China’s State Council has put forth draft legislation that would ban smoking in public spaces, part of the government’s larger advocacy efforts to help curb tobacco use nationwide. Matthew Kohrman, a professor of anthropology at Stanford University, said it’s a step forward but the ban’s long-term success would depend on local enforcement.

Despite popular belief, global cigarette production has tripled worldwide since the 1960s. Leading the surge has been China.

“China has become the world’s cigarette superpower,” said Kohrman, in an interview on National Public Radio’s program, Marketplace.

Moreover, local governments in China have become dependent on tax revenues generated from tobacco sales, thus reinforcing the cigarette’s ubiquity and ease of access.

China has implemented smoking bans in the past, but with varied success. Now rising healthcare costs caused by tobacco-related diseases are creating urgency for new regulations.

“Whether or not these new regulations will be enforced will, in the end, come down to local politics,” he said.

Matthew Kohrman is part of the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, and leads the project, Cigarette Citadels, a peer-sourced mapping project that compiles more than 480 cigarette factories globally.

The full audioclip is available on the Marketplace website.

A middle class is emerging in China, and simultaneously, its population is rapidly aging. These two phenomena are impacting the country’s traditional consumer habits, including spending on healthcare. Experts say private-sector services are one important part of the future of China’s healthcare system, and perhaps also a sign of what’s to come for other countries in the region. Entrepreneurs can provide innovative services that cater widely to consumers and support a shift toward integrated care for health promotion and long-term management of chronic disease, also supplementing resources available in traditional public facilities.

Three experts visited the Walter H. Shorenstein Asia-Pacific Research Center and shared perspectives on those trends at the panel discussion, “Healthcare Entrepreneurs in East Asia: Innovations in Primary Care and Beyond,” hosted by the Asia Health Policy Program.

Historically, healthcare services in China have been almost entirely government-run. A patient would go to a public clinic, stand in a queue, and receive treatment within a few hours – being referred elsewhere if additional treatment was required.

Now, the private sector is growing, based on the promise of improved care and an enhanced experience, both removing the waiting line and ushering in new technologies. The government has also issued several policies encouraging “social capital” investment in health and fitness services.

The private sector for preventative care services now holds around fifteen percent of the entire marketplace in China, and “is expected to get much bigger over the next five years,” said Lee Ligang Zhang, the founding chairman and chief executive officer of iKang, a healthcare group based in Beijing.

Zhang oversees the company’s operation of 50 self-owned healthcare centers and an extended network of 300 affiliates. iKang is one of many groups catering to a growing consumer base of corporate workers and senior managers seeking care outside of the public system.

Comparative view

Increased development of premium healthcare facilities is not only emerging in China, but also in neighboring Taiwan. Since 1995, Taiwan implemented a national health insurance system, and has been lauded for its success in service provision.

Taiwan transitioned its healthcare market to universal coverage. Under this system, a patient can essentially “shop around” and select where to go for services, most of which are covered under the country’s insurance collective system at public or private providers.

“On average, every Taiwanese goes to see a doctor 14 times a year, compared to five times a year in the United States, and two times [a year] in China,” said Dr. Fred Hun-Jean Yang, a physician and chairman of MissionCare, Inc.

Such numbers reflect the higher availability of services compared to China, he said. Even as a small island, Taiwan has over 15,000 clinics and the price for services is generally affordable for the average citizen. Despite this availability of public and private services, Taiwan’s newer healthcare entrepreneurs seek to fill a market demand shaped by similar factors as in China. Yang says technology and the efficiency of the private sector healthcare system is attracting new consumers.

Missioncare is headquartered in northern Taiwan’s Taoyuan City and consists of four community hospitals with a larger network of clinics across the country as well as coordinated long-term care services for the elderly and those with chronic disease. The group has already expanded into China, and plans to integrate healthcare innovations, such as wearable monitoring and mobile payment.

Patient-centric service

Chinese citizens, particularly those with greater expendable income, are more willing to pay out-of-pocket for an improved patient experience, the panelists said.

“The consumer psyche is important,” said Dr. Wei Siang Yu, the founder of the Borderless Healthcare Group (BHG), a group of companies based in Singapore that focuses largely on health telecommunications.

One perspective is that consumers desire a “high-end” environment made possible by tailored design aesthetics and effective branding. Guided by this trend, Yu, a business executive and physician by training, started the “smart cities, smart homes” initiative at BHG.

BHG is now launching an incubator model in Shanghai, which combines intelligent design aesthetics with patient care, and is planning to localize such centers across China. The model is referred to as an “experience center,” rather than a hospital or clinic, and healthcare services – examinations, operations and value-added activities like wellness and education activities – are all centralized in one location.

Looking ahead, Yu said healthcare is likely to move even further away from the traditional hospital setting, and more toward experiential and home-based care models.

Two weeks ago, North Korea surprised the world by sending three of its top leaders to the South to attend the closing ceremony of the 17th Asian Games in Incheon. The visit occurred in the midst of growing speculation that North Korea's young leader, Kim Jong Un, was seriously ill, or even that he had been removed from power. That dramatic and unprecedented visit gave renewed hope for improved inter-Korean relations, which have been frozen since the sinking of a South Korean vessel in 2010.

The strategic situation on the Korean Peninsula has continued to worsen over the past several years. To produce material for more nuclear devices, Pyongyang has proceeded with a large-scale uranium enrichment program. The International Atomic Energy Agency recently expressed concern that North Korea may also have reactivated its plutonium production facilities, another means of making fissile material for nuclear bombs. Meanwhile, having rocketed its first satellite into orbit in December 2012, the North is busily developing longer-range missiles to target not only the South but also Japan and the United States.

Unfortunately, there is no initiative on the horizon likely to change this dangerous trajectory. The United States was willing to negotiate with Pyongyang when there was a chance of preventing it from developing nuclear weapons. With that goal now deemed unachievable, Washington is instead intent on containing the threat through increased sanctions and counterproliferation efforts, missile defense, and heightened defense cooperation, with South Korea and Japan. U.S. engagement with North Korea, much less negotiation, is off the table and likely to stay that way.

China's buffer     

Earlier hopes that China would prove to be a deus ex machina have also foundered. While Beijing does not want Pyongyang to have nuclear weapons, it has always been more concerned about preventing instability in the North that might spill across their shared border. More recently, deepening suspicions among Beijing's leaders about U.S. strategic intentions have made North Korea even more important to China as a strategic buffer. China remains by far Pyongyang's most important foreign supporter, as reflected in the burgeoning trade across their border.

That leaves South Korea as the only country that could play a larger and more positive role in tackling the North Korea problem. South Korea is no longer a "shrimp among whales," as it used to think of itself, but a major "middle power." Strategically, Seoul is increasingly important not only to Washington but also to Beijing.

South Korea, however, has been a house divided when it comes to how to deal with the North. Conservative administrations, fearing that a North Korean nuclear arsenal would change the long-term balance of power on the peninsula, have made the North's denuclearization a condition for virtually all engagement with it. Progressive governments, on the other hand, have glossed over the nuclear issue, believing that increased contact will eventually promote change for the better in Pyongyang. The result has been South Korean policies that, whether from the left or the right, have proved unsustainable and ineffective.

"Tailored engagement"     

Based on a yearlong study, my colleagues and I have called for more active South Korean leadership to ameliorate the situation on the Korean Peninsula. We call the concept "tailored engagement." It is based on the conviction that engagement is only one means of dealing with North Korea, but an essential one, and it must be carefully "tailored" or fitted to changing political and security realities on and around the peninsula. It eschews an "appeasement" approach to Pyongyang as well as the notion that inter-Korean engagement under the current circumstances would be tantamount to accepting the North's misbehavior, especially its nuclear weapons program.

Such engagement would not immediately change the nuclear situation, but, if carefully considered and implemented, it need not encourage Pyongyang in that regard, either. Meanwhile, it could help to reduce bilateral tensions, improve the lives of ordinary North Koreans and bring the two societies closer together. It could reduce the risk of conflict now while fostering inter-Korean reconciliation and effecting positive change in the North.

South Koreans must first, however, develop a broader domestic consensus in areas and in ways that do not undermine the international effort to press Pyongyang to give up nuclear weapons. That is possible because many forms of engagement are in fact largely irrelevant to the nuclear program. For example, South Korea could provide much more humanitarian assistance to ordinary North Koreans; it could also engage in more educational and cultural programs, including sports exchanges. Concrete offers of expanded economic exchanges and support for the development of the North's infrastructure could become part of an incentive package in renewed six-party talks on ending the North's nuclear program.

Speculation about the state of Kim Jong Un's health and the North Korean leaders' visit to the South underline the fact that North Korean politics and society are experiencing great flux. For the outside world, this creates uncertainty, but also offers the possibility of positive change. Tailored engagement can at least test, and perhaps also influence, a changing North Korea.

Even a carefully "tailored" engagement strategy is no panacea. It is only one tool for dealing with the North -- military deterrence, counterproliferation and human rights efforts are among the others that are essential -- but why not try all available means when the situation is so worrisome? Japan should support such an approach because its interests, too, are threatened by the increasingly precarious situation on the peninsula.

This article was originally carried by Nikkei Asian Review on Oct. 16 and reposted with permission.