The July/August issue of Health Affairs, the leading U.S.-based health policy journal, focuses on China and India. The special issue includes an article on China’s pharmaceutical policy by five contributors to Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, a book forthcoming in 2009 from the Shorenstein Asia-Pacific Research Center series with Brookings Institution Press. Chapters on Korea and Japan by Soonman Kwon (Seoul National University) and Toshiaki Iizuka (Aoyama Gakuin University) also appear in Chinese translation in the journal Bijiao (Comparative Studies), along with an overview paper (“Pharmaceutical policy reforms to separate prescribing from dispensing in Japan and South Korea: Possible implications for China”) by Karen Eggleston, Asian Health Policy Program Director.

As Eggleston writes in the introduction to Prescribing Cultures, pharmaceuticals and their regulation play an increasingly important and often contentious role in the health care systems of the Asia Pacific.  For example, some economies such as China have extraordinarily high drug spending as a percentage of total health spending; India and a few others host thriving domestic pharmaceutical industries of global importance, while controversy surrounds patents, trade-related aspects of intellectual property (TRIPS), and pharmaceutical pricing within bilateral trade agreements (Australia-US, Republic of Korea-US); nations throughout the region struggle with appropriate regulation of drugs, from patents to evidence-based purchasing (e.g., Australia’s Pharmaceuticals Benefit Scheme) and direct-to-consumer advertising; deeply-rooted traditions of indigenous medicine are modernizing and integrating into broader health care systems; and policies to separate prescribing and dispensing re-write the professional roles of physicians and pharmacists, with modifications to accommodate cultural norms and strong economic interests. Effective prescribing and pharmaceutical use will be central to controlling infectious diseases, both old and emerging; protecting the global public good of antimicrobial effectiveness; and treating the growing burden of chronic disease in the Asia Pacific.

The forthcoming book will explore these issues in detail, through a multi-disciplinary lens. The first section of the book features chapters on pharmaceutical policy within seven selected health care systems of the Asia Pacific: South Korea, Japan, Thailand, Taiwan, Australia, India, and China. The second section focuses on the cross-cutting themes of prescribing cultures and access versus innovation. Taken as a whole, the contributions aim to provide an evidence base for policy while acknowledging the historical and cultural context that makes policies distinctive.

Clear evidence suggests the importance of health service provider payment incentives for achieving efficiency, equal access, and quality, including attention to primary, secondary, and tertiary prevention. “Pay for performance” may be on the cusp of significant expansion in Asia, and reform away from fee-for-service has been underway for several years in several economies. Yet despite the policy relevance, the evidence base for evaluating payment reforms in Asia is still very limited.

China in particular has been undertaking significant reforms to its health care system in both rural and urban areas. With the expansion of insurance coverage and need to resolve incentive problems like “supporting medical care through drug sales,” there is an urgent need for evaluating alternative ways of paying health service providers. Evidence from policy reforms in specific regions of China, as well as other economies of the Asia-Pacific, can provide valuable evidence to help inform policy decisions about how to align provider incentives with policy goals of quality care at reasonable cost.

To illuminate these questions, the Asia Health Policy Program and several collaborating institutions are planning to convene a conference on health care provider payment incentives on November 7-8, 2008 in Beijing. The conference will highlight and seek to distill “best-practice” lessons from rigorous and policy-relevant evaluations of recent reforms in China and elsewhere in the Asia Pacific.

The organizing committee – including health economists from Shorenstein APARC, Peking University, Tsinghua University, and Seoul National University – reviewed submissions in June 2008 and accepted sixteen. The conference papers cover payment issues in Korea, Japan, China, Taiwan, Thailand, Tajikistan, the Philippines, and the US, and the disciplines of economics, health services research/health policy, public health, medicine, and ethics. Topics include institutionalized informal payments; the impact of global budget policies on high-cost patients; public-private partnerships; public-sector physicians owning private pharmacies; evidence-informed case payment rates; payment and hospital quality; bonuses and physician satisfaction; physician prescription choice between brand-name and generic drugs; and differences in pharmaceutical utilization across insurance plans that pay providers differently (fee-for-service versus capitation).

Policymakers from China’s National Development and Reform Commission and Ministry of Health will also speak at the conference. Selected research papers will be published through the Shorenstein Asia-Pacific Research Center either in a special volume or in a special issue of an English-language health policy journal.

Discussions began, tentatively at first, as the delegates slipped into the roles they had been assigned and for which they had prepared for several months. The tension mounted as they anticipated meeting with their heads of state, to whom they would propose their country’s goals for the upcoming U.N. Security Council meeting.

Thus began the Third Annual IDL Student Conference in International Security, sponsored by the Initiative on Distance Learning (IDL). IDL offers Stanford courses in international security to nine Russian universities via distance-learning technologies. Its annual conference brings together top students and instructors from each of the participating universities with students and faculty from Stanford. This was the first year that the conference centered on an international security simulation, led by political science professor Scott D. Sagan, director of CISAC, and Coit D. Blacker, director of FSI. Sagan has been conducting such security simulations for eight years at Stanford and other U.S. universities.

This year’s simulation scenario was the referral of Iran to the U.N. Security Council by the International Atomic Energy Agency (IAEA) for failure to fully disclose its nuclear activities. Council delegates convened in the Russian provincial capital of Yaroslavl, 150 miles northeast of Moscow, due to “security concerns”— as they were informed—about U.N. headquarters in New York.

Delegates’ opening statements reflected a wide range of views on Iran’s status with the IAEA. The U.S. delegation called for sanctions and showed little interest in negotiation. “We find the Iranian regime corrupt and repressive,” said Oleg Borisov, head U.S. delegate and a student at Petrozavodsk State University. He added, rather menacingly, “The United States is not intending to use military force unless Iran keeps up its nuclear capability and continues to support terrorism.”

At the other end of the spectrum, Venezuela, Pakistan, and Iraq indicated no willingness to consider sanctioning Iran. China urged delegates to “choose the only right option—diplomacy.”

By the end of the two-day session, delegates had overcome seemingly intractable differences during four intensive legal drafting sessions. The council’s resolution gave Iran three months to comply with IAEA demands and provided for Iran to obtain enriched uranium from Russia, with the production, transport, and waste disposal to occur on Russian soil under IAEA controls.

As a learning experience, the simulation is well matched to the IDL program’s goal of fostering critical analysis among a new generation of students in post- Soviet Russia. FSI director Coit Blacker wants to develop future generations of diplomats and policymakers whose worldview is shaped “by how they think, not what they’re told to think.”

After the session ended, students reflected on what they had learned. Putting themselves in others’ shoes seemed the most valuable aspect for many. Natasha Pereira-Klamath, one of the Stanford undergraduates who participated in the Yaroslavl simulation as a representative of the Russian Federation, said she was surprised at the “extent to which people reflected the views of their (assigned) countries.” This was echoed by other students, who expressed their surprise at how easy it was to begin thinking as a representative of another country, although their official position might be very different from their own.

“I’m glad to see the resolution passed today,” said Homkosol Bheraya, an exchange student from Thailand who attends Ural State University. “I hope that in the real world this can happen someday.” Perhaps she will be in a position to advance that goal. “My dream,” she said, “is to one day work for the IAEA.”

In his new book, The Spirit of Democracy: The Struggle to Build Free Societies Throughout the World (Times Books 2008), Larry Diamond intensely scrutinizes the global effort on democracy promotion. By both exploring the sources of progress as well as the locations and reasons for failure, Diamond presents a comprehensive assessment that is realistic but also hopeful. Diamond presents his arguments through a world of examples, citing the negative Putin's Russia and Musharraf's Pakistan; the unsuccessful politcally but nevertheless exemplary Toledo's Peru; and even the more difficult places like Nepal, Iran, and Thailand.

We are pleased to announce the first article of the new academic year in our series of Shorenstein APARC Dispatches. This month's piece comes from Dr. John D. Ciorciari, one of this year's Shorenstein Fellows. Dr. Ciorciari's current research centers on the alignment policies of small states and middle powers in the Asia-Pacific region. He also has interests in international human rights law and international finance. In this piece, Dr. Ciorciari shares some comments on "Myanmar After the Saffron Revolution."

In late September, tens of thousands of Buddhist monks took to the streets of Myanmar, leading the largest uprising against the ruling State Peace and Development Council (SPDC) since 1988. A sharp and sudden hike in fuel prices sparked the protests, but to the regime's many critics, the revolt displayed the depth of popular discontent with economic mismanagement, corruption, and political repression in Myanmar. Images of unarmed monks confronting the feared tatmadaw (armed forces) won the protesters considerable moral support from abroad, as did a public appearance by Aung San Suu Kyi. Some observers anticipated that the "saffron revolution" would lead to the overthrow of the regime, as occurred during the "rose," "orange," and "tulip" revolutions in Georgia, Ukraine, and Kyrgyzstan.

The tatmadaw responded swiftly and brutally, however. Troops imposed tight curfews, raided pagodas, and used clubs and tear gas to disperse protesters. In a matter of days, the armed forces killed numerous demonstrators, arrested or detained thousands more, and re-imposed control. The saffron revolution thus appears to have subsided, and the outlook is not promising for advocates of regime change or dramatic policy shifts in Myanmar.

The episode did reveal some minor cracks in the SPDC edifice. Colonel Hla Win, a longtime senior member of the junta, reportedly defected into an ethnic Karen rebel-controlled area and is seeking political asylum after defying an order to massacre a group of monks. At least one senior army official has leaked incriminating evidence to the press, and a foreign ministry official resigned at the government's "appalling" response to the protests. Prime Minister Soe Win has been hospitalized with leukemia for months. Rumors even swirled of a coup. Nevertheless, SPDC chairman Than Shwe, his deputy Maung Aye, and other cabinet members appear to have closed ranks, and the SPDC looks quite firmly entrenched.

International responses to the uprising and military response have been mixed. Western governments and activist groups quickly condemned the SPDC and pushed the regime to open dialogue with Aung San Suu Kyi's opposition National League for Democracy. U.S. President George W. Bush announced tighter sanctions shortly after the crackdown began. Japan--which has favored engagement in the past--is now considering sanctions and has demanded an explanation and an apology for the shooting of a Japanese journalist.

To dampen international pressure, the SPDC allowed Nigerian diplomat Ibrahim Gambari to enter the country as a UN special envoy. Gambari has met with both Than Shwe and Aung San Suu Kyi to convey the UN's concerns about the crackdown. The SPDC has also appointed retired general U Aung Kyi as an official interlocutor with Aung San Suu Kyi and has made gestures of conciliation to the clergy. However, the Myanmar leadership has rebuffed demands for more serious political dialogue or far-reaching policy reforms.

A degree of Chinese and Russian protection has helped shield the SPDC from international pressure. China and Russia vetoed a U.S.-sponsored UN Security Council resolution demanding that the SPDC free all political prisoners. Officials in Beijing and Moscow argued that the unrest was an "internal matter" unsuited for Security Council action. Their defense of a strong norm of sovereignty--rooted largely in their fear of similar Western attacks--provides political cover for the SPDC. Their objection to isolating Myanmar economically also makes it unlikely that a program of enhanced U.S. and European sanctions will bring the junta to its knees. As long as Myanmar's neighbors do business with the SPDC, it will probably survive.

To date, divergent foreign policy priorities have conspired against a genuinely multilateral policy to drive reform in Myanmar. For China, Myanmar is a strategic gateway to the East Indian Ocean and a source of prized raw materials, as well as a political ally on issues of state sovereignty. India and Thailand have also been loath to cut off or alienate their troublesome neighbor. India has little ideological affection for the SPDC but rejects sanctions and has responded quietly to recent events in Myanmar. Indian officials view Myanmar as an important regional pivot with China and a source of natural resources. Thai policymakers, worried about refugees and instability in ethnic minority enclaves along the border, have tended to prioritize stability over reform in relations with the SPDC. Both India and Thailand derive considerable economic benefits--both legal and illicit--from an open border. In addition, they fear that using their limited leverage to attack the junta will drive it further into China's embrace.

The governments of other member states of the Association of Southeast Asian Nations (ASEAN) have split on the issue. Indochinese states defend Myanmar's sovereignty, while the Philippines, Singapore, Malaysia, and Indonesia have been more openly critical. With a bit of diplomatic legerdemain, Singapore expressed ASEAN's grave concern to Myanmar, speaking as the Association's chair. Discourse in regional think tanks suggests that a growing number of Southeast Asian officials advocate Myanmar's suspension from ASEAN. Although suspension would push Myanmar even further into the margins of international society, it would be unlikely to unseat the SPDC. Isolation also bears obvious risks; cloning North Korea is not in any ASEAN government's interest.

Most analysts agree that China holds the key to improving the prospects for reform, development, and democracy in Myanmar. Indeed, a change in Chinese policy would increase the likelihood of tougher Indian and ASEAN stances, since a fear of encouraging close Sino-Myanmar ties helps justify their existing approaches. The possibility of embarrassment at the upcoming Olympic games provides a short-term incentive for China to press the SPDC for better governance. A longer-term incentive will be to secure the countries' shared border, which is plagued by narco-trafficking, illegal migration, and ethnic conflict. Finally, China has an incentive to build its credibility as a constructive force in Southeast Asia and beyond. Chinese officials have led a well-documented "charm offensive" in the region, both bilaterally and through multilateral institutions, to build influence. To the extent that ASEAN governments make reform in Myanmar a priority, China can show itself to be a responsible stakeholder in Southeast Asia's future.

In the near term, a coalescence of the policies of regional powers is unlikely. Moreover, strong regional pressure does not guarantee seismic policy shifts in Myanmar. The SPDC's harsh response to the protests--like its 2006 decision to move the national capital to a remote area--testifies to considerable paranoia. Still, the outside world has economic, security, and moral reasons to hold Myanmar to higher standards of governance. The pace and direction of change will depend only marginally on the severity of Western sanctions, which bite but do not cripple the regime. Western governments' ability to identify common objectives and forge cooperation with Asian partners will be more determinative. Ultimately, the development of concerted action by relevant Asian states is likely to be the rate-limiting step in the equation. The saffron revolution suggests that many domestic actors are prepared to assume risks to promote reform if Myanmar's neighbors take a tougher stand and help provide the enabling conditions for change.

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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.