In 2008 an Indonesian economist, Sudarno Sumarto, was chosen to become the second Shorenstein APARC/Asia Foundation Visiting Fellow. He will be in residence at Stanford during the 2009-2010 academic year.  

An edited summary of Dr. Sumarto's proposed research and writing at Stanford follows:

Facing the major damage wreaked by the Asian financial crisis of 1997-98 on already poor and/or vulnerable Indonesians, the government in Jakarta was forced to launch a series of emergency social safety nets.  These programs targeted multiple sectors:  employment, education, health, food security, and community empowerment.  

Now that a decade has gone by since these measures were undertaken, it is time to draw policy lessons from the experience.  Special attention will be paid in this project to the dynamics of the process of deciding and delivering social protection, the difficulty of enlisting or creating appropriate targeting and implementation mechanisms, institutional enablers and impediments, the role of civil society, the impact of commodity subsidy reforms, and the relevance of good (and bad) governance.  

The study will also draw comparisons between Indonesia's record of targeted social protection and the experiences of other developing countries.  

Dr. Sumarto heads the SMERU Research Institute (Jakarta).  He also lectures at the Bandung Institute of Technology, Universitas Nusa Bangsa (Bogor), and the University of Indonesia (Jakarta).  

Dr. Sumarto has contributed to more than sixty co-authored articles, chapters, reports, and working papers, including "Agricultural Growth and Poverty Reduction in Indonesia," in Beyond Food Production (2007); "Reducing Unemployment in Indonesia," SMERU Working Paper, 2007; and "Improving Student Performance in Public Primary Schools in Developing Countries:  Evidence from Indonesia," Education Economics, December 2006.

Dr. Sumarto has spoken on poverty and development issues in Australia, Chile, China, Egypt, Ethiopia, France, Japan, Morocco, Thailand, and the United Kingdom, among other countries.  He has a PhD and an MA from Vanderbilt University and a BSc Cum Laude from Satya Wacana Christian University (Salatiga), all in economics.  He and his wife Wiwik Widowati have three children.  

“Emerging democracies must demonstrate that they can solve governance problems and meet citizens’ expectations for freedom, justice, a better life, and a fairer society.”

If the big global story of the 1980s and 1990s was the remarkable expansion of democracy, the bad news of this decade is that democracy is slipping into recession. In the two decades following the Portuguese revolution in 1974, the number of democracies tripled (from 40 to 120) and the percentage of the world’s states that are at least electoral democracies more than doubled (to about 60 percent). Since the late 1990s however, there has been little if any net progress in democracy. To be sure, significant new transitions to democracy took place in countries like Mexico, Indonesia, Serbia, Georgia, and Ukraine. But globally, the democratic wave has been neutralized and is now at risk of being overtaken by an authoritarian undertow, which has extinguished democracy in such states as Pakistan, Russia, Nigeria, Venezuela, Bangladesh and Kenya. In fact, two-thirds (15) of all the reversals of democracy (23) since 1974 have taken place just in the last eight years, since the October 1999 military coup in Pakistan.

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Two other negative trends are important to note. One is the implosion of democratic openings in the Arab world. Under pressure from the George W. Bush administration beginning in 2003, several authoritarian Arab regimes liberalized political life and held competitive, multiparty elections. Then, Islamist political forces made dramatic gains in Egypt and Lebanon and won a majority of seats in Palestine and Iraq — and suddenly the Bush Administration got cold feet. Arab democrats who had surfaced and mobilized felt abandoned and betrayed. The liberal secular politician Ayman Nour, who had the temerity to challenge President Hosni Mubarak in Egypt’s first contested presidential election, languishes in prison three years later. The country’s political opening is now frozen, while more than a billion dollars in American aid continues to flow to the regime.

The second negative trend is that authoritarian states have, unfortunately, learned some of the lessons of democratic breakthroughs of the past decade, particularly the color revolutions that brought down neocommunist autocracies in Serbia, Georgia, Ukraine, and Kyrgyzstan. As a result, they have closed political space, swallowed up or arrested independent media, crushed independent political opposition, sabotaged or shut down innovative uses of the Internet, and sought to block or sever external flows of democratic assistance. Vladimir Putin’s Russia (with its sinister cabal of savvy Kremlin “political technologists”) has blazed the trail in this authoritarian pushback, but China, Belarus, Iran, Azerbaijan, Uzbekistan, and other “post” communist and Middle Eastern dictatorships have followed suit. To make matters worse, China and Russia have drawn together with the Central Asian dictatorships in a new club, the Shanghai Cooperation Organization, to formalize and advance their authoritarian pushback.

To renew democratic progress in the world, we must understand the reasons for the democratic recession. Authoritarian learning is one. Another has been the inconsistent and often unilateralist policies of the United States. Although President Bush has done much to put democracy promotion at the center of American foreign policy and has substantially increased funding for U.S. democracy assistance programs, he has also alienated potential allies in the effort to advance democracy globally by associating democracy promotion with the use of (largely unilateral) force, as in Iraq; by promoting democracy with a tone that was often self-righteous and a style that was too often poorly coordinated with our democratic allies; and then by failing to sustain pressure for democratic change when the going got rough in the Middle East.

Structural factors have also driven the recession of democracy. One has had to do with the global political economy. As the price of oil has gone up, the prospects for democracy have receded. Russia, Nigeria, and Venezuela have all seen their democracies slip back into authoritarianism as oil prices have skyrocketed, sending huge new infusions of discretionary revenue into the hands of autocratic leaders, which they have used to buy off opponents and strengthen their security apparatuses. In Iran and Azerbaijan, surging oil revenues have shored up authoritarian states that once seemed vulnerable.

A second and more pervasive factor has had to do with the performance of the new democracies. Some new democracies are holding their own (like Mali) and even making progress (like Brazil and Indonesia) in the face of enormous accumulated problems and challenges. But the general reality, even in these countries, is that democracy often does not work for average citizens. Rather, it is blighted by multiple forms of bad governance: abusive police and security forces, domineering local oligarchies, inept and indifferent state bureaucracies, corrupt and pliant judiciaries, and ruling elites who routinely shred the rule of law in the quest to get rich in office. As a result, citizens grow alienated from democracy and become susceptible to the patronage crumbs of corrupt political bosses and the demagogic appeals of authoritarian populists like Putin in Russia and Hugo Chávez in Venezuela.

“If democracies do not work better to contain crime and corruption, generate economic growth, relieve economic inequality, and secure freedom and a rule of law, people will eventually lose faith and turn to authoritarian alternatives.”Before democracy can spread further, it must take deeper root where it has already sprouted. Emerging democracies must demonstrate that they can solve governance problems and meet citizens’ expectations for freedom, justice, a better life, and a fairer society. If democracies do not work better to contain crime and corruption, generate economic growth, relieve economic inequality, and secure freedom and a rule of law, people will eventually lose faith and turn to authoritarian alternatives. Struggling democracies must be consolidated, so that all levels of society become enduringly committed to democracy as the best form of government and to the country’s constitutional norms and restraints. Western governments and international aid donors can assist in this process by making most foreign aid contingent on key principles of good governance: a free press, an independent judiciary, and vigorous, independently led institutions to control corruption. International donors also need to expand their efforts to assist these institutions of horizontal accountability as well as initiatives in civil society that monitor the conduct of government and press for institutional reform.

The only way to stem the democratic recession is to show that democracy really is the best form of government — that it can not only provide political freedom but also improve social justice and human welfare.

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.”