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Mark Thompson
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Some theorists of modernization have influentially claimed that successful “late industrialization” led by developmental states creates economies too complex, social structures too differentiated, and (middle-class-dominated) civil societies too politically conscious to sustain nondemocratic rule. Nowhere is this argument—that economic growth drives democratic transitions—more evident than in Northeast and Southeast Asia (hereafter Pacific Asia).

South Korea and Taiwan, having democratized only after substantial industrialization, seem to fit this narrative well. But “late democratizers” have been the exception rather than the rule. Indonesia, the Philippines, and Thailand democratized before high per capita incomes were achieved. Malaysia, and especially Singapore are more wealthy than they are democratic. The communist “converts” to developmentalism, China and Vietnam, are aiming for authoritarian versions of modernity. Table 1* shows that there is no clear pattern in Pacific Asia. Indeed, according to the nongovernmental organization Freedom House (and using the World Bank categories of low, lower middle, upper middle, or high income), poor and rich countries alike in Pacific Asia are rated “free,” “partly free,” or “not free.”

What key factors have influenced the different timing of democratization in Pacific Asia? Democratization has occurred early in the developmental process when authoritarian states have failed to create sustainable economic growth, which in turn has led to mounting debt. Many reasons explain this phenomenon, but a primary cause is the so-called failure to “deepen”—that is, certain countries’ inability to become major manufacturers of high-tech and heavy industrial goods. For example, when economic crises rocked the Philippines in the mid-1980s and Indonesia in the late 1990s, both nations lacked the economic maturity and breadth to rebound, prompting abrupt financial collapse. These nations’ political systems were too ossified to channel popular unrest, and mass mobilization resulted. Ideologically, the Marcos and Suharto regimes faced accusations of cronyism, as favored business leaders stepped in to rescue failing conglomerates, sidelining once-influential technocrats in the process. In the end, these countries’ limited economic development actually broke down their authoritarian systems.

 “Late industrializers,” by contrast, do succeed in industrial “deepening.” But they are often less successful in terms of “widening”—the perception that the benefits of development are being fairly shared in society. Statistics show that South Korea and Taiwan are relatively equal societies. Nevertheless, neither of these technocratically oriented authoritarian regimes was able to blunt criticisms that growth was unjustly distributed. South Korean workers and native Taiwanese felt particularly disadvantaged. In Malaysia, too, tensions are now mounting about distribution along ethnic lines. Electoral authoritarianism helped to defuse earlier crises in South Korea and Taiwan, but beginning in the mid-1980s, opposition forces in both nations launched successful challenges through the ballot box to bring about democratization. In Malaysia, the opposition scored major gains in the 2008 elections. Ideologically, all three authoritarian regimes were weakened by activist campaigns for social justice, which mobilized middle class professionals.

One can only speculate about whether Singapore will one day democratize. Its economy has continually deepened, most recently through a major drive to grow a biotech industry. At the same time, it has widened through a series of welfare-related measures focused on housing and pensions. The Singaporean government has also perfected a system of electoral authoritarianism, allowing some competition and participation without threatening the ruling party’s hold on power. Ideologically, the government has long determined the political agenda through its collectivist campaigns (including the once high-profile “Asian values” discourse). However, when Singapore’s founding father, Lee Kuan Yew, eventually passes away, the nation’s technocratic elite may be tempted to democratize. Democratization would give the government greater legitimacy to reform welfare provision, which many believe is currently limiting Singapore’s competitiveness. The main arguments are summarized in table two.*

It is evident that China and Vietnam are trying to imitate the Singaporean model. Though each faces many obstacles, both countries have already made great strides in industrial deepening and widening through an elaborate postcommunist welfare system. Ideologically, these countries will rely not just on growth—which will inevitably slow during the current economic crisis—but also on appeals to a collectivist identity that is simultaneously both nationalist and neo-Confucianist in character. Whether China and Vietnam eventually democratize or remain authoritarian despite modernization is one of the most important political questions in the world today.

* Please contact the Manager of Corporate Relations for a full PDF copy of this dispatch, including tables.

 

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In 2009, buffeted by the global economic slowdown, Malaysia’s economy is predicted to shrink.  Deputy Prime Minister Najib Razak is expected to replace unpopular Prime Minister Abdullah Badawi as Malaysia’s top leader early in April.  On 23 March the government banned the two main opposition newspapers, Suara Keadilan and Harakah.  Earlier in March an opposition lawmaker was forced out of the national parliament after demanding that Najib answer allegations of involvement in the gruesome murder of a Mongolian model, Altantuya Shaaribuu, in 2006.  The killing has been linked to a 110-million-euro “commission” paid to a close confidante of Najib by a French firm for the sale of submarines to Malaysia.  In February Najib used local parliamentary defections to take over Perak, one of the five states won in March 2008 by the opposition in elections whose results embarrassed the government.  An independent poll shows that Najib is even less popular than Badawi.  Prof. Chin will address the implications of these and other aspects of current political turbulence in Malaysia.

James Chin has written widely on Malaysian politics and the Chinese diaspora in Southeast Asia, among other topics.  Minority rights, ethnic politics, and good governance are among his current interests.  Before his Monash appointment he headed a business school.  Before that he worked as a financial journalist.  He has a doctorate from Victoria University in Wellington, New Zealand.

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James Chin Head, School of Arts and Social Sciences Speaker Monash University's Malaysian Campus, Petaling Jaya, Malaysia
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What makes some governments perform better than others? With rising levels of decentralization and local democracy, the focus of "good governance" is increasingly shifting from national to subnational levels. While much of the existing development literature remains preoccupied with formal institutional and society-centered explanations, there is growing evidence that local policy reforms are strongly affected by informal norms and elite-centered processes.

Post-Suharto Indonesia, a country with one of the most pronounced shifts to democratic decentralization anywhere in recent history, is a case in point. Drawing on empirical comparisons across ten districts (comprising 1000 business surveys and 150 interviews), Dr. von Luebke argues that societal pressures are often less significant in explaining policy differences than the quality of local government leadership. In the early transition to democracy, local firms, associations, and district councils continue to be constrained by collective action and political incentive problems. Local government leaders, on the other hand, have wielded historically strong formal and informal powers and stand, for better or worse, at the gateway to local policy reform. Motivated by direct elections and prospective donor funding, some district heads have become catalysts for better governance by introducing informal public-private dialogues, innovative monitoring instruments, and meritocratic promotion schemes. In response to current development debates, these findings highlight the importance of government leadership as an often underestimated policy determinant that can compensate for weak societal checks in periods of transition from authoritarian rule.

Christian von Luebke is completing a book manuscript titled “Heterodox Governance: The Political Economy of Local Policy Reform in Post-Suharto Indonesia.”  He has been awarded a 2009-2011 German Science Foundation Fellowship for a follow-up project incorporating cases from the rest of Southeast Asia and China.  In 2001-2006 he worked in rural Indonesia as a technical advisor for the World Bank and the German Development Agency. He holds a Ph.D. in public policy from the Crawford School of Economics and Government at the Australian National University.

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CvL_APARC_Photo_-_Oct_2010_2.jpg MA, PhD

Christian von Luebke is a political economist with particular interest in democracy, governance, and development in Southeast Asia. He is currently working on a research project that gauges institutional and structural effects on political agency in post-Suharto Indonesia and the post-Marcos Philippines. During his German Research Foundation fellowship at Stanford he seeks to finalize a book manuscript on Indonesian governance and democracy and teach a course on contemporary Southeast Asian politics.

Before coming to Stanford, Dr. von Luebke was a research fellow at the Center of Global Political Economy at Waseda (Tokyo), the Institute for Developing Economies (Chiba), and the Center for Strategic and International Studies (Jakarta). He received a JSPS postdoctoral scholarship from the Japan Science Council and a PhD scholarship from the Australian National University.

Between 2001 and 2006, he worked as technical advisor in various parts of rural Indonesia - for both GTZ and the World Bank. In 2007, he joined an international research team at the Institute of Development Studies (IDS) analyzing the effects of public-private action on investment and growth.

Dr. von Luebke completed his Ph.D. in 2008 in Political Science at the Crawford School of Economics and Government, the Australian National University. He also holds a Masters in Economics and a B.A. in Business and Political Science from Muenster University.

His research on contemporary Indonesian politics, democratic governance, rural investment, and leadership has been published in the Bulletin of Indonesian Economic Studies, Contemporary Southeast Asian Affairs, Asian Economic Journal, and ISEAS. He regularly contributes political analyses on Southeast Asia to Oxford Analytica.

Christian von Luebke 2008-2009 Shorenstein Fellow Speaker Shorenstein Asia-Pacific Research Center
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Hospitals in Thailand operate in a multiple insurance payment environment. This paper examines 1) access to medicines and other medical technologies, 2) treatment outcomes, and 3) efficiency in resource use, among beneficiaries of the three government health insurance schemes in Thailand. Using 2003-2005 inpatient data for patients with three tracer diseases from three government hospitals, we find that utilization of more expensive items differs between patients whose insurers pay on a closed- or open-ended basis. Where new vs. conventional drugs are both available, patients whose insurer pays on a fee-for-service basis tend to have greater access to new drugs, compared to patients whose insurer pays on a capitated or case basis. Similar patterns were found where there are options between originator vs. generic drugs, drugs in different dosage forms, and more vs. less advanced diagnostic technologies. Effects of insurance payment are more pronounced where price gaps among the medical technologies are significant. Efficiency results are mixed, depending on nature of the disease conditions and type of resources required for treatment.

Published: Hirunrassamee, Sanita, and Sauwakon Ratanawijitrasin. "Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand." International journal of health care finance and economics 9.2 (2009): 153-168.

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This seminar will feature two presentations: an attempt to evaluate the impact of health policy under a decade of progressive governments in Korea; and an investigation into the health and economic well-being of the elderly in Korea. The presenters will be Dr. Byongho Tchoe, a 2008-09 visiting scholar at Stanford University, and Dr. Young Kyung Do, the inaugural postdoctoral fellow in the Asia Health Policy Program at Stanford.

Korea achieved universal health care coverage in 1989 only twelve years after the introduction of social health insurance under an authoritarian government. In 1992 a civil government won the presidential election. Consistent with a conservative ideology oriented toward market principles and globalization, that government emphasized competitive principles in health care policy. However, at the end of 1997 in the face of economic crisis, the progressive party won the Korean presidential election; their health emphasized strengthening equity, redistribution, and regulation of providers’ rent seeking behavior. Under successive progressive governments from 1998 to 2007, ambitious health policy reforms integrated insurers, separated prescribing from dispensing, reformed provider payment, expanded benefits coverage, increased medical-aid enrollees, and increased the role of government providers in the health care market. But in the election of 2007, they were defeated by a conservative party, which insists that competition among insurers and providers will enhance efficiency and quality in health care, and stresses consumer choice and responsibility.

Dr. Tchoe's talk will attempt to evaluate impact of health care policy under a decade of progressive governments in Korea. Although equity in both access to care and financial responsibility appear to be enhanced, there is controversy about whether the policies were cost-effective or improved health, and what will happen as the new government repeals regulations in the health care market. The return of economic crisis also brings renewed urgency to debates of economic and social policy.

Byongho Tchoe is a 2008-09 visiting scholar at Stanford University. After working at the Korea Development Institute from 1983 to 1995, he took up his current post with the Korea Institute for Health and Social Affairs. He has been influential in formulating health and social policy in Korea, having served as an advisor to the minister of health and social welfare and participated in many task forces and committees. In 2007, he was awarded a National Medal in honor of 30 years achievement related to Korea’s National Health Insurance. He has published many articles and books and served as president of the Korean Association of Health Economics and Policy and as vice president of the Korea Association of Social Security. He holds a master’s degree in public policy from Seoul National University and a Ph.D. in economics from the University of Georgia.

Young Kyung Do is the inaugural Postdoctoral Fellow in Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center. He completed his Ph.D. in health policy and administration at the University of North Carolina at Chapel Hill School of Public Health in August 2008. He has also earned M.D. and Master of Public Health degrees from Seoul National University (in 1997 and 2003, respectively). He earned board certification in preventive medicine from the Korean Medical Association in 2004. He received the First Prize Award in the Graduate Student Paper Competition in the Korea Labor and Income Panel Study Conference in 2007. He also is the recipient of the Harry T. Phillips Award for Outstanding Teaching by a Doctoral Student from the UNC Department of Health Policy and Administration in 2007. In May 2008, he was selected as a New Investigator in Global Health by the Global Health Council.

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Byongho Tchoe is a 2008-09 visiting scholar at Stanford University. He began his research career at the KDI (Korea Development Institute) which is a topnotch government think tank in Korea and served from 1983 to 1995. After earning his PhD in economics, he continued his research career at KIHASA (Korea Institute for Health and Social Affairs) from 1995 up to now. 

He has always been an influential resource in formulating health and social policy in Korea, and served as an advisor to the minister of health and social welfare in 2000. He participated as a member of many task forces and committees for health and social policy making. He was awarded a National Medal for contributing 30 years achievement of National Health Insurance in 2007. 

He was also active in academic society. He published many articles and books. He served as a president of Korean Association of Health Economics and Policy and a vice president of Korea Association of Social Security. He holds a master's degree in public policy from Seoul National University and a PhD in economics from the University of Georgia. 

Byong Ho Tchoe Visiting Scholar, 2008-09 Speaker Shorenstein APARC
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Postdoctoral Fellow in Asia Health Policy Program, 2008-09
Do.JPG MD, PhD

Young Kyung Do is the inaugural Postdoctoral Fellow in the Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center. He completed his Ph.D. in health policy and administration at the University of North Carolina at Chapel Hill School of Public Health in August 2008. He has also earned M.D. and Master of Public Health degrees from Seoul National University (in 1997 and 2003, respectively). He earned board certification in preventive medicine from the Korean Medical Association in 2004. His research interests include population aging and health care, comparative health policy, health and development, quality of care, program evaluation, and quantitative methods in health research.

He received the First Prize Award in the Graduate Student Paper Competition in the Korea Labor and Income Panel Study Conference in 2007. He also is the recipient of the Harry T. Phillips Award for Outstanding Teaching by a Doctoral Student from the UNC Department of Health Policy and Administration in 2007. In May 2008, he was selected as a New Investigator in Global Health by the Global Health Council.

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Young Kyung Do Postdoctoral Fellow, 2008-09 Speaker Shorenstein APARC
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In late 2006, the Chinese government appointed a high-level inter-ministerial commission—composed of fourteen government agencies, co-chaired by the National Development and Reform Commission and the Ministry of Health—to develop a blueprint for China’s healthcare system. One party to that process, China’s Insurance Regulatory Commission (CIRC), has developed a program of cooperation with its U.S. counterpart, the National Association of Insurance Commissioners (NAIC). To provide input to policymaking, representatives of CIRC, NAIC, private insurers in China and the United States, as well as Chinese and American scholars of health insurance gathered in Yichang, Hubei, PRC, on 18-19 June 2007, for a joint seminar on the role of commercial health insurance in the Chinese and U.S. healthcare systems.

The first section of this field report provides a brief description of China’s health care reforms in the past decades. The second section highlights the progress and challenges to date in developing commercial health insurance in China, and the final section summarizes the recommendations that the NAIC Commissioners provided to CIRC in 2007 at this critical juncture in China’s health policy reforms.

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Karen Eggleston
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This systematic review examines what factors explain the diversity of findings regarding hospital ownership and quality. We identified 31 observational studies written in English since 1990 that used multivariate analysis to examine quality of care at nonfederal general acute, short-stay US hospitals. We find that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies. Ownership does appear to be systematically related to differences in quality among hospitals in several contexts. Whether studies find for-profit and government-controlled hospitals to have higher mortality rates or rates of adverse events than their nonprofit counterparts depends on data sources, time period, and region covered. Policymakers should be aware of the underlying reasons for conflicting evidence in this literature, and the strengths and weaknesses of meta-analytic synthesis. The "true" effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time.

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Health Economics
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Karen Eggleston
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Christian von Luebke
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At first sight, political turmoil in Thailand and the Philippines—repeated violent protests, impeachment battles, and military coups—gives the impression that democracy in Southeast Asia is on a downward spiral. One country in the region, however, has sustained a stable pluralistic democracy: the Republic of Indonesia.

In 1999, after thirty years of Suharto’s centralistic, authoritarian rule, Indonesia embraced far-reaching decentralization and election reforms. Within a brief period of two years, the Indonesian government reshaped its administrative architecture, including the devolution of local tax and service responsibilities to more than 400 district governments. In view of its deep-seated authoritarian traditions, beginning with Javanese kingdoms and sultanates, moving through Dutch colonialism (1619–1942), and ending with Suharto’s New Order (1965–98), Indonesia’s rapid shift toward democratic decentralization stands out as one of the most remarkable political transitions in recent history.

Particularly notable is the peaceful and competitive conduct of Indonesian elections. Over the last decade, local citizens have elected more than 30,000 local councilors and over 400 mayors, regents, and governors, with little violence or intimidation. High voter turnouts (around 70 percent) and high replacement rates of incumbent executives (roughly 40 percent) bear witness to rising electoral competition in local polities. While subnational elections display considerable flux, the upcoming presidential elections in July 2009 suggest continuity. The latest national polls, for example, predict a comfortable lead for President Susilo Bambang Yudhoyono (49 percent) over his main competitor, Megawati Soekarnoputri (36 percent).

The institutionalization of democracy and decentralization, however, has yet to translate into substantive public sector reforms. Indonesia continues to score low in global governance assessments. According to Transparency International and the World Bank, Indonesia’s government ranks 126th (out of 180) in terms of corruption, and 129th (out of 181) in terms of administrative efficiency for business start-ups. With the introduction of regional autonomy, these governance problems have, to a considerable extent, been decentralized to hundreds of districts. Yet, despite formally uniform institutional settings, local governments exhibit vast differences in regulatory quality, administrative efficiency, and anticorruption measures.

What motivates some local governments to perform better than others? Implicit in this question, which stands at the center of my research, is the idea that local democracy is not only an end in itself, but also a means for improving government outcomes. The pronounced policy differences that arise in Indonesia’s district polities provide a good opportunity to examine the workings of Indonesian local democracy or, to use a different terminology, the political economy of local decision-making.

The findings from controlled case comparisons and subnational datasets suggest that policy variations are best explained by differences in government leadership. Good policy environments emerge primarily in cases where local regents and mayors, whose career aspirations are tested by direct elections, skillfully use their office powers to forge reform coalitions and supervise bureaucratic practices. Societal reform pressures that arise from local parliaments, business chambers, and nongovernmental organizations, in comparison, tend to be less significant drivers of good governance. While broad-based interest groups continue to struggle with collective-action problems, district council members seem more concerned with provincial/national party elites (and their party list positions) than with representing local constituencies. Thus, in Indonesia’s early stage of democratic transition, where societal pressures are yet to fully unfold, much seems to depend on leadership efforts to initiate, facilitate, and oversee government improvements.

Under what conditions, then, are local leaders likely to act in the public interest, rather for private gain? While direct elections provide basic incentives, the direction and strength of these incentives also hinge upon existing socioeconomic structures. Government leaders need to accommodate interests of powerful economic groups in order to secure support for campaign funding and co-investments in public goods. Whether these interest alignments result in unproductive rent-seeking and corruption, or in constructive government reforms, depends on the constellation and transparency of economic powers.  The more economic powers become concentrated in specific sectors, groups, and firms, and the less public-private interactions are monitored by local media, the greater the likelihood that leaders will pursue self-preferential and collusive strategies.

As a result, it is plausible to assume that a moderate economic concentration and strong media presence are conducive to better governance. At this point, only some districts fall into this category. But as globalization and communication technologies progress, local polities are bound to become more economically diverse and politically informed. With growing political awareness and increased incentives for better leadership, it is likely that Indonesia, over time, will see more public-private symbioses for reform and, thus, bridge the gap between well-functioning elections on the one hand and poor governance
on the other.

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Marcus Mietzner is currently Lecturer in Indonesian Studies at the Faculty of Asian Studies, Australian National University. Between 1998 and 2008, he lived, worked and researched in Indonesia. He has published extensively on Indonesian politics, among others in Journal of Southeast Asian Studies, Southeast Asian Research and Contemporary Southeast Asia. His most recent book is Military Politics, Islam, and the State in Indonesia: From Turbulent Transition to Democratic Consolidation, published by ISEAS in Singapore in December 2008.

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Marcus Mietzner Lecturer in Indonesian Studies and Faculty of Asian Studies Speaker Australian National University
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