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How do countries in the vast and diverse Asia-Pacific region differ in “prescribing cultures”? How do health systems in the region balance access to pharmaceuticals with incentives for innovation? How do the forces of globalization shape, and in turn are shaped by, cultural legacies about health and health care? These are the key questions addressed by the new Asia Health Policy Program book, Prescribing Cultures and Pharmaceutical Policy in the Asia Pacific.

AHPP held a book launch event September 23rd with three authors of the book detailing how pharmaceutical policies are interlinked globally and at the same time deeply rooted in local culture. 

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Shorenstein APARC
Stanford University
Encina Hall E301
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2009-10 visiting scholar
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Dr. Woo, former president of Yeungnam University in Korea, is a 2009-2010 Fulbright Senior Research Schlar.  He was a board member of Korean Council for University Education, and a member of Personnel and Policy Advisory Committee of the Civil Service Commisson of Korea.

He received a Ph.D. in Socio-Economic Planning from University of Tsukuba, Japan, an M.S. in Human Settlements Development from Asian Institute of Technology, Thailand, and a B.A. in Public Administration from Yeungnam University, Korea.

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Aims The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.

Methods We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.

Results Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.

Conclusions With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.

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Shorenstein APARC/Asia Foundation Visiting Fellow
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Sudarno Sumarto is the Shorenstein APARC / Asia Foundation fellow for 2009-10.  He has a PhD and an MA from Vanderbilt University and a BS from Satya Wacana Christian University (Salatiga), all in economics.  Prior to joining Shorenstein APARC he was the director of SMERU for nearly 10 years. SMERU is an independent institution for research and public policy studies which professionally and proactively provides accurate and timely information, as well as objective analysis on various socioeconomic and poverty issues considered most urgent and relevant for the people of Indonesia. The institute has been at the forefront of the research effort to highlight the impact of government programs and policies, and has actively published and reported its research findings. The work expanded to include other areas of applied and economic research that are of fundamental importance to contemporary development issues. He was also a lecturer at Bogor Institute of Agriculture (IPB), Bogor, Indonesia.

Sumarto has contributed to more than sixty co-authored articles, chapters, reports, and working papers, including "Agricultural Growth and Poverty Reduction in Indonesia," in Beyond Food Production (2007); "Reducing Unemployment in Indonesia," SMERU Working Paper, 2007; "Improving Student Performance in Public Primary Schools in Developing Countries:  Evidence from Indonesia," Education Economics, December 2006; and “The Effects of Location and Sectoral Components of Economic Growth on Poverty: Evidence from Indonesia.” Journal of Development Economics, 89(1), pp. 109-117, May 2009.  As well as conducting research and writing papers, Sumarto has worked closely with the Indonesian government, giving advice on poverty issues and government poverty alleviation programs.

Sumarto has spoken on poverty and development issues in Australia, Chile, Peru, China, Egypt, Ethiopia, France, Japan, Morocco, Thailand, and the United Kingdom, among other countries.

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PrescribingCultures front cover

Pharmaceutical policies are interlinked globally and at the same time deeply rooted in local culture. Prescribing Cultures examines how pharmaceuticals and their regulation play an important and often contentious role in the health systems of the Asia-Pacific.

The first section of this timely book analyzes pharmaceutical policy in China, Korea, Japan, Thailand, Taiwan, Australia, and India. The second section focuses on two cross-cutting themes: differences in "prescribing cultures" and physician dispensing; and the challenge of balancing access to drugs with incentives for innovation.

The book's contributors discuss important issues for U.S. policy. These include such hot-button topics as drug imports from Asia, regulation of global supply chains to assure drug safety and quality, new legislation to encourage development of drugs for neglected diseases, and the impact that decisions about pricing, regulation, and bilateral trade agreements have on access to medicines at home and abroad. In Prescribing Cultures, pharmaceutical policy reveals the economic trade-offs, political compromises, and historical trajectories that shape health systems.

Prescribing Cultures also illustrates how cultural legacies shape and are shaped by the forces of globalization, and thus will be of interest to students and scholars well beyond the confines of health policy.

Desk, examination, or review copies can be requested through Stanford University Press

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Donald K. Emmerson
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Jim Castle is a friend of mine. I have known him since we were graduate students in Indonesia in the late 1960s. While I labored in academe he went on to found and grow CastleAsia into what is arguably the most highly regarded private-sector consultancy for informing and interfacing expatriate and domestic investors and managers in Indonesia. Friday mornings he hosts a breakfast gathering of business executives at his favorite hotel, the JW Marriott in the Kuningan district of Jakarta.

Or he did, until the morning of July 17, 2009. On that Friday, shortly before 8am, a man pulling a suitcase on wheels strolled into the Marriott's Lobby Lounge, where Jim and his colleagues were meeting, and detonated the contents of his luggage. We know that the bomber was at least outwardly calm from the surveillance videotape of his relaxed walk across the lobby to the restaurant.

He wore a business suit, presumably to deflect attention before he blew himself up. Almost simultaneously, in the Airlangga restaurant at the Ritz Carlton hotel across the street, a confederate destroyed himself, killing or wounding a second set of victims. As of this writing, the toll stands at nine dead (including the killers) and more than 50 injured.

On learning that Jim had been at the meeting in the Marriott, I became frantic to find out if he were still alive. A mere 16 hours later, to my immense relief, he answered my e-mail. He was out of hospital, having sustained what he called "trivial injuries", including a temporary loss of hearing. Of the nearly 20 people at the roundtable meeting, however, four died and others were badly hurt. Jim's number two at CastleAsia lost part of a leg.

The same Marriott had been bombed before, in 2003. That explosion killed 12 people. Eight of them were Indonesian citizens, who also made up the great majority of the roughly 150 people wounded in that attack - and most of these Indonesian victims were Muslims. This distribution undercut the claim of the country's small jihadi fringe to be defending Islam's local adherents against foreign infidels.

But if last Friday's killers hoped to gain the sympathy of Indonesians this time around by attacking Jim and his expatriate colleagues and thereby lowering the proportion of domestic casualties, they failed. Of the 37 victims whose names and nationalities were known as of Monday, 60% were Indonesians, and that figure was almost certain to rise as more bodies were identified. The selective public acceptance of slaughter to which the targeting of infidel foreigners might have catered is, of course, grotesquely inhumane.

Since Susilo Bambang Yudhoyono was first elected president in 2004, Indonesia's real gross domestic product has averaged around 6% annual growth. In 2008 only four of East Asia's 19 economies achieved rates higher than Indonesia's 6.1% (Vietnam, Mongolia, China and Macau). In the first quarter of 2009, measured year-on-year, while the recession-hit economies of Malaysia, Singapore and Thailand all shrank, Indonesia's grew 4.4%. In the first half of 2009, the Jakarta Stock Exchange soared.

The economy is hardly all roses. Poverty and corruption remain pervasive. Unemployment and underemployment persist. The country's infrastructure badly needs repair. And the economy's performance in attracting foreign direct investment (FDI) has been sub-par: The US$2 billion in FDI that went to Indonesia in 2008 was less than a third of the $7 billion inflow enjoyed by Thailand's far smaller economy, notwithstanding Indonesia's far more stable politics.

Nevertheless, all things considered, the macro-economy in Yudhoyono's first term did reasonably well. We may never know whether the killer at the Marriott aimed to maximize economic harm. According to another expat consultant in Jakarta, Kevin O'Rourke, the day's victims included 10 of the top 50 business leaders in the city. "It could have been a coincidence," he said, or the bombers could have "known just what they were doing".

Imputing rationality to savagery is tricky business. But the attackers probably did hope to damage the Indonesian economy, notably foreign tourism and investment. In that context, the American provenance and patronage of the two hotels would have heightened their appeal as targets. Although the terrorists may not have known these details, the Ritz-Carlton Hotel Company is an independently operated division of Marriott International, Inc, which owns the JW Marriott brand, and both firms are headquartered on the outskirts of Washington DC.

Second-round revenge against the Marriott may also have played a role - assaulting a place that had rebuilt and recovered so quickly after being attacked in 2003. Spiteful retribution may have influenced the decision to re-attack the Kuta tourist area in Bali in 2005 after that neighborhood's recovery from the bomb carnage of 2002. Arguable, too, is the notion that 9/11 in 2001 was meant to finish the job started with the first bombing of the Twin Towers in 1993. And in all of these instances, the economy - Indonesian or American - suffered the consequences.

Panic buttons are not being pushed, however. Indonesian stock analyst Haryajid Ramelan's expectation seems plausible: that confidence in the economy will return if those who plotted the blasts are soon found and punished, and if investors can be convinced that these were "purely terrorist attacks" unrelated to domestic politics.

Sympathy for terrorism in Indonesia is far too sparse for Friday's explosions to destabilize the country. But they occurred merely nine days after Yudhoyono's landslide re-election as president on July 8, with three months still to go before the anticipated inauguration of his new administration on October 20. That timing ensured that some would speculate that the killers wanted to deprive the president of his second five-year term.

The president himself fed this speculation at his press conference on July 18, the day after the attacks. He brandished photographs of unnamed shooters with handguns using his picture for target practice. He reported the discovery of a plan to seize the headquarters of the election commission and thereby prevent his democratic victory from being announced. "There was a statement that there would be a revolution if SBY wins," he said, referring to himself by his initials.

"This is an intelligence report," he continued, "not rumors, nor gossip. Other statements said they wished to turn Indonesia into [a country like] Iran. And the last statement said that no matter what, SBY should not and would not be inaugurated." Barring information to the contrary, one may assume that these reports of threats were real, whether or not the threats themselves were. But why share them with the public?

Perhaps the president was defending his decision not to inspect the bomb damage in person - a gesture that would have shown sympathy for the victims while reassuring the population. He had wanted to go, he said, "But the chief of police and others suggested I should wait, since the area was not yet secure. And danger could come at any time, especially with all of the threats I have shown you. Physical threats."

Had Yudhoyono lost the election, or had he won it by only a thin and hotly contested margin, his remarks might have been read as an effort to garner sympathy and deflect attention from his unpopularity. The presidential candidates who lost to his landslide, Megawati Sukarnoputri and Jusuf Kalla, have indeed criticized how the July 8 polling was handled. And there were shortcomings. But even without them, Yudhoyono would still have won. In this context, speaking as he did from a position of personal popularity and political strength, the net effect of his comments was probably to encourage public support for stopping terrorism.

One may also note the calculated vagueness of his references to those - "they” - who wished him and the country harm. Not once in his speech did he refer to Jemaah Islamiyah, the network that is the culprit of choice for most analysts of the twin hotel attacks. Had he directly fingered that violently jihadi group, ambitious Islamist politicians such as Din Syamsuddin - head of Muhammadiyah, the country's second-largest Muslim organization - would have charged him with defaming Islam because Jemaah Islamiyah literally means "the Islamic group" or "the Islamic community".

One may hope that Din's ability to turn his Islamist supporters against jihadi terrorism and in favor of religious freedom and liberal democracy will someday catch up to his energy in policing language. Yet Yudhoyono was right not to mention Jemaah Islamiyah. Doing so would have complicated unnecessarily the president's relations with Muslim politicians whose support he may need when it comes to getting the legislature to turn his proposals into laws. Nor is it even clear that Jemaah Islamiyah is still an entity coherent enough to have, in fact, masterminded last Friday's attacks.

Peering into the future, one may reasonably conclude that the bombings' repercussions will neither annul Yudhoyono's landslide victory nor derail the inauguration of his next administration. Nor will they do more than temporary damage to the Indonesian economy. As for the personal aspect of what happened Friday, while mourning the dead, I am grateful that Jim and others, foreign and Indonesian, are still alive.

Donald K Emmerson heads the Southeast Asia Forum at Stanford University. He is a co-author of Islamism: Contested Perspectives on Political Islam (Stanford University Press, November 2009) and Hard Choices: Security, Democracy, and Regionalism in Southeast Asia (Stanford/ISEAS, 2008).

Copyright 2009 Asia Times Online (Holdings) Ltd. All rights reserved.

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Pharmaceutical policies are interlinked globally, yet deeply rooted in local culture. The newly published book Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, edited by Karen Eggleston, examines how pharmaceuticals and their regulation play an important and often contentious role in the health systems of the Asia-Pacific.

In this colloquium, contributors to Prescribing Cultures discuss how the book analyzes pharmaceutical policy in China, Korea, Japan, Thailand, Taiwan, Australia, and India, focusing on two cross-cutting themes: differences in “prescribing cultures” and physician dispensing; and the challenge of balancing access to drugs with incentives for innovation.

As Michael Reich of Harvard University says in his Forward to Prescribing Cultures,

“The pharmaceutical sector…promises great benefits and also poses enormous risks.… Conflicts abound over public policies, industry strategies, payment mechanisms, professional associations, and dispensing practices—to name just a few of the regional controversies covered in this excellent book.

The tension between emphasizing innovation versus access -- a topic of hot debate on today’s global health policy agenda -- is examined in several chapters…

This book makes a special contribution to our understanding of the pharmaceutical sector in China… Globalization is galloping forward, with Chinese producers pushing the pace at breakneck speed. More and more, our safety depends on China’s ability to get its regulatory act together…”

The colloquium features presentations by Naoko Tomita (Keio University), Anita Wagner (Harvard University), and Karen Eggleston (Stanford FSI Shorenstein Asia-Pacific Research Center). They will give specific examples of how pharmaceutical policy serves as a window into the economic tradeoffs, political compromises, and historical trajectories that shape health systems, as well as how cultural legacies shape and are shaped by the forces of globalization.

Oksenberg Conference Room

Anita Wagner Speaker Harvard University
Naoko Tomita Speaker Keio University

Shorenstein APARC
Stanford University
Encina Hall E301
Stanford, CA 94305-6055

(650) 723-9072 (650) 723-6530
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Senior Fellow at the Freeman Spogli Institute for International Studies
Center Fellow at the Center for Health Policy and the Center for Primary Care and Outcomes Research
Faculty Research Fellow of the National Bureau of Economic Research
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
karen-0320_cropprd.jpg PhD

Karen Eggleston is a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford University and Director of the Stanford Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center at FSI. She is also a Fellow with the Center for Innovation in Global Health at Stanford University School of Medicine, and a Faculty Research Fellow of the National Bureau of Economic Research (NBER). Her research focuses on government and market roles in the health sector and Asia health policy, especially in China, India, Japan, and Korea; healthcare productivity; and the economics of the demographic transition.

Eggleston earned her PhD in public policy from Harvard University and has MA degrees in economics and Asian studies from the University of Hawaii and a BA in Asian studies summa cum laude (valedictorian) from Dartmouth College. Eggleston studied in China for two years and was a Fulbright scholar in Korea. She served on the Strategic Technical Advisory Committee for the Asia Pacific Observatory on Health Systems and Policies and has been a consultant to the World Bank, the Asian Development Bank, and the WHO regarding health system reforms in the PRC.

Director, Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center
Stanford Health Policy Associate
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