"The Role of the Private Sector in Health" was the topic of a full day symposium held July 11th at the Beijing International Convention Center. Convened one day before the World Congress of the International Health Economics Association, the private sector symposium attracted over a hundred participants from nations around the world. Aiming to foster dialogue between researchers interested in the private sector and policymakers, the event is one in a series with the long-term goal of promoting greater research interest and knowledge generation regarding the private sector to benefit health systems development. The program featured several scientific paper presentations and panels as well as keynote addresses by representatives from the Chinese Ministry of Health and the World Bank.

Karen Eggleston of the Asia Health Policy Program worked alongside several others on the organizing committee for this ongoing collaboration about the role of the private sector in health policy. Other committee members included Ruth Berg, PSP ONE, Abt Associates; Peter Berman, World Bank; Birger Forsberg, Karolinska Institutet; Gina Lagomarsino, Results for Development; Qingyue Meng, Shandong University; Dominic Montagu, University of California, San Francisco; Sara Bennett, Alliance for Health Systems and Policy Research; and Stefan Nachuk, Rockefeller Foundation.

Selected papers about the private health sector in Asia presented at the symposium will appear in the Asia Health Policy Program's working paper series on health and demographic change in the Asia-Pacific.

East and Southeast Asia are aging rapidly. South Korea, for example, has become one of the fastest aging societies in the world. In France, 115 years (1865–1980) were required for the proportion of population aged 65 and over to rise from 7 percent to 14 percent, but in South Korea, it is expected that a comparable change will occur in only eighteen years (2000–2018). More strikingly, it will take only eight years (2018–2026) for the proportion of South Korea’s elderly to increase from 14 percent to 20 percent. The nation’s old-age dependency ratio grew from 5.7 percent in 1970 to 12.6 percent in 2005, and is projected to further increase to 72.0 percent by 2050. At the macroeconomic level, these figures suggest an increasing burden on the working-age population to support the elderly population.

Such figures, however, do not tell the whole story about the burden shouldered by the working-age population. The lives of elderly and working-age individuals are not separate but rather, are linked by the institution of the family. Working-age adult children often take on the role of caring for elderly parents, who may have functional limitations and cognitive impairments. Such informal family caregiving is embedded in traditional Korean culture, as it is in many Asian societies that uphold traditional norms of filial piety.

As the elderly population grows, the demand for elderly long-term care will increase sharply. The supply of informal care, however, is decreasing for a number of reasons. Declining fertility rates have already diminished the potential pool of family caregivers. Further reducing the availability of family caregivers is an array of socioeconomic changes, such as increased migration, decreasing rates of intergenerational co-residence, and increasing labor force participation rates among women, who have historically served as the main family caregivers. Adult children, therefore, will increasingly experience a conflict between parental care responsibilities and their own work. Anecdotal evidence suggests that many daughters or daughters-in-law give up their professional employment to care for their disabled parent(s) or parent(s)-in-law. The work-family conflict also has important implications for the economy—informal caregiving may have additional negative effects on the labor force participation of the already shrinking working-age population.

I recently conducted a study using data from the Korean Longitudinal Study of Aging. My study indicated that providing at least ten hours of care per week reduces the probability of female labor force participation by 15.2 percentage points. I concluded that informal care is already an important economic issue in South Korea even though its population aging is still at an early stage. If the current trend continues, the labor market costs of informal caregiving will increase as the country experiences the full force of the demographic transition. One of the expected benefits of the public long-term care insurance implemented in July 2008 is to help family caregivers participate more easily in the labor force. In Japan, there is some evidence that long-term care insurance positively affects female labor force participation, but such beneficial effects have not yet materialized clearly in Korea. In both countries, there is much to learn from early experience with long-term care insurance.

In most parts of Asia, informal caregivers remain invisible on the policy agenda, not only because of cultural norms that perpetuate family-centered care but also because informal care incurs no public cost. However, the demographic transition, coupled with socioeconomic changes in the region, underscores the need to examine whether informal care is really without costs, at both individual and societal levels. Throughout Asia, the challenge for public policy will be finding the optimal mix of informal, family-based and formal, socially supported elder care.

The Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center is pleased to announce that Brian K. Chen has been awarded the %fellowship1% for 2009-2010.  Brian is currently completing his Ph.D. in Business Administration in the Business and Public Policy Group at the Haas School of Business, University of California at Berkeley.  He received a Juris Doctor from Stanford Law School in 1997, and graduated summa cum laude from Harvard College in 1992. 

As an applied economist, Brian’s research focuses on the impact of incentives in health care organizations on provider and patient behavior.  For his dissertation, Brian empirically examined how vertical integration and prohibition against self-referrals affected physician prescribing behavior.  His job market paper has been selected for presentation at the American Law and Economics Association’s Annual Meeting in 2009.

Brian comes to the Shorenstein Asia-Pacific Research Center not only with a multidisciplinary law and economics background, but also with an international perspective from having lived and worked in Taiwan, Japan, and France.  He has a particularly intimate knowledge of the Taiwanese health care system from his experience as an assistant to the hospital administrator at a medical college in Taiwan.

During his residence as a postdoctoral fellow with the Asia Health Policy Program, Brian plans to conduct empirical research on cost containment policies in Taiwan and Japan and how those policies impacted provider behavior. His work will also contribute to the program’s research activities on comparative health systems and health service delivery in the Asia-Pacific, a theme that encompasses the historical evolution of health policies; the role of the private sector and public-private partnerships; payment incentives and their impact on patients and providers; organizational innovation, contracting, and soft budget constraints; and chronic disease management and service coordination for aging populations.

David G. Victor says a comprehensive, national-level climate change policy with bi-partisan support is necessary in the U.S. before engaging, seriously, with other nations. Although the Democrats control both the White House and Congess, previous landmark environmental legislation were authored under centrist Republican administrations. Furthermore, the Administration needs time to carefully construct a national policy that considers current, more stringent, policies at the state-level while balancing the economic crisis.

One effect of the new Obama administration's global charm is that America could be let out of the environmental doghouse. The Obama plan to restart the economy is stuffed full of green incentives, and the new president has earned global cheers for his promise to cut the gases that cause global warming. But hope and change are not easy to implement in Washington, and the first big disappointment is likely to come later this year when the world's governments gather in Copenhagen to replace the aging and ineffective Kyoto treaty.

In reality, the greenish tinge on nearly every economic recovery plan, even China's, show that this crisis offers green opportunity.

Pundits have been talking down the Copenhagen summit on the theory that the current financial crisis makes 2009 a tough time for governments to focus on costly and distant global goals like protecting the planet. In reality, the greenish tinge on nearly every economic recovery plan, even China's, show that this crisis offers green opportunity. The real reason Copenhagen will be a disappointment is that the new Obama administration can't lead until it first learns what it can actually implement at home. And delivering greenery in the American political system is harder than it looks-even when the same left-leaning party controls both the White House and Congress.

On environmental issues, America is barely a nation. Under a single flag it uneasily accommodates a host of states pushing greenery at wildly different speeds. In the 1970s and 1980s, this multispeed environmentalism propelled America to a leadership position. The key was truly bipartisan legislation, which allowed Washington to craft a coherent national approach. In fact, most of the major U.S. environmental laws did not arise solely from the environmental left but were forged by centrist Republican administrations working closely with centrist and left-leaning Democrats. Republican President Nixon created America's pathbreaking clean air and water regulations; Republican George H.W. Bush updated the air rules to tackle acid rain and other pernicious long-distance pollutants. In his more moderate second term, Ronald Reagan was America's champion of the ozone layer and helped spearhead a treaty-probably the world's most effective international environmental agreement-that earned bipartisan support at home and also pushed reluctant Europeans to regulate the pollutants.

Ever since the middle 1990s-about the time that the U.S. government was shut down due to a partisan budget dispute-such broad coalitions supporting greenery have been rare. In the vacuum of any serious federal policy, for nearly a decade the greener coastal states devised their own rules to cut warming gases. The United States as a whole let its green leadership lapse. (At the same time, the project to create a single European economy has shifted authority in environmental matters from individual member states into the hands of central policymakers in Brussels, where a coterie of hyperrich and very green countries have set the agenda. Europe, long a laggard on environmental issues, is now the world leader.)

The normal multispeed script was playing out on global warming as the Obama administration took power. Industry, worried about the specter of a patchwork of regulations, has lobbied for a coherent national strategy. But the Obama administration's first major policy on global-warming policy went in precisely the opposite direction: he reversed the Bush administration's decision that blocked California from adopting its own strict rules on automobile efficiency.

Today's challenge, which won't be solved by Copenhagen, is for Obama to stitch these many state environmental efforts together. That's no easy task. Global-warming regulation will probably have a larger impact on the nation's economy than any other environmental program in history, and any plan will have to allow enough room for some states to move quickly while also satisfying industry's well-founded need for harmony. Obama's Democratic Party controls both the White House and Congress, but that does not guarantee success. It will be difficult to craft a national policy that earns broad and bipartisan support while also taking the big bite out of the emissions that the rest of the world is hoping Obama will promise to the Copenhagen treaty. The difficulties aren't just in dragging along wary conservative Republicans. In fact, the most important skepticism about an aggressive national strategy has been from a coalition of centrist Democrats who fear the impact on jobs and economic growth.

One key to success will be crafting a deal with China and other developing countries to show that they, too, are making an effort. But serious efforts on that front are still in their infancy.

The big challenge for Copenhagen will be to find a way to allow negotiations to stretch beyond the unrealistic 2009 deadline while still keeping momentum. America's slowness in getting serious about global warming should be welcome because it is a contrast to its rushed behavior in negotiating the Kyoto treaty. At Kyoto, Bill Clinton's administration promised deep cuts in emissions without any plan for selling them at home, which is why the Bush administration could so easily abandon the treaty. Repeating that mistake would be a lot worse than waiting a bit for America to craft real leadership. If that's why Copenhagen falls short of the mark, then that's good news-real greenery, rather than fakery.