implementing the U.S. rebalance to Asia strategy has been a focus of the Navy’s interaction in the region.

“We’re doing it diplomatically, we’re doing it economically, we’re doing it in every region that we as a government are active in,” said Mabus, who formerly served as U.S. ambassador to Saudi Arabia and governor of Mississippi.

Sixty percent of the United States naval presence is located in the Asia-Pacific region and it is poised toward growth, Mabus said. Three more guided missile destroyers will be stationed in Japan and be "on station when North Korea launches one of its missiles," he said.

“If something does happen, if a crisis does erupt, we’re already there,” Mabus said, emphasizing the importance of force readiness.

Responding to crises effectively, however, requires an awareness and interoperability between many countries, he said. To practice and prepare, around 500 naval exercises occur between the United States and other countries each year, including Malabar, a trilateral exercise between India, Japan and the United States, and the biannual 27-nation Rim of the Pacific “RIMPAC” exercise, which China joined last year.

South China Sea issues

Answering a question from the audience about fortifications being built by China on land features in the South China Sea, Mabus said, “We don’t think any one country should try and change the status quo.”

Mabus reaffirmed the United States’ commitment to both sail and fly over the land features in accordance with international law. The American naval presence in the region has been there for 70 years and will remain steadfast, he said.

He noted the importance of upholding international law and warned of the dangers of setting a precedent of reinterpreting the U.N. Convention on the Law of the Sea regarding the South China Sea, attempting to do so would have “a really dramatic impact, not just there, but around the world."

A main goal for the U.S. Navy is to continue engagement between China and the United States, he said. The two countries already collaborate on a number of bilateral measures, such as scheduled passing exercises and visits by the navies to each other’s ports of call.

“What we want China to do is to assume the responsibilities of a naval power, to work with us, and to make sure that freedom of navigation is ensured.”

Gi-Wook Shin, a Stanford professor of sociology and director of Shorenstein APARC, concluded the event by thanking Mabus, and recognized the secretary’s friendship with the late Walter H. Shorenstein, after whom the center was named.

The Shorenstein Asia-Pacific Research Center (APARC) has named Yong Suk Lee as the deputy director of its Korea Program for a three-year term, starting Oct. 1.

Lee, the SK Center Fellow in the Freeman Spogli Institute for International Studies, will work closely with Director Gi-Wook Shin to continue to expand the program’s research and teaching activities on policy-relevant topics on Korea.

Additionally, Thomas Fingar, a distinguished fellow at Shorenstein APARC, will be the acting director of the China Program when Director Jean Oi is on sabbatical leave during winter quarter this academic year.

Three foreign policy experts explored U.S.-China relations in a panel discussion at Stanford earlier this week. In a wide-ranging conversation, they described current relations as often complementary, sometimes conflicting, and above all, unavoidably crucial.

The panel titled “The United States, China and Global Security” included He Yafei, former Chinese ambassador to the United Nations, and Stanford’s Michael Armacost, Shorenstein Distinguished Fellow and former U.S. ambassador, and Karl Eikenberry, a distinguished fellow and former U.S. ambassador to Afghanistan.

Jean Oi, a Stanford professor of political science, moderated the event, which was co-hosted by the China Program and the U.S.-Asia Security Initiative, two entities in the Shorenstein Asia-Pacific Research Center at the Freeman Spogli Institute for International Studies.

“The [U.S.-China] relationship is very complicated and full of complexity,” said He, a career diplomat who was recently appointed as a professor at Peking University.

Shifts in the international system that accompanied the end of the Cold War and China’s rapid growth have brought new demands and necessitated more engagement, He said, weighing the outcomes of “the great convergence,” or closing of the development gap between developed and developing countries, and its impact on the bilateral relationship.

“China has been a major beneficiary of the global system created by the United States,” He said, suggesting it would be unrealistic to assume China would have become the second largest economy without that context, moreover, that Beijing would seek its deterioration.

Uncertainty and the next U.S. administration

China and the United States, as two of the world’s most populous countries, face domestic politics and a range of challenges such as slowed economic growth, population aging and minority and ethnic issues.

“There’s a lot of uncertainty,” Oi said. “As you know, the U.S. presidential election will be taking place quite soon and China itself is going through a period of some uncertainty in its economic development.”

The panelists from the United States offered an optimistic view of the outcome of the presidential election. Armacost, who held a 24-year career in the U.S. government before coming to Stanford, said he foresees consistency in U.S. policy toward China, and more broadly, toward the region, during the next administration.

“Asia is destined to be a huge priority,” Armacost said. Two outstanding areas bound to be “sticking points” on the policy agenda are territorial issues in the South China Sea and international trade, he said. The Trans-Pacific Partnership, a trade agreement between 12 countries of which the United States is a party, has drawn tepid support in the U.S. Congress. And in July, China rejected a ruling by the Permanent Court of Arbitration on maritime rights in a case brought by the Philippines respective to the South China Sea.

Eikenberry shared a similar sentiment about the likelihood of policy continuity from the current U.S. administration to the next, and described the capacity for deepened cooperation between China and the United States as “profound.”

“And we’re already doing it,” he remarked. The Paris Agreement on climate change is one recent testament of the countries’ ability to successfully cooperate and galvanize support for solving global issues, he said.

The panelists agreed that the future of U.S.-China cooperation may well depend on youth, citing surveys of younger generations that show they are more amenable to engaging the other than older generations.

‘Global network of partnerships’

Asked to evaluate the China-Russia relationship, He said the countries have reached a “historic high” in their relationship, underscored by common interests, shared borders and a fraying U.S.-Russia relationship. Russia and China, however, have no intension of forming a formal strategic alliance, he added.

China’s approach to interaction with other countries is based on “a global network of partnerships” focused on trade, cultural exchange and relationships, He said.

The panelists highlighted the importance of striving for more dialogue and consultation between the United States and China on security, an area that is often superseded by economic aspects in bilateral talks.

Concluding the event, Oi emphasized the need for “frank discussions” about the challenges that affect the two countries. During the day, He held closed-door discussions with faculty members, senior research scholars and students focused on East Asia.