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.”

Under the aegis of the Forum on Contemporary Europe, Ambassador Jan Eliasson, former U.N. Special Envoy to Darfur, visited Stanford and FSI to offer a new model for global crisis management of a wide range of issues, from piracy to global poverty.   As the former president of the U.N. General Assembly, Eliasson called for concerted action by NATO, the European Union, the U.N., and other actors on pressing security and humanitarian issues.  Arguing that current security and humanitarian challenges are greater than at any time in recent memory, Eliasson urged that world powers, along with international institutions, seek new leadership from the Obama administration grounded in recognition of the global impact of regional crises. 

To make his case for seeing the global in the regional, Eliasson raised the specter of the escalating sea piracy off the coast of Somalia.  Pirates in that region launch from the shores of a failed state – a polity that has degenerated into rival war-lord militias after combined forces of U.N. and Western powers lost their appetite for engagement, and turned their attention elsewhere.  While much of the world is refocused on the wars in Iraq and Afghanistan, multinational corporations are increasingly subject to and pay out multi-million dollar ransoms for the release of ship crews and cargoes that include the world’s commercial arms shipments.  The piracy has grown beyond instances of local plunder, into crime that threatens one of the most heavily trafficked shipping lanes between western and emerging markets.  Merchant marine as well as naval fleets have been forced to change course, altering global transportation and security routes.  Most recently, Eliasson’s call for international leadership would seem to have been heeded by nations attending the international summit in Brussels on the piracy crisis.  At the summit, the E.U. foreign policy chief, the U.N. Secretary General, and U.S. officials joined with more than sixty countries – including Iraq – to pledge over $200 million in aid to the Somali government for security and development.  This international cooperation, and attention to root causes, would seem to be the first sign of the kind of vision that Ambassador Eliasson urges for new and more comprehensive response.

Ambassador Eliasson completed his depiction of the most effective international policy responses with a focus on the world problem of poverty.  Drawing on his years of experience in the international and Swedish diplomatic corps, Eliasson explained that in the most impoverished areas of the world, the most effective investment in international aid is that which funds the education of girls and young women.  Teach a girl essential education, and she herself, along with her family, and her community, benefits in manifold ways. Raising his glass, Eliasson noted that great numbers of peoples still do not have access to cheap and clean water – an essential provision for health and development.  Water, and access to its diminishing supply, must be understood by the world’s new leaders as the high stake behind multiple border wars. 

The Forum hosted Ambassador Eliasson at FSI and Stanford for two days of talks to reach multiple audiences.  At a Stanford Speakers Bureau event, Ambassador Eliasson addressed an overflow crowd of students and offered  insights into the crisis in Darfur.  The Forum welcomed the opportunity to bring Ambassador Eliasson, so recently from his mission in Darfur, to spur student interest in the role of international (U.N.) and regional (European Union and African Union) peace keeping operations.  During the same visit to Stanford, the Forum on Contemporary Europe hosted Kerstin Eliasson, Board Member of the European Commission Joint Research Center, and former Assistant Undersecretary of the Swedish Ministry of Education and Science, to speak on research reforms in the European higher education system.  Kerstin Eliasson’s public address was co-hosted with the Forum by the faculty seminar series of the Stanford Institute for Higher Education Research.  The visit by Ambassador Eliasson, and Kerstin Eliasson, was a highlight of spring 2009 research and public dissemination of the Program on Sweden, Scandinavia, and the Baltic Region at the Forum on Contemporary Europe.

Stephen D. Krasner, the Graham H. Stuart Professor of International Relations, and senior fellow at the Freeman Spogli Institute for International Studies (FSI) and the Hoover Institution, has been named deputy director of FSI, announced FSI Director Coit D. Blacker, the Olivier Nomellini Professor in International Studies. Larry Diamond, a senior fellow at FSI and the Hoover Institution, and professor, by courtesy, of political science and sociology, has been named director of FSI's Center on Democracy, Development, and the Rule of Law (CDDRL).

Krasner succeeds political science Professor Michael McFaul, former deputy director of FSI and CDDRL director, who has joined the Obama administration as special assistant to the president for National Security Affairs and senior director for Russian and Eurasian Affairs at the National Security Council.  Diamond will direct CDDRL while McFaul is on leave.

"We are delighted that Steve Krasner and Larry Diamond are assuming these leadership roles at this dynamic time in FSI's growth and development," said Blacker. "Steve and Larry's exemplary scholarship, research, and teaching, and their passionate commitment to the expansion of democracy and good governance, are a wellspring of inspiration to Stanford faculty and students, and to current and aspiring leaders the world over."

Krasner served as deputy director of FSI and CDDRL director from January 2003 to January of 2005. He then served as director of policy planning at the U.S. Department of State from February 2005 through April of 2007. In that role, Krasner was the driving force behind foreign assistance reform designed to more effectively target American foreign aid. He was also involved in activities related to the promotion of good governance and democratic institutions around the world.

Among extensive publications, Krasner is the author of Defending the National Interest: Raw Materials Investment and American Foreign Policy (1978), Structural Conflict: The Third World Against Global Liberalism (1985), and Sovereignty: Organized Hypocrisy (1999). Publications he has edited include Problematic Sovereignty: Contested Rules and Political Possibilities (2001). He taught at Harvard and UCLA before coming to Stanford in 1981.

Krasner received a BA in history from Cornell University, an MA in international affairs from Columbia University, and a PhD in political science from Harvard. He is a fellow of the American Academy of Arts and Sciences and a member of the Council on Foreign Relations.
Diamond is the founding coeditor of the Journal of Democracy, the co-director of the International Forum for Democratic Studies of the National Endowment for Democracy, and has been coordinating CDDRL's democracy program. His newest book, The Spirit of Democracy: The Struggle to Build Free Societies Throughout the World (Times Books, 2008), explores the sources of democratic progress and stress and the prospects for future democratic expansion.

Diamond's other published works include Squandered Victory: The American Occupation and the Bungled Effort to Bring Democracy to Iraq (Times Books, 2005), Developing Democracy: Toward Consolidation (1999), Promoting Democracy in the 1990s (1995), and Class, Ethnicity, and Democracy in Nigeria (1998).

In May 2007, Diamond was named "Teacher of the Year" by the Associated Students of Stanford University for teaching "that transcends political and ideological barriers." At Stanford Commencement ceremonies in June 2007, he was honored with the Dinkelspiel Award for Distinctive Contributions to Undergraduate Education and cited, inter alia, for "the example he sets as a scholar and public intellectual, sharing his passion for democratization, peaceful transitions, and the idea that each of us can contribute to making the world a better place."

Diamond received a BA, MA and PhD from Stanford, all in sociology.

Krasner and Diamond are part of the distinguished Stanford faculty group who lead the Draper Hills Summer Fellows on Democracy and Development Program each summer, which brings to Stanford some 30 rising leaders from major transitioning countries such as Russia, Iran, Iraq, Pakistan, Afghanistan, Nigeria, and Kenya to examine and foster linkages among democracy, sustainable economic development, and good governance.

Venture capital (VC) investment provides a unique mechanism for gauging the technological and entrepreneurial sophistication of a national economy. It is no surprise, then, that the two giants of Asia—China and India—have rapidly become important destinations for VC investment. The latest data available from Ernst & Young reveals an astonishing development: China received more VC investment than any nation except the United States. India, though lagging behind China, still received $862 million. To compare, over $30 billion in VC money was invested in the United States in 2007; $823 million was invested in Canada. Clearly, China and India are becoming nodes for the global VC practice. Many of the largest and most prestigious Silicon Valley VC firms have established significant presences in both nations.

China and India differ in many ways, but with respect to the development of VC they share important characteristics. Until late 2008, both nations had rapidly growing consumer economies. The Chinese and Indian governments and populations both agree that education—and particularly engineering—is critical to their future. Both China and India are leaders in sending their graduate students abroad, which has created a pool of well-trained nationals overseas who can advise their peers at home, or even return home themselves to set up new ventures. Many of these Chinese and Indian nationals have worked in U.S. sciences and engineering-based firms. Such professional experience, especially during the last two decades, has laid the basis for successful technology-based entrepreneurship, and the growth in VC that accompanies it.

When VC investing is viewed globally, U.S. dominance is unquestioned. In the United States, 30–35 percent of all VC-financed firms are located in the San Francisco Bay area. Another 10–12 percent are located in the Boston and New York areas, respectively. In India and China, VC investments are similarly concentrated, and generally occur in locations with the greatest concentrations of highly educated persons. As Table 1 indicates, the investment concentration is remarkable. Forty percent of all the VC-funded firms are located in Beijing, 26 percent are in Shanghai, and the Southern Chinese triangle of Shenzhen, Guangzhou, and Hong Kong accounts for another 14 percent. VC investment in China is even more concentrated than in the United States.

Table 1 VC Investments in China and India by City, 2004–2007
(more than 5 investments per city)

Chinese City    Number of Firms    Percent    Indian City    Number of Firms    Percent
Beijing                   213                  40          Bangalore           55                    38
Shanghai               137                  26          Mumbai              31                    21
Shenzhen                36                    7          Chennai             21                     14
Hong Kong              19                    4          New Delhi           16                    11
Guangzhou             16                    3           Hyderabad          11                     8
Hangzhou               13                    2           Pune                   8                      5
Nanjing                  11                    2             n/a       
Suzhou                    9                    2             n/a       
Wuhan                     7                    1             n/a       
Others                   66                   13           Others                4                      3
Unknown                  1                    0          Unknown             0                       0
Total                      528               100            Total                146                  100
Binational                9                    2          Binational             45                    31


VC-backed startups in India, though more diffuse in terms of the top six, are more concentrated overall. Three city regions—Bangalore (38 percent), Mumbai (21 percent), and Chennai (14 percent)—attract the largest investment. However, when including Delhi (11 percent), Hyderabad (8 percent), and Pune (5 percent), these six cities account for an even greater percentage of overall VC investment. The most technology-oriented cities in both nations, Beijing and Bangalore, have received approximately 40 percent of all VC investment. The second largest recipients are Shanghai and Mumbai, which are also the financial capitals.

In China, an enormous economy growing at nearly 10 percent per year even as it emerges from a socialist past, there are significant opportunities in infrastructure development and in supplying the burgeoning underserved consumer market. In a recent Ernst & Young report, Fan Zhang, one of the founding managing partners of Sequoia Capital China, was quoted as saying that “one of the factors that attracted Sequoia Capital to China is the country’s booming consumer market that provides an opportunity to create companies to define certain sectors and fill the need for strong brands, not only in technology but also tech-related consumer services and more traditional industries.”

Zhang is correct—VC investing in China does not directly compete with U.S. firms seeking VC investment. Table 2 shows the fields that VC firms are targeting in China. The table is divided into two binary categories—whether the firm receiving the investment targets the domestic or the global market across a variety of industries, and whether a given firm is in a high technology or non-high technology sector. Chinese firms, even those in technology-based fields, overwhelmingly target the domestic market (87 percent). The Internet has given rise to the largest number of VC startups, nearly all of which are focused on the Sinophone market. Two other key areas—software (10 percent) and mobile phone applications (10 percent)—also cater almost exclusively to the Chinese market. This domestic focus suggests that it will be quite some time before VC-backed Chinese firms threaten counterpart firms in the United States. A possible exception may be semiconductor design, where there are some Chinese startups. Though few Chinese VC-financed firms are likely to be directly competitive with U.S. firms in global markets, many of these Chinese firms compete ferociously against U.S. multinationals trying to make their own inroads into the Chinese domestic market.

Table 2 VC Investments in China and India by Sector and Market, 2004–2007

                                         India                               China
Sector                      Domestic*    Global         Domestic **    Global

Semiconductors               0               7                  22                20
Internet                        16               3                144                  2
Software                         2             14                  55                  4
Communications              1               4                  23                  9
Services                          4             53                  28                  9
Mobile phone                   7              5                   51                  1
Media                             2              0                    35                 0
Healthcare                      1               4                   26                 4
Retail                             1               1                   19                  0
Miscellaneous                  2               0                  20                  2
Components                    0               0                   2                   1
Energy                            0               0                   6                   8
Environment                    0               0                   5                   1
Manufacturing                  0               0                 25                  6
Total                              34             91                461                67

* Domestic firms are identified as those that made no apparent attempt to serve overseas markets.

The profile of Indian firms differs from those in China. First, Indian firms are internationally oriented (73 percent); only 27 percent focus on the domestic market. With respect to sector concentration, VC investing in India favors the services sector (46 percent) and software (13 percent). This is not surprising, given India’s well-known comparative advantage in these arenas. Unlike most VC-backed companies in China, many Indian firms may well create competition for U.S. service firms, despite the less developed nature of the Indian economy as a whole.

China and India continue to attract significant VC investment, albeit in different sectors. Today, China is second only to the United States in terms of VC investing, and this is unlikely to change. In China, the preponderance of VC investment is geared to the rapidly growing internal market. The size and unique nature of this market offers entrepreneurs lucrative opportunities to provide “knock-off” U.S. Internet sites for the Chinese market. There are Chinese interpretations of Yahoo!, Google, eBay, Facebook, and Monster.com that service Chinese customers. These firms are self-limited by the language; as such, they do not threaten companies overseas. Moreover, these Chinese companies do not own unique or global class technology that could challenge larger multinational players. It is unclear whether this situation will change over time.

Indian firms differ from Chinese firms in their strong outward orientation. In percentage terms, more Indian than Chinese firms operate in hard-core technology fields. Thus, while China currently enjoys greater VC investment, it is possible that Indian firms may ultimately play a bigger role in the global economy.