Seminar: Guide to Elections 2010
Daniel and Nancy Okimoto Conference Room
Daniel and Nancy Okimoto Conference Room
The Republic of the Philippines began on the path to universal coverage with the passage of the National Health Insurance Act of 1995 (Republic Act 7875) which established the Philippine Health Insurance Corporation (PhilHealth) . Building on the Philippine Medicare program which began in 1971, PhilHealth has expanded coverage to more than 80% of the population with basic benefits, but accounts for only 10% of total health financing—wide population coverage with thin public benefits. An extensive system of private insurance provides additional benefits for high-income Filipino households. While the Philippines is pursuing a public insurance approach with private add-ons, Hawaii has mandated private employment-based coverage through the Pre-paid Health Care Act of 1974 and operates under a Congressionally granted ERISA exemption as well as an exemption from the Affordable Care Act of 2010. Combining the employer mandate with generous Medicaid and SCHIP programs, Hawaii has achieved a coverage rate exceeding 90% of the resident population with extensive benefit packages. The presenter will provide an overview of the two systems and present original research on the labor market effects and public insurance effects of the Hawaii system.
Daniel and Nancy Okimoto Conference Room
The Chinese health care system has experienced profound changes like retrenchment of state financial support in the past decades. These changes have prompted the Chinese media and some academics to suggest that patients have a relatively low level of trust in physicians in today's China. In this colloquium, Dr. Tam reports the results of his survey of patient trust in physicians in Beijing's public hospitals. The survey was conducted by Horizon Research Group between November 2009 and January 2010, and 434 patients were interviewed.
The survey asked the respondents their degree of trust regarding the following three dimensions: physician agency, competence, and information provision. The survey finds a relatively high level of patient trust in physicians in Beijing public hospitals. Additionally, the survey data highlight three major determinants of patient trust in physicians, namely exposure to negative media reports about physicians and hospitals; the patient's self-assessed health status; and the patient’s level of education and income.
Waikeung Tam received his Ph.D. in political science at the University of Chicago in 2009. He is currently a Research Fellow at the LKY School of Public Policy at the National University of Singapore. His research focuses on public policy, political development, law and society, with special reference to China and Hong Kong. His research has been published in China Review, Asian Perspective, Journal of Contemporary Asia, and Law & Social Inquiry.
Daniel and Nancy Okimoto Conference Room
How does a corrupt government stop corruption? What if that government is democratic, and must cultivate the support of political parties that are themselves corrupt? Is fostering reform in such a political economy the equivalent of trying to make snow in hell?
These questions may be overstated, but the dilemmas they convey are all too real. Witness the storm of concern triggered by the recent resignation of the highest-profile reformist in Indonesia, Sri Mulyani Indrawati, from her linchpin job as minister of finance in a country that was ranked the most corrupt and the most democratic in Southeast Asia in 2009.
Sri Mulyani waged unremitting war on graft. Under her stewardship of the finance ministry, more than 150 of its personnel were dishonorably discharged. Nearly 2,000 more were otherwise punished for infractions. She led a vigorous campaign against tax cheats. Among them were rich and influential people who had grown accustomed to absconding with funds they owed the government.
Euromoney named her ‘finance minister of the year’ in 2006—a post she had only taken up the year before. In 2008 and again in 2009 Forbes magazine admiringly listed her among ‘the 100 most powerful women in the world.’ Correspondingly, on the heels of her resignation on 5 May 2010, Indonesian stocks and rupiahs fell.
Indonesian president Susilo Bambang Yudhoyono (SBY) was directly elected to that office in 2004 and, for a second five-year term, in 2009. As president he has opposed corruption and championed reform. Fatefully, however, in 2004 he chose a wealthy businessman, Aburizal Bakrie, to join his government as coordinating minister for the economy.
In 2006 in East Java, a Bakrie-controlled company using an unprotected drill while probing for gas may have triggered a mud volcano that would swallow more than a dozen villages and render more than 15,000 people homeless. In 2010 the volcano continued to spew an estimated 100,000 tons of mud daily onto the surface. Bakrie’s reputation for probity was not enhanced when, reportedly against Mulyani’s advice, he insisted on denying responsibility for the disaster. Instead he blamed an undersea earthquake that had struck off the south coast of Java, some 250 kilometers away, two days before the mud erupted. Opinions remain divided as to what caused what.
An unambiguously man-made crisis in 2008, the global financial meltdown, shrank the Jakarta stock market, Bakrie’s holdings included. Trading on the exchange was temporarily suspended. Bakrie urged his fellow cabinet member Mulyani to extend the suspension. She refused. He was furious. Her relations with him worsened further when she slapped travel bans on certain Bakrie company executives accused of tax evasion.
In 2009 Bakrie became chair of the Golkar Party. Toward the end of that year he led a fierce campaign in the Indonesian legislature against both Mulyani and another nonpartisan technocrat, Indonesian vice-president Boediono, for malfeasance related to the government’s decision in 2008 to rescue an ailing financial institution, Bank Century. The bailout may have prevented a spiral of withdrawals, and thus helped Indonesia weather the global crisis, but the effort cost far more than expected, and some of the infusions apparently benefited key depositors more than the bank itself.
Legitimate financial questions were soon superseded, however, by a thoroughly political effort on the part of politicians and their supporters opposed to Mulyani and her reforms to oust not only her but the vice-president as well. Mulyani’s and Boediono’s opponents included, in addition to Bakrie, others whose circumstancial links to corruption she had uncovered.
An anti-Mulyani case in point is the Justice and Welfare Party (PKS). Despite priding itself on upholding Islamic ethics and opposing corruption, the PKS rejected allegations that one of its legislators, Muhammad Misbakhun, could have been implicated in a fictitious Bank Century letter of credit for US $22.5 million. When, at the end of April 2010, Misbakhun was arrested and detained on a warrant signed by the national police official in charge of economic and tax crimes, PKS leaders accused the police of having an ulterior motive. The party had by then, in effect, joined the anti-Mulyani chorus.
Subjected to intense and prolonged criticism by these politicians in the glare of the media, Mulyani had ample reason to quit the spotlight, resign, and leave Indonesia. (On 1 June 2010 she will become a managing director of the World Bank in Washington DC.) But her long record of nonpartisan tenacity in the struggle against corruption makes it hard to believe that she simply lost her will to fight. For the time being it is impossible to rule out that she was sacrificed for the sake of a restoration of political comity between SBY and his opponents.
The irony is that Golkar and the PKS had joined with SBY’s Democrat Party to form a ruling coalition, to which they continue to belong. SBY had built that coalition with the expectation that its members, having joined the government, would support it, including its campaign against corruption.
That inclusive or ‘rainbow’ strategy was a triple failure. First, cabinet posts that might have been held by competent and ethical nonpartisans motivated by a desire for public service were allocated instead to partisans whose skills and motives, shall we say, varied. Governance suffered. Second, coalition-party leaders who were given ministerial posts in return for ensuring broad legislative backing for the government in the legislature either would not or could not deliver that support. Cooptation failed. Third, some ruling-team politicians, who might have at least stood back from the fray, instead jumped in, seemingly hoping to blunt the government’s efforts to diminish corruption and improve governance while protecting themselves and furthering their own careers. Discipline frayed.
Mulyani has resigned. Has Bakrie won?
In a recent conversation, an off-the-record analyst anticipated ‘more stability, which, in Indonesia, correlates inversely with reform.’ He could be wrong. But it may not be coincidental that on 6 May 2010, one day after Mulyani announced her resignation, SBY met with ruling-coalition leaders. Or that the meeting launched a Coalition Parties Forum whose daily activities will be led by none other than the chair of the Golkar Party, Aburizal Bakrie. Or that Bakrie reported that SBY had agreed that the Forum would not try to bind the coalition to a common position. Or that, again according to Bakrie, whereas previously the coalition parties were only asked to help safeguard the government’s policies, henceforth they would be asked to help determine them as well. Much will depend on Mulyani’s replacement as minister of finance, and on whether he or she is told to stop rocking the boat.
If Mulyani’s remarkable legacy is indeed erased, illiberal circles in Singapore may think, ‘We thought so. Democracy does thwart reform.’ But my own judgment in hindsight will be less sweeping.
Indonesia’s Democrat Party is still basically an extension of the appealing personality of SBY. Over the six years since he was first elected president, more time, energy, and resources could have been invested in deepening the roots and popularity of the party itself. Had those assets been so spent, the Democrats might have been able, in the legislative elections of 2009, to enlarge their contingent of lawmakers enough to be able to rule, not by the dubious grace of Sri Mulyani’s antagonists, but in SBY’s and his party’s own right—subject to democracy’s checks and balances, yes, but freed of the need to cobble together a coalitional rainbow of colors that clash.
Donald K. Emmerson heads the Southeast Asia Forum at Stanford University and is also the editor of Hard Choices: Security, Democracy, and Regionalism in Southeast Asia. (Stanford/ISEAS, 2008/9)
A heartening number of analysts helpfully commented on an earlier draft of this essay. While protecting their privacy by not naming them, I am grateful to them. Complementing my focus here on the politics of Sri Mulyani’s exit is the economic context ably reviewed by Arianto A. Patunru and Christian von Luebke in their ‘Survey of Recent Developments’ in the Bulletin of Indonesian Economic Studies, 46: 1 (2010, 7-31.)
What explains the recent large swings in the behavior of Japanese voters? Last August, for the first time in the post-WWII era, Japan's leading political party, the Liberal Democratic Party, lost power, making way for a new DPJ government. During the preceding months leading up to the lower house elections in August 2009, popular media coverage pointed to fundamental structural changes in the Japanese political economy as the underlying causes for changing voter preferences. To what extent can structural changes in the economy and society explain changing voter behavior and electoral outcomes? Japan's two decade old stagnating economy, rapidly graying society, and post-industrial advanced economic structure provide an ideal case for studying this question. Using both national and sub-national level data spanning two decades, we test both popular theories and conventional wisdom about the political effects of a graying society, widening income disparities, and industrial structural change.
Kay Shimizu is an Assistant Professor in the Department of Political Science at Columbia University. She received her undergraduate degree and PhD in political science from Stanford University (2008). Her research concerns the political economy of Japan and China, with a focus on fiscal politics, central local relations, and the politics of economic structural change. Her book manuscript, Private Money as Public Funds: the Politics of Japan's Recessionary Economy, examines the role of private financial institutions in Japan's political struggles to adjust to a changing economic and demographic landscape. She is on leave during the 2009-2010 academic year as an Advanced Research Fellow at the Weatherhead Center for International Affairs Program on US Japan Relations at Harvard University.
Philippines Conference Room
In early spring, historic health reform passes, extending insurance to millions of uninsured. Despite problems with workplace-based coverage, controversy over government subsidies for insurance premiums, and disparities across a large and diverse nation, dramatic shift to a single-payer system was seen as impractical.
Instead, reforms focus on expanding current social insurance programs as well as new initiatives to cover the uninsured, improve quality, and control spending. They provide a basic floor, subsidized for the poorest, but preserve consumer freedom to choose in health care. No government body dictates choice of doctor or hospital; investor-owned and private not-for-profits compete alongside government-run providers like community health centers and rural hospitals.
Left to be addressed in later phases are the difficult questions of how to slow the relentless pace of health care spending increases -- driven in part by technological change and population aging, but also perverse incentives embedded in fee-for-service payment and fragmented delivery. Pushed through despite multiple crises confronting the leadership, the final landmark health reform works in conjunction with measures enacted as part of the fiscal stimulus package to strengthen the healthcare system. Some provisions take effect immediately; others will take many years to unfold.
President Obama’s triumph on his top domestic priority? Actually, there were no votes along partisan lines, no controversy over abortion. I am describing health reform in China, which was announced almost exactly a year ago.
We do not hear much about the parallels in the US and Chinese social policy. But we cannot fully understand each other if we ignore these commonalities. We do not hear much about those who, in both societies, have been rendered destitute merely because they or a family member became sick or injured in a system with a social safety net full of gaping holes.
It will surprise many Americans to know that government financing as a share of total health spending was lower in socialist China over the last decade than in the United States. Now China has pledged about US$124 billion over 3 years to expand basic health insurance, strengthen public health and primary care, and reform public hospitals.
In China, the injustice of differential access to life-saving healthcare had sparked cases of social unrest. The April 2009 reform announcement was the culmination of years of post-SARS (2003) soul searching for a healthcare system befitting China’s dynamically transforming society. Special interests block change. (Sound familiar?) The CPC Central Committee and the State Council acknowledge that successful health reform will be “an arduous and long-term task”.
If the US can pass sweeping health reform despite an unprecedented financial crisis, and China can envision universal health coverage for 1.3 billion while “getting old before getting rich,” then together we should be able to look past our many differences to focus on our common interests. Our two proud nations must work together to confront numerous challenges, such as upholding regional stability (e.g. on the Korean peninsula); redressing global economic imbalances (increasing health insurance can help spur China towards more domestic consumption); and investing in “green tech” for a warming planet and “grey tech” for an aging society.
* * *
When searching for insights about how other countries deal with similar challenges, Americans often look to Europe and Canada. Rarer is the comparison to counterparts across the Pacific. Yet President Obama has clearly articulated the vision of the US as a Pacific Nation, and there are developments around the Pacific Rim that merit consideration in our debates.
Australia pioneered cost-effectiveness in health care purchasing, while the US continues to debate whether cost should be part of comparative effectiveness research and policy decisions.
Both Japan and South Korea, like Germany, have enacted long term care insurance to smooth the transition to an aging society. Their experiences might be fruitful as we implement the first national government-run long-term care insurance program, a little-heralded component of the newly passed legislation (and a fitting legacy of Senator Edward Kennedy).
Japan and Singapore provide universal coverage to older populations than ours with health systems that, although surprisingly different from each other in terms of public financing and role of market forces, both ranked among the best in the world -- and far higher than the US -- in the World Health Organization’s ranking of health systems in the year 2000. Although one may quibble with the ranking, it is indisputable that Japan spends a much smaller share of GDP on healthcare than the US does, despite being one of the oldest and longest-lived societies in the history of the world and having (like the US) a fee-for-service payment system.
Japan and South Korea are also democracies, where health policies occasionally engender heated debates. In South Korea, physicians went on nationwide strike three times to oppose the separation of prescribing from dispensing. Although Japan’s incremental reforms rarely spur such drama, the passions aroused by end-of-life care – embodied in the bizarre “death panels” controversy in the US health reform debate of 2009 – has its counterpart in the bitter nickname for Japan’s separate insurance plan for the oldest old: “hurry-up-and-die” insurance.
Yet Japan, Singapore, and Hong Kong all offer health systems that provide reasonable risk protection and quality of care for populations older than ours, with a diverse range of government and market roles in financing and delivery, while spending far less per capita than the US.
No system has all the answers. But the US and our neighbors across the vast Pacific have a common interest in sharing what we’ve found that works for health reform. Despite divergence in our political and economic systems, we all value long, healthy lives for ourselves and our children -- and we’re united in health reforms that try to further that goal.
Background: The literature comparing private not-for-profit, for-profit, and government providers mostly relies on empirical evidence from high-income and established market economies. Studies from developing and transitional economies remain scarce, especially regarding patient case-mix and quality of care in public and private hospitals, even though countries such as China have expanded a mixed-ownership approach to service delivery. The purpose of this study is to compare the operations and performance of public and private hospitals in Guangdong Province, China, focusing on differences in patient case-mix and quality of care.
Methods: We analyze survey data collected from 362 government-owned and private hospitals in Guangdong Province in 2005, combining mandatorily reported administrative data with a survey instrument designed for this study. We use univariate and multi-variate regression analyses to compare hospital characteristics and to identify factors associated with simple measures of structural quality and patient outcomes.
Results: Compared to private hospitals, government hospitals have a higher average value of total assets, more pieces of expensive medical equipment, more employees, and more physicians (controlling for hospital beds, urban location, insurance network, and university affiliation). Government and for-profit private hospitals do not statistically differ in total staffing, although for-profits have proportionally more support staff and fewer medical
professionals. Mortality rates for non-government non-profit and for-profit hospitals do not statistically differ from those of government hospitals of similar size, accreditation level, and patient mix.
Conclusions: In combination with other evidence on health service delivery in China, our results suggest that changes in ownership type alone are unlikely to dramatically improve or harm overall quality. System incentives need to be designed to reward desired hospital performance and protect vulnerable patients, regardless of hospital ownership type.
In this colloquium, we hear about Tsinghua University researchers' studies on physician-patient trust and satisfaction with health care in China. Professor Shen describes her research on “Social distance and its impact on patients’ trust in their providers in transitional China.” Using 2008 data from over 3500 patients that includes unique measures of patient trust – such as whether or not patients followed doctor recommendations for treatment – Dr. Shen and colleagues find large differences in trust, with patients of lower socio-economic status displaying higher trust in doctors than other groups. Analyses also examine how trust is related to satisfaction with health services, and how patient dissatisfaction in China compares to that in other countries’ health systems. Related research explores patients’ and providers’ attitudes towards separation of prescribing and dispensing, a key component of the 2009 health reforms, and how patient mistrust of providers stems from concerns about both competence and profiteering from overprescribing.
Philippines Conference Room
Shorenstein APARC
Stanford University
Encina Hall, Room E-301
Stanford, CA 94305-6055
Prominent Indonesian Muslim intellectual Nurcholish Madjid once declared “Islam Yes; Islamic political party No!” Voters in contemporary Indonesia seem to agree with this basic sentiment. Despite the recent Islamic revival that has dramatically increased public expressions of piety, Islamic political parties have failed to gain any significant electoral traction in Indonesia. In fact, between the 2004 and 2009 national elections, support for Islamic parties actually decreased from 38 percent to approximately 28 percent. Yet during those same five years, the Islamic political parties that failed to win at the ballot box mobilized enough political and popular support to pass one of Indonesia’s most divisive pieces of legislation—the Anti-Pornography Law. These seemingly contradictory elements of Indonesian politics provide starkly different impressions of Islam’s political role. Does a weak showing in the country’s electoral politics indicate the imminent demise of Islam in Indonesian politics? Or does the politically adept maneuvering of Islamists—who seek political power through legislation about bodily discipline—foretell gloomy days ahead?
Explanations for this paradox depend largely on where we look for “the political.” Political scientist Greg Fealy has described Islam in Indonesia as a mosaic. If we spend too much time focusing our gaze on one single area, he observes, we lose sight of other patterns elsewhere in the mosaic. To understand political Islam by ballot box alone is to miss the cultural undercurrents that have direct bearing on Islam and politics in Indonesia.
The anti-pornography bill was not only a political battle waged inside the parliament building; it was also a media drama that played out in the newspapers, televisions, and on the Internet. Human rights and women’s advocacy groups vehemently protested an early version of the bill, which stipulated that women would be prevented from leaving their homes during certain evening hours. From a different vantage point, the mostly Hindu island province of Bali threatened to secede, arguing that the article prohibiting “revealing” clothing in public would wreak havoc on the island’s tourism industry, still sluggish after devastating bomb attacks in 2002 and 2005. Whereas many non-Muslims worried about the “Islamization” of Indonesia, proponents of the bill lamented the “degradation of national morality.”
Popular Muslim television preachers were among the bill’s most vocal supporters. Eager to parlay their celebrity appeal into political clout, TV preachers Ustad Jefri Al-Buchori and Arifin Ilham helped to lead the so-called Million Muslim March to rally public support for the anti-pornography bill. Celebrity preacher and self-help guru Abdullah Gymnastiar led a sophisticated multimedia campaign to promote the bill through television, radio, the Internet, text messages, and public rallies. All of these popular preachers, in step with the political strategy of the Indonesian Council of Ulamas, invoked the religio-political language of moral crisis in an attempt to control the terms of political debate. Unable to win an election, Islamic groups flexed their moral muscle in the public sphere. From the pulpit of his Sunday afternoon television program, Gymnastiar characterized those against the bill as “having no shame” before God or country. Nearly every single political party, anxious not to appear “un-Islamic,” voted to support the anti-pornography legislation.
The political participation of a new generation of media-savvy religious leaders reveals a sentiment quite different from Nurcholish Madjid’s liberal aspirations. As one proponent of the Anti-Pornography Law put it, “Islamic political party No; Political Islam Yes!” Whereas utopian visions of the international caliphate may not resonate with Indonesian voters, it appears that political Islam—as played out on the public stage—is alive and well. What remains to be seen, however, is whether those who engage in the politics of piety also have the moral courage to champion Indonesia’s more pressing issues of poverty and corruption.
------------------
Shorenstein APARC Dispatches are regular bulletins designed exclusively for our friends and supporters. Written by center faculty and scholars, Shorenstein APARC Dispatches deliver timely, succinct analysis on current events and trends in Asia, often discussing their potential implications for business.