Sophia Hu, a Stanford student and prospective anthropology major, writes a summary of an annual forum that examines China’s health policy in comparative perspective

The Asia Health Policy Program held its Third Annual Forum on China’s Community Health Services and Primary Health Care Reform on June 22 in Beijing. The forum featured a diverse panel of speakers who addressed how to improve China’s primary care and community health care services. From discussing insurance plans to evaluating national policies and encouraging students to consider working as rural doctors, the speakers presented a wide array of research and experience. A brief summary of each presentation is detailed below.

Weichang Wang, director of the Ningxia Health Care Reform, discussed his experiences implementing a reformed health insurance payment system, originally developed by a team of researchers at Harvard and executed in Ningxia, China. Through this plan, his team created a medical insurance fund for the town that prioritized reimbursement for lower-level institutions, i.e. primary care centers. The plan resulted in increased accessibility, frequency of visits and patient satisfaction at primary care centers. It also saved money; however, some issues did arise such as how to develop accurate projections for the medical fund.

Quilin Chen of the Chinese Academy of Social Sciences, informed by his experience in Inner Mongolia, examined the disparity of hospitalization rates among different regions. He analyzed several factors, including financial incentives for patients and hospitals, regional differences in culture, and technological changes among primary care centers.

Jiaying Zhao of Australia National University and Shanghai University proposed using artificial intelligence (AI) to support primary care centers. She highlighted the benefits of AI, including how it can help inform physician decisions and bolster patient trust in primary care centers. Zhao, whose presentation motivated a spirited debate, shared important insights on the growing role of technology/CS in the health care field.

Jeroen Struijs of the Netherlands National Institute of Public Health and the Environment gave an overview of the primary care system in the Netherlands. With one of the most highly regarded systems in the world, the Netherlands prioritizes primary care-centric health care. He described how Dutch citizens seek care with their primary care physicians first – or face a penalty – before going on to specialists or hospitals. He also explained their bundled payment system. This system pays health services providers for a “bundle” of treatment for certain diseases, helping to align provider incentives with efficient convenient care, rather than fee-for-service which financially rewards quantity of services.

Hyuncheol Kim, an assistant professor at Cornell University, examined trends in long-term care insurance and public cancer screening programs in South Korea with a regression discontinuity design. His analyses helped to explain the relative success and failure of those programs. For example, his analysis was consistent with a theory that an intervention has a higher likelihood of failing if those receiving the intervention have other channels to receive benefits, i.e. patients are able to seek private as opposed to public insurance. His presentation also inspired discussion about primary care in Korea and the challenges Korea faces – similar to those in China – in trying to move away from a hospital-centric delivery system.

Lingui Li, director of Ningxia Medical University’s Public Sector Management Centre, delivered an overview of strategies to recruit health care workers in rural areas. He emphasized the need to balance primary public health service with primary clinical service and highlighted the dearth of doctors in villages.

Jinglin Yue, deputy dean of the Zhongshan University’s Institute of Public Administration, presented about his experiences establishing a hierarchical treatment system that aims to bring more people to primary care before pursuing treatment at hospitals. He explained the various incentives of the diverse interest groups involved, and emphasized the need for future government policies that support a 2-way referral system.

Xiaoguang Yang of Fudan University’s School of Public Health also described efforts to create a two-way referral system, based on his research of an integrated health system in Shenzhen. This initiative, using a people-centered reform paradigm, introduced the concept of “community of common destiny” to Luohu, China. The reformers tried to manage supply and demand using financial incentives to help providers including hospital groups coordinate in promoting a more integrated system.

Xiaoyun Liu of Peking University examined the efficacy of a new national program that contracts with students to commit to practicing medicine in rural areas in exchange for free medical school tuition. Using surveys, he gathered data on why students chose the program and where they chose to become rural doctors, among other factors. He then used this data to propose changes to enhance the effectiveness of the program.

Guanyang Zou, a researcher at Queen Margaret University, presented an overview of international experiences or “models” of health and social care that catered specifically to aging populations. These models included the integration of ambulatory medical care and aspects of social care and long-term care services.

Bei Lu of the University of New South Wales took an economic approach toward addressing the issue of long-term care for elderly populations. In her research, she worked closely with policymakers in Qingdao, China, and used a model to estimate how long-term care insurance could be structured so that the elderly could get optimal care without imposing a disproportionate financial burden on young taxpayers and fairly compensate providers.

Each presentation contributed important knowledge toward understanding primary care in China and elicited substantial discussion. This forum would not have been possible without the participation of the numerous speakers and the generous support of the Asia Health Policy Program and Chinese affiliates.

The latest American assertion of freedom-of-navigation rights in the South China Sea may have reassured some that new bonhomie between presidents Donald Trump and Xi Jinping won’t lead to abandonment of the region. But questions remain.

On 24 May, the guided missile destroyer USS Dewey transited within 12 nautical miles of Mischief Reef, a land feature occupied by China in the South China Sea. Analysts who had followed and criticized China’s campaign to control the sea, upon learning of this Freedom of Navigation Operation may have shared the same thought: Finally! Not since mid-October 2016 had the US been reported to have conducted such operations in the South China Sea. Since Trump’s inauguration in January, the Pacific Command had repeatedly been denied permission to conduct such a transit. 

Speculation abounds. Was the Dewey’s sail-by a one-off? Or did it augur a resumption of US efforts to forestall Chinese maritime dominion? Defense Secretary James Mattis will speak at the Shangri-La Dialogue in Singapore this week, and perhaps the Dewey’s route is meant to reinforce a message of reassurance for Asian leaders, that the United States is not resigned to Chinese primacy in the South China Sea. News of the Dewey’s trip was not formally announced. Nor was it accompanied by an official promise to follow up with further freedom-of-navigation operations. Any assuaging message, if intended, was thereby undercut, all the more so by Trump’s reputation for unpredictability and impulsiveness. 

Uncertainty abounds, too, as the region is left to wonder whether the Trump administration will make an ongoing commitment or will it offer, by implication, a transaction in the shorter run: suspension of US willingness to check China in the South China Sea, in return for Chinese willingness to check North Korea.

China’s behavior may have made these questions academic. For several years, Washington has watched Beijing turn the South China Sea into a Chinese lake. Impunity has benefited the pace of appropriation, and already some analysts have concluded the game is over. The stronger, less reversible, China’s maritime position becomes, the less valuable – bargainable – an American offer to accommodate it will be. American indifference has facilitated, or at least not impeded, China’s efforts eventually to establish full-spectrum sway over one of the economically and strategically most crucial waterways in the world. A million square kilometers larger than the Mediterranean, the South China Sea is vital for the many countries that border or use it – including China, Japan, India, South Korea, Australia, members of the Association of Southeast Asian Nations and, not least, the United States.

Obama-style “strategic patience” not only failed to lessen the missile-tossing truculence of Pyongyang. It failed to slow Beijing’s drive to dominate the South China Sea. Washington warned Beijing not to build up the land features it controlled; China did so anyway.  Washington warned Beijing not to militarize those properties; China did so anyway despite Xi’s public pledge to the contrary. Freedom-of-navigation operations were few, intermittent and increasingly far between, despite a promise to conduct them twice every three months. 

Meanwhile, ASEAN’s leaders were the objects of vigorous yuan diplomacy by China – attractive gifts and loans repayable in silence and deference. The Obama administration offered principles instead: good governance and navigational freedom. The Trans-Pacific Partnership promoted the first; freedom-of-navigation operations in the South China Sea defended the second.

In San Francisco in February 2016, an astute Malaysian asked his American audience to put themselves in Southeast Asian shoes: The Chinese offer you a stack of cash to spend.  The Americans offer you a stack of principles to follow. Which offer do you accept? It was a rhetorical question.

Trump may have abandoned the Trans-Pacific Partnership’s provisions for reasons of good economic governance. But why was the principle of navigational freedom neglected?  Why were the freedom-of-navigation operations performed less often under Obama and stopped altogether under Trump? 

A one-word answer could be linkage. Obama’s White House, including the National Security Council, viewed US relations with China as multi-stranded. Provoking Beijing with such operations risked losing cooperation on other issues that mattered to Washington: economic discrimination, cybersecurity, global warming, North Korea. As for Trump, initially, discontinuance of the operations could have been due to the new administration’s internal disarray and lack of staff. By May, however, it appeared that Washington might not be restarting them for a different reason: to incentivize Beijing to alleviate American economic concerns and restrain Pyongyang. 

It’s become conventional to distinguish Obama’s “strategic patience” from Trump’s “transactional dealing,” but linkage is present in both approaches. Both subordinate America’s interest in restraining Chinese maritime assertions in East Asia to America’s interest in gaining Chinese cooperation on other matters. In effect, Obama and Trump alike had bigger fish to fry. China’s salami-slicing tactic also made its incremental advances too insignificant to pick a fight over.

The Dewey’s voyage past Mischief Reef has broken a string of seven months without freedom-of-navigation operations, raising more policy questions. If operations do resume, does that mean Washington has also broken the linkage to other issues on which China could be helpful?  Is that freedom were worth defending in its own right? And what if no further operations ensue or follow a haphazard pattern?

Reassurances matter. In May, during his first trip to Europe, president Trump could have recommitted his country to defense of NATO partners by endorsing Article 5. He did not. Europeans now have reason to doubt America’s willingness to defend them against Russia President Vladimir Putin’s desire to destabilize or even retake Russia’s former satellite states. If the Dewey’s journey was not a resumption, but merely a one-time blip, will ASEAN’s leaders echo Germany Chancellor Angela Merkel in doubting America’s willingness to restrain Xi’s maritime ambitions in its own “near abroad”?

Southeast Asian policy elites may already assume that the Trump administration doesn’t care about their region. The gap between what these elites want from the US and what they expect to get emerges clearly in an April survey of more than 300 influential officials, businesspeople, scholars, journalists and activists across the 10 ASEAN countries on “How do Southeast Asians View the Trump Administration,” conducted by ISEAS Yusof Ishak Institute.

Of these respondents, an impressive 70 percent agreed that “Southeast Asia is more stable and secure with active US engagement.” But 56 percent expected the US to become less engaged in Southeast Asia in future, while 52 percent felt that the Trump administration was “not interested” in the region or considered it “irrelevant.”  As to which country or regional organization was the “most influential” in Southeast Asia, a mere 4 percent of the respondents chose the United States, compared to the 18 percent who cited ASEAN and the whopping 74 percent who chose China. An even higher proportion, 80 percent, expected China to fill any “strategic vacuum” in the region that American “indifference” might create.

There is one supportive result for Washington in the April survey: 68 percent of the respondents agreed that “the US will uphold freedom of navigation in the South China Sea.” The Trump administration should live up to that expectation. The Dewey’s sail-by should be followed by additional trips, performed regularly, publicly acknowledged, and justified by stating and restating strategic conviction: that no one country – not the United States, China, Japan nor any other state – should exercise exclusive control over the South China Sea. Such commitment, far from a chip to bargain with, is a key interest of the United States itself.

This piece was originally carried by YaleGlobal Online on June 1, 2017, and reposted with permission.

Colonel Patrick Winstead, the 2016-17 FSI senior military fellow at Shorenstein APARC, writes about the second annual orientation at U.S. Pacific Command headquarters

The mission of the Department of Defense (DoD) in the Indo-Asia-Pacific region recently became a bit clearer for 22 faculty and military fellows from Stanford, the Massachusetts Institute of Technology, the Naval Postgraduate School and the Daniel K. Inouye Asia-Pacific Center for Security Studies (APCSS). The U.S.-Asia Security Initiative at the Shorenstein Asia-Pacific Research Center (APARC) in the Freeman Spogli Institute (FSI) organized a group of faculty and fellows for a two-day orientation of United States Pacific Command (USPACOM) and its component military organizations in and around Honolulu, Hawaii, April 13-14, 2017. The purpose of the orientation was to provide researchers with a comprehensive understanding of how America’s armed forces both develop and implement U.S. national security strategy, doctrine and policy throughout Asia.

The trip began with a visit to the headquarters of USPACOM at Camp H.M. Smith. After receiving briefings about USPACOM's mission and operations, the group engaged in roundtable discussions with General Terrence O’Shaughnessy (Commander, U.S. Pacific Air Forces); Major General Kevin B. Schneider (Chief of Staff, USPACOM); Rear Admiral Mark Montgomery (Director for Operations, USPACOM); Major General Steven Rudd (Director for Strategic Planning and Policy, USPACOM); as well as other key joint directors and members of the command staff. The faculty and fellows provided short presentations on the situation in the South China Sea, U.S.-Philippine relations and cyber warfare to an audience of mid-grade military officers and civilian personnel assigned to USPACOM.

In addition to meeting with the leadership of USPACOM, the group was also afforded the opportunity to interact with personnel from the four separate component commands. Deputy Commanding General of U.S. Army Pacific, Major General Charlie Flynn, provided a command briefing at the U.S. Army Pacific headquarters at Fort Shafter. The briefing stimulated a wide-ranging discussion about Army initiatives and activities in support of USPACOM’s mission in the Indo-Asia-Pacific region. At Marine Corps Base Hawaii at Kaneohe Bay, under the guidance of trainers, the visitors took part in a hands-on experience operating Humvee simulators in a virtual-reality convoy setting and firing simulated weapons that Marines typically employ in combat operations. The first day of the trip ended with a working dinner at the historic Nimitz House with the Commander of the U.S. Pacific Fleet, Admiral Scott Swift, where the conversation ranged from Chinese military modernization to evolving U.S. naval doctrine.

Those themes carried into the second day, when the group met for several hours with faculty at APCSS for plenary presentations and multiple breakout sessions to facilitate in-depth dialogue on select topics including the threats posed by nuclear weapons on the Korean Peninsula and in South Asia. The day continued with a tour of the U.S.S Hopper, an Arleigh-Burke class guided missile destroyer, based at Pearl Harbor, Hawaii. Once onboard, the ship’s captain, Lieutenant Commander J.D. Gainey, provided briefings on Hopper’s mission and operational capabilities. In addition, the group spoke with members of the ship’s crew. The experience allowed the faculty and fellows to interact informally with sailors who serve in the Asia-Pacific theatre and to candidly discuss issues of concern. The second day of the orientation ended with a visit to the headquarters of U.S. Pacific Air Forces and a dialogue with O’Shaughnessy and his staff about the unique security challenges of the Indo-Asia-Pacific region, such as tyranny of distance, limited support bases and multiple emerging threats, and how those challenges impact the Air Force and the entire U.S. military’s preparations for contingencies in the region.

Overall, the orientation provided a unique opportunity to engage directly with high-level leaders of USPACOM and to learn first-hand about the challenges faced by those who serve in the armed forces. The orientation also provided a forum to discuss the United States’ national security interests in the region and its efforts to maintain peace and stability in the Indo-Asia-Pacific and to help maintain a rules-based, liberal democratic order.

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"If the threat posed by North Korea’s nuclear weapons were easy to solve, the problem would have been solved long ago. In addressing the threat from North Korea, a very real threat in which the North Korean’s could develop ICBMs that could deliver nuclear weapons to the American mainland, the United States must confront two very difficult challenges," explains Stephen Krasner in the Lawfare. Read the whole article here.