This is the second part of a series leading up to the publication of Fateful Decisions. You can read the first installment here.

In the last forty years, China has reemerged as a tremendous geopolitical, economic, and technological power on the world stage. But the easy phases of China’s quest for wealth and influence are over, argue Shorenstein APARC Fellow Thomas Fingar and China Program Director Jean Oi in a new article published by The Washington Quarterly.

In this piece, drawing on the findings and insights of contributors to their forthcoming edited volume Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press, available May 2020), Fingar and Oi outline the daunting array of difficult challenges China now faces and explain why its future depends on the policy choices its leaders make in what will be seen as a watershed moment.

An excerpt from their article is available below. For the full version, visit The Washington Quarterly and download the PDF.
 

From, “China’s Challenges: Now it Gets Much Harder”

Some years ago, one of us had a running partner who wanted a bigger challenge than the dozens of marathons he had completed. When asked to describe his first 50-mile race, he replied, “The first 30 miles weren’t bad, but after that it got really hard.” China is approaching the metaphorical 30-mile mark in its developmental marathon. The challenges it encountered and managed effectively during the past 40 years were not easy, but they pale in comparison to those looming on the horizon. The way ahead will be more difficult, less predictable, and highly contingent on the content and efficacy of complex policy choices. The easy phases of China’s quest for wealth and power are over.

We begin with this cautionary note because so much of the new narrative about China’s rise posits capabilities and evolutionary trajectories that we find implausible. That China has done well in the past does not assure that it will do equally well (or better) in the future. That the Leninist party-state system adopted in the 1950s has proven sufficiently agile to manage the easier phases of modernization does not assure that it will be equally adept at meeting the more difficult challenges of a country being transformed by past successes and demographic change. The number, magnitude, and complexity of these challenges do not foreordain that China will stagnate, fail, or fall apart, but they do raise serious questions about the putative inevitability of China’s continued rise and displacement of the United States. China’s future is neither inevitable nor immutable; its further evolution will be shaped by internal economic and social developments, the international system, and above all, the policy choices of party leaders facing a daunting array of difficult challenges.

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We refer to China’s current approach as “back to the future” because it seeks to resuscitate institutions, methods, and rationales adopted in the 1950s and shelved during the period of reform and rapid modernization. We do not know why party leaders decided that it is in their — and thus China’s — interest to curtail or reverse policies that facilitated sustained growth and rapid improvement of living standards and China’s international image, but speculate that they hope doing so will buy time before incurring the risks (and for the elite, the costs) of fundamental reform.

Beijing has announced a number of very ambitious goals such as moving into the ranks of highly-developed countries by the centenary of the PRC in 2049, achieving global preeminence in key technologies like robotics and artificial intelligence, providing urban social benefits to most citizens, and building a number of green megacities. The likelihood of achieving all of the proclaimed goals is nil, but China will make substantial progress on some of them. It is impossible to predict which will succeed, which will fail, and which will flounder, but we can anticipate a mix of all three outcomes. Whatever the precise mix, it is likely to produce a China that is less prosperous and less powerful than predicted by the predominant narrative about where China is headed. Whether China’s leaders will risk tackling the difficult reforms that remain or continue to embrace key and thus far counterproductive structures and methods from the past remains to be seen.  Whether the party-state system is able to maintain acceptable levels of growth and public satisfaction under the new conditions is also uncertain. The only certainty is that China can no longer ride the wave that helped along its economic growth and resultant capabilities for at least ten reasons.

Read the full text of this article via The Washington Quarterly.

This is the first installment in a series leading up to the publication of Fateful Decisions.

China has tremendous resources, both human and financial, but it may now be facing a perfect storm of challenges. Its future is neither inevitable nor immutable, and its further evolution will be highly contingent on the content and efficacy of complex policy choices.

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One of these challenges — how China must soon achieve economic growth as it grapples with the realities of a rapidly aging population and a shrinking workforce — is the subject of a chapter authored by Karen Eggleston, the deputy director of APARC and director of the Center’s Asia Health Policy Program. In the following interview, Eggleston shares perspectives from her chapter, “Demographic Challenges.”

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Q: What are some of the fateful decisions China is facing regarding the responsibilities of caring for a large, aging population?

A: China has achieved impressive improvements in health and longevity. It has implemented universal health coverage and is experimenting with financial support for long-term care for older adults. Yet significant gaps between the most- and least-privileged Chinese citizens persist, and in some cases are growing. As I have written elsewhere, it is not surprising that there are wide disparities in health and healthcare between different population subgroups in a country as populous, expansive, and diverse as China. How effectively and efficiently China meets these and other health- and aging-related issues will have a major impact on its ability to manage other social and economic challenges.

In the chapter I contributed to the volume Fateful Decisions, I note that China’s current population and demographic trends — including relatively rapid aging — reflect the success of earlier investments in infectious disease control, public health measures, and other contributors to mortality reduction. The lingering effects of family planning policies, historic preferences for sons, and rapid economic development are also major considerations. Together, these factors have produced a shrinking working-age population, a growing number of elderly, a gender imbalance, and hurdles for inclusive urbanization. An urgent question for China’s future is to what extent policies will ameliorate disparities in health, healthcare use, and the burden of medical spending.

The unfolding COVID-2019 outbreak is a powerful illustration of just how fateful decisions about health systems can be. Compared to the SARS outbreak almost two decades ago, China has been better prepared for this situation. SARS raised health system reform to the top of the political agenda and, many argue, played a direct role in China’s achieving universal health coverage and vastly strengthening the public health system.

But as China has become a middle-income global economic powerhouse in the years since SARS and the ensuing wave of health policy reforms, the expectations of its citizens about their health system have also risen. Has the health system, including public health and medical care, been strengthened to the same degree as other parts of the economy and public services? The impact of and lasting response to COVID-2019 may prove a litmus test.

Q: Why do these decisions about health carry such importance for China’s future development?

Through the last four decades, China has benefitted from a demographic dividend caused by the large bulge in the working-age population. But to achieve future economic growth and productivity, investments in human capital — particularly in health and education —need to be made. This higher productivity will, in turn, be the means by which a smaller workforce can support China’s large and growing cohort of retirees.

As we’ve already seen, health expenditures have increased rapidly as China has developed its system of universal health coverage. Double-digit health spending growth surpassed the rate of economic growth, and as a result, health spending absorbs an increasingly larger share of the total economy. China needs to make sure additional spending on health and elderly care is efficient and effective, while also addressing the nonmedical determinants of health and promoting healthy aging. The health system needs to be reengineered to emphasize prevention, provide coordinated health care for people with multiple chronic diseases, assure equitable access to rapidly changing medical technologies, and ensure long-term care for frail elderly, all without unsustainable increases in opportunity costs for China’s future generations.

Q: What is the Chinese government doing to improve healthcare quality and delivery, and what more could it do to affect meaningful change in its systems?

China’s current policies seek to balance individual responsibility, community support, and taxpayer redistribution through safety-net coverage funded by central and local governments. Like many countries, China would benefit from improved coordination across multiple agencies and structure incentives to avoid or mitigate unintended consequences that undermine the goals of its health system. Recent governance reforms, such as the creation of the National Healthcare Security Administration, aim to address these challenges.

China’s achievements and remaining challenges can be illustrated with the Healthcare Access and Quality Index (HAQ), which measures premature mortality from causes that should not occur if the individual had access to high-quality healthcare: among 195 countries and territories, China achieved the highest absolute increase in the HAQ Index from 2000 to 2016. However, the 43-point regional disparity in HAQ within China is the equivalent of the difference between Iceland (the highest HAQ in the world) and North Korea.

Q: The subject of your chapter, China’s demographic challenges, is one of the issues you investigate in your upcoming book, Healthy Aging in Asia. As you show in this volume, challenges at the intersection of aging, economics, demographic transition, and healthcare policy are not unique to China. How are other countries in Asia responding to them and what lessons could benefit China?

 As I note in the introduction of Healthy Aging in Asia, the demographic transition from high to low fertility and mortality has been more rapid in much of Asia than in Europe and North America. That means social institutions, such as retirement, living arrangements, and intergenerational support, have to adapt quickly. For example, extending work-lives (as is happening in Japan) will be necessary but feasible only if the added years are healthy ones and equitable only if the least advantaged also benefit from healthy aging. The blessings of longevity dim when clouded by pain, disability, and loss of dignity.

 Investment strategies in insurance and managing chronic conditions are also important considerations. Japan and Korea have adopted insurance systems for financing long-term care for frail elderly, while places like Hong Kong have good empirical research on chronic condition management.

 No country or system has a “magic pill” to address these challenges, but the empirical evidence and rich policy experience documented in Healthy Aging from health systems as diverse as those in the cities of Singapore and Hong Kong to large economies such as Japan, India, and China can certainly be instructive.

APARC is pleased to announce that two young scholars, Jeffrey Weng and Nhu Truong, have been selected as our 2020-21 Shorenstein postdoctoral fellows on contemporary Asia. They will begin their appointments at Stanford in autumn 2020.

The Shorenstein Postdoctoral Fellowship on Contemporary Asia is open to recent doctoral graduates dedicated to research and writing on contemporary Asia, primarily in the areas of political, economic, or social change in the Asia-Pacific, or international relations in the region.

Fellows develop their dissertations and other projects for publication, present their research, and participate in the intellectual life of APARC and Stanford at large. Our postdoctoral fellows often continue their careers at top universities and research organizations around the world and remain involved with research and publication activities at APARC.

Meet our new postdoctoral scholars:

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Research focus: How does society shape language, and how does language shape society?

Jeffrey Weng is completing his Ph.D. in sociology at the University of California, Berkeley. He holds a BA in political science from Yale University, and his work has appeared in the Journal of Asian Studies and Theory and Society. His research focuses on the evolution of language, ethnicity, and nationalism in China.

Jeffrey's dissertation examines language in the context of Chinese nation-building. Mandarin Chinese was artificially created about a century ago and initially had few speakers. Now, it is the world’s most-spoken language. How did this transition happen? Weng's research shows how the codification of Mandarin was done with the intention to match existing practices closely, but not exactly. Top-down efforts by the state to spread the new language faced enormous difficulties, and ultimately its wide-spread adoption may have been catalyzed more by economic growth and urban migration. By investigating how these monumental social and political changes occurred, Weng’s work deepens the understanding of societal shifts, past and present, in one of the world’s predominant nations, while also contributing more broadly to scholarship on class, the educational reproduction of privilege, and the construction and reconstruction of race, ethnicity, and nation.

At Shorenstein APARC, Weng will continue to publish papers based on his doctoral research while reworking his dissertation into a book manuscript.

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Research focus: Why are some authoritarian regimes more responsive than others?

Nhu Truong is a Ph.D. candidate in comparative politics in the Department of Political Science at McGill University, with an area focus on China, Vietnam, and Southeast Asia. She received an MPA in International Policy and Management from the Wagner Graduate School of Public Service at New York University, an MA in Asian Studies from the University of Texas at Austin, and a BA in International Studies from Kenyon College. Prior to embarking on her doctoral study, she worked in international development in Vietnam and Cambodia, and with policy research on China.

Her research focuses on authoritarian politics and the nature of communist and post-communist regimes, particularly as it pertains to regime repressive-responsiveness, the dynamics of social resistance, repertoires of social contention, and political legitimation.
 
Nhu Truong’s dissertation explains how and why the communist, authoritarian regimes of China and Vietnam differ in their responsiveness to mounting unrest caused by government land seizures. Drawing on theory and empirical findings from 16 months of fieldwork and in-depth comparative historical analysis of China and Vietnam, Truong uses these two regimes as case studies to explore the nature of responsiveness to social pressures under communist and authoritarian rule and the divergent institutional pathways that responsiveness can take. She posits that authoritarian regimes manage social unrest by relying on raw coercive power and by demonstrating responsiveness to social demands. But not all authoritarian regimes are equally responsive to social pressures. Despite their many similarities, the Vietnamese communist regime has exhibited greater institutionalized responsiveness, whereas China has been relatively more reactive.
 
As a Shorenstein Fellow, Truong will develop her dissertation into a book manuscript. She plans to continue exploring the variable outcomes and knock-on effects of authoritarian responsiveness in places like Cambodia, which will further support her comparative research on China and Vietnam and lay the groundwork for her next project.

In a recent interview with People's Daily Online, APARC Fellow Thomas Fingar reflects on some of the milestones in the developing and diversifying relationship between the United States and China over the past forty years. The interview is part of a series of short documentaries produced by People's Daily Online West USA to commemorate the 40th anniversary of the establishment of formal diplomatic relations between the United States and China in 1979. The series was premiered at the San Francisco Public Library on January 18, 2020.

"So much of my career has been devoted to this relationship, [to] making this relationship work," says Fingar. He recounts how his own interest in China was sparked as a student in an anthropology class, where he began trying to understand why China and the United States "did things differently."

That initial question led him to a lifetime of building connections between the two countries, both in academia and government. Fingar was instrumental in launching Stanford's U.S.-China Relations Program in 1975, which promoted the exchange of learning, technology, and training between U.S. academics and students and their Chinese counterparts.

The focus on promoting U.S.-China engagement continues to inform Fingar’s perspectives today. "I'm concerned about the relationship [between the U.S. and China], but I'm not worried about it. I'm confident that both sides understand the stakes, [and] both sides understand the pressures to make this work".

Watch the interview below: