The Director of the Asia Health Policy Program, Karen Eggleston, served as guest editor of the International Journal of Healthcare Finance and Economics for the June 2009 issue. The eight papers of that issue evaluate different provider payment methods in comparative international perspective, with authors from Hungary, China, Thailand, the US, Switzerland, and Canada. These contributions illustrate how the array of incentives facing providers shapes their interpersonal, clinical, administrative, and investment decisions in ways that profoundly impact the performance of health care systems.

The collection leads off with a study by János Kornai, one of the most prominent scholars of socialism and post-socialist transition, and the originator of the concept of the soft budget constraint. Kornai’s paper examines the political economy of why soft budget constraints appear to be especially prevalent among health care providers, compared to other sectors of the economy.

Two other papers in the issue take up the challenge of empirically identifying the extent of soft budget constraints among hospitals and their impact on safety net services, quality of care, and efficiency, in the United States (Shen and Eggleston) and – even more preliminarily – in China (Eggleston and colleagues, AHPP working paper #8).

The impact of adopting National Health Insurance (NHI) and policies separating prescribing from dispensing are the subject of Kang-Hung Chang’s article entitled “The healer or the druggist: Effects of two health care policies in Taiwan on elderly patients’ choice between physician and pharmacist services” (AHPP working paper #5).

In “Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand” (AHPP working paper #4), Sanita Hirunrassamee of Chulalongkorn University and Sauwakon Ratanawijitrasin of Mahidol University study the impact of multiple provider payment methods in Thailand, providing striking evidence consistent with standard predictions of how payment incentives shape provider behavior. For example, patients whose insurers paid on a capitated or case basis (the 30 Baht and social security schemes) were less likely to receive new drugs than those for whom the insurer paid on a fee-for-service basis (civil servants). Patients with lung cancer were less likely to receive an MRI or a CT scan if payment involved supply-side cost sharing, compared to otherwise similar patients under fee-for-service. (This article is open access.)

The fourth paper in this special issue is entitled “Allocation of control rights and cooperation efficiency in public-private partnerships: Theory and evidence from the Chinese pharmaceutical industry” (AHPP working paper #6). Zhe Zhang and her colleagues use a survey of 140 pharmaceutical firms in China to explore the relationships between firms’ control rights within public-private partnerships and the firms’ investments.

Hai Fang, Hong Liu, and John A. Rizzo delve into another question of health service delivery design and accompanying supply-side incentives: requiring primary physician gatekeepers to monitor patient access to specialty care (AHPP working paper #2).

Direct comparisons of payment incentives in two or more countries are rare. In “An economic analysis of payment for health care services: The United States and Switzerland compared,” Peter Zweifel and Ming Tai-Seale compare the nationwide uniform fee schedule for ambulatory medical services in Switzerland with the resource-based relative value scale in the United States.

Several of the papers featured in this special issue were presented at the conference “Provider Payment Incentives in the Asia-Pacific” convened November 7-8, 2008 at the China Center for Economic Research (CCER) at Peking University in Beijing. That conference was sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center at Stanford University and CCER, with organizing team members from Stanford University, Peking University, and Seoul National University.

As Eggleston notes in the guest editorial to the special issue, AHPP and the other scholars associated with the issue “hope that these papers will contribute to more intellectual effort on how provider payment reforms, carefully designed and rigorously evaluated, can improve ‘value for money’ in health care.”

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.