Aging
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Abstract:

One of the key objectives of introducing a compulsory health insurance is to provide citizens, regardless of socioeconomic status, with financial risk protection against unexpected catastrophic expenditures in the face of illness.  South Korea and Taiwan achieved universal health coverage (UHC) through mandatory social insurance schemes in 1989 and 1995, respectively.  Despite both countries' efforts to achieve the goal of financial risk protection for more than two decades, past research has demonstrated that household out-of-pocket (OOP) payment still accounts for more than one-third of total health expenditures in both countries.  When OOP payment represents a significant share of financial sources for health care, one should be particularly concerned about the distribution of such payments, in particular, catastrophic health expenditures, across households of differing economic levels.  This talk sets out to examine the change in the incidence and distribution of catastrophic health expenditures before and after the introduction of the National Health Insurance programs in South Korea and Taiwan.

 

Given similarity in the health and National Health Insurance (NHI) system characteristics observed in South Korea and Taiwan, substantial variation in the distribution of catastrophic payment among households was noted. The rich are more likely to incur catastrophic payment in South Korea, but the opposite trend is noted in Taiwan.  Further assessment on the impact of universal health coverage (UHC) on reducing catastrophic headcount (defined as the proportion of households incurring catastrophic health payment) is observed in Taiwan, but not in South Korea.  We found that when South Korea introduced the NHI program with a limited benefit package and high copayment, it produced little effect (if not none) in reducing financial burden in terms of proportion of catastrophic headcount. On the contrary, the impact of universal health coverage on catastrophic headcount ranged from -1.82% to -4.08% for Taiwan, due to the provision of a rather comprehensive benefit package with modest copayment. While UHC is a well-lauded policy goal and may be a magic word for many countries striving for the achievement, it is definitely not a panacea to resolve the incidence of catastrophic payment and potential medical impoverishment.  To provide sufficient financial protection against unexpected medical expenses, the design of the benefit coverage and risk sharing mechanism is key to the success of effectively achieving UHC. 

 

Bio

Jui-fen Rachel Lu, Sc.D., is the Fulbright Visiting Scholar at Center for East Asian Studies, Stanford University, and a Professor at Chang Gung University (CGU) in Taiwan, where she teaches comparative health systems, health economics, and health care financing and has served as department chair (2000-2004), Associate Dean (2009-2010) and Dean of College of Management (2010-2013).  She earned her B.S. from National Taiwan University, and her M.S. and Sc.D. from Harvard University, and she was also a Takemi Fellow at Harvard (2004-2005).  Prof. Lu is currently the President of Taiwan Society of Health Economics (TaiSHE) and an Honorary Professor at Hong Kong University (2007-2017).  Dr. Lu was also the recipient of IBM Faculty Award in 2009.   

 

Her research focuses on 1) the equity issues of the health care system; 2) impact of the NHI program on health care market and household consumption patterns; 3) comparative health systems in Asia-Pacific region.  She is a long-time and active member of Equitap (Equity in Asia-Pacific Health Systems) research network and was the coordinator for the catastrophic payment component of Equitap II research project which involved 21 country teams and was jointly funded by IDRC, AusAID, and ADB.  Professor Lu has also been appointed to serve as a member on various government committees dealing with health care issues in Taiwan.  

Okimoto Conference Room, Encina Hall 3rd Floor, East Wing

Rachel Jui-fen Lu Visiting Scholar, Center for East Asian Studies Stanford University
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Life expectancy at aged 65 is remarkably similar in the three Chinese cities of Hong Kong, Shanghai, and Taipei, even though the cities differ in levels of socioeconomic development, health systems, and other factors. Edward Jow-Ching Tu will discuss research that aims to understand this phenomenon. Despite unprecedented increases in life expectancy and attainment of similar current levels of life expectancy, the cities differ in the contributions of changes in major causes of death to the improvements in life expectancy among the elderly. Tu and colleagues have explored several possible determinants of these different patterns and trends in the three cities, including socioeconomic development, health service delivery systems, cause-of-death classification systems, and competing risks from cardiovascular disease and other diseases. Their analysis suggests that the effect of equity of health service delivery has become more important over time.

Edward Jow-Ching Tu is a senior lecturer of demography in the Division of Social Science at Hong Kong University of Science and Technology. His work is focused on the impact of fertility, mortality, and migration on socio-economic changes in East Asia countries with special emphasis on nations experiencing a transition from planned economy to market economy; on causes and impacts of mortality changes and health transition on aging societies; and on the causes of lowest-low fertility in many East Asia countries. He has several active research projects ongoing in China, Japan, Taiwan, Hong Kong, and Singapore. He holds graduate degress from West Virginia University, the University of Pennsylvania, and the University of Tennessee (Knoxville). Tu has worked extensively in Asia, and has served as an adjunct professor and taught in many universities in China, including Peking University, Peoples University, Nankai Univerity, and Fudan University. He had served as a senior research scientist at the New York State Health Department and as a research fellow (full professor) at the Institute for Social Sciences and Philosophy at Academia Sinica. Tu has also taught at the State University of New York in Albany.

Philippines Conference Room

Edward Jow-Ching Tu Senior Lecturer of Demography at the Division of Social Science Speaker Hong Kong University of Science and Technology
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Larry Diamond
Larry Diamond
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Commentary
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After the peaceful mass uprising that toppled one of the world's oldest autocracies, it is now possible to imagine the emergence of a genuine democracy in Egypt-the most important country in the Arab world. The very possibility of it marks an historic turning point for the entire region. However, there is a long and often treacherous distance between the demise of an authoritarian regime and the rise of a democracy.

With no experience of democracy in recent decades, and no apparent government leadership that is committed to bringing it about, Egypt's transition faces more formidable challenges than the transitions that led to democracy in recent decades in countries like Spain, Greece, Argentina, Brazil, Chile, the Philippines, Poland, South Africa, Indonesia, and Ukraine. (Which isn't to say these were easy: We forget how difficult each of these transitions seemed at the time, and how fraught they were with dangers and uncertainties.) With an energized civil society and deep resources of youthful talent, creativity, and mobilizing skill, Egypt has a real chance to get to democracy in the next few years. But doing so will require a keen analysis of the numerous potential traps that could sandbag the process.

The first trap is the Machiavellian opaqueness of the aging generals who are now running the country. Beginning with the Defense Minister (and now junta leader) Mohamed Tantawi, until a few days ago a close ally of the deposed President Mubarak, Egypt's new military rulers cannot be trusted to structure the political process and emergent rules in a way that will favor genuine democracy. Their principal goal, it appears, is to preserve as much of the old order as possible-Mubarakism without Mubarak (the father or the son). This means another round of the old shell game of Arab regimes-what Daniel Brumberg has called "liberalized autocracy." The process of liberalization-which runs in cycles, and which countries like Morocco and Jordan have seen many iterations of-institutes just enough change in the rules and faces to give the appearance of movement toward democracy without any of the dangers (for the ruling elite). But the changes, imposed from above, stop well short of the sweeping institutional transformations that would open wide the political arena (and the functioning of government) while leveling the playing field.

In their initial "communiqués," Egypt's ruling generals show signs of treading down this duplicitous path. Their initial choices have evinced the seductive veneer of democratic change but the closure and control of authoritarian continuity. To begin with, there appears so far to be little consultation with democratic forces in determining the character and pace of transition. Despite opposition demands, emergency rule remains in place, and so do many political prisoners. The military's initial decisions have been unilateral and preemptory. We learn there will be a constitution drafted within two months, followed by a referendum. A respected retired judge will head the process. This will produce "amendments" to the now-suspended authoritarian constitution. But what will be the role for Egyptian opposition and civil society in this process? What will be the scope down the road to draft a completely new, more democratic and legitimate constitution with broad popular participation and support? Will the president to be elected later this year serve another imperial six-year term, or be a caretaker heading a neutral government until a new constitution can be adopted and fresh elections held? At this point, if anyone knows the answers to these questions, it is only the junta.

The military is talking about early presidential and legislative elections, within six months. What could be more democratic than that? But, in fact, after the fall of a longstanding autocracy, it typically takes a lot longer than six months to organize competitive, free, and fair elections. Think of the steps. A neutral and independent electoral administration must be established. This requires not just legal authorization but also new leadership, and recruitment, training, funding, and deployment of new staff and equipment. If Egypt's generals intend to have elections administered by the same Ministry of Interior that shamelessly rigged the vote for Mubarak and his ruling National Democratic Party (NDP), that will be a sure sign that they do not intend to deliver democracy-or are too incompetent and cavalier to care. Then, the next step must be to produce a new register of voters. Experts believe only a quarter of eligible Egyptians are registered to vote today. The exclusion was very useful to perpetuating autocracy but could be deadly for an emerging democracy. That will take months, money, and far-reaching organization to do even reasonably well.

It will be one thing to elect a new president and quite another to choose a new parliament in Egypt's transitional flux. The military now suggests the two elections can be held together within six months. But they will have very different logics and requirements. A presidential election will be much simpler. The old order will no doubt throw up a somewhat more palatable face, perhaps the former Foreign Minister Amr Moussa. The democratic opposition may well rally behind a single candidate (though the regime, no longer able to exclude a democratic alternative, will probably try to fragment the field with as many opposition candidates as possible). Still, voters will be faced with a few principal choices for national leadership, and it won't matter where people vote, so long as they are of voting age and only vote once. This kind of election can be done more roughly and quickly, tossing aside the voter register and just dipping every forefinger in indelible ink after it has marked a ballot for one presidential candidate or another. It will be important in this election-and every future one-to ensure transparency and citizen monitoring of the vote, as well as to have Egypt's judiciary oversee the balloting (as it did in previous elections until the judges got too good at it and Mubarak cut them out). But, otherwise, a presidential election won't be a complicated affair.

By contrast, new parliamentary elections present formidable challenges. First, Egyptians (and hopefully not just the military) must decide what electoral system will be used. This choice can invoke arcane debate, but it may be one of the most important that Egypt makes in pursuit of democracy. If the electoral rules are "majoritarian," in that they make it hard for small minorities to get elected, they will work to the disadvantage of not just small ideological tendencies but also the welter of new, emerging parties and political forces-many of them liberal and secular-that will just be taking shape and starting to test their strength. This will inflate the strength of the only two political forces that now have effective political organizations on the ground-the old ruling party and the Muslim Brotherhood (with a smattering of some of the other older opposition parties). If Egypt retains the current electoral system of two-member districts (with each voter getting two votes), these two established political forces could sweep most of the seats between them, marginalizing the moderates, polarizing the parliament and political system, and dooming democracy from the start. Creating a liberal center in democratic politics requires more than moral and technical support for these parties to function; it also requires rules that enable them to get traction.

A much better-and fairer-alternative would be to elect the new parliament using some form of proportional representation, so that parties would win seats roughly in proportion to their vote shares. That way, new parties could begin to gain a foothold in the political process. Perhaps ironically, the best way to do this might be the way Iraq now does, by using the existing governorates (29 in Egypt) as multimember districts, and having each district then elect a share of seats equivalent to its share of the population. This would allow for very proportional results, with districts generally containing ten to 25 seats, while still enabling some accountability and candidate familiarity at the local level.

A truly democratic parliamentary election in Egypt cannot be pulled off in six months. In fact, it might require well over a year to prepare. But the alternative would be to rush to a vote with a flawed system that would leave Egypt's new democratic forces on the margins not just of legislating but of constitution-making as well.

How a new permanent constitution will be drafted-if it is even intended by the military-also remains a mystery at this point. The worst option would be to have a closed and hurried process dominated from above by the military. But that seems to be what the junta intends for the transitional period. Successful democratic transitions either use an expert but broadly representative constitutional drafting commission, and then a popular referendum to confirm the draft, or an elected constitutional assembly (often acting simultaneously as a parliament), possibly followed also by a popular referendum (as in Iraq). Some have used all of these methods combined. Experience of recent decades underscores the importance for future democratic legitimacy and stability of eliciting extensive public dialogue and broad popular participation in the constitution-making process, with adequate preparation and civic education and widespread media exposure, as in South Africa. A thorough, inclusive, and deliberate process of constitutional drafting and debate can also help to breed a more democratic culture at both the elite and mass levels. A rushed and closed process perpetuates authoritarian mentalities (and, often, authoritarian rules as well).

Prior to all of this is the most basic question of who writes the rules, the timetable, and the mode of transition. Egypt has now entered a classic transition game where the authoritarian regime and the democratic opposition have sharply different interests and little basis for cooperation and trust. As an institution, Egypt's military may not be hated the way Mubarak and his cronies were, but many of the generals were Mubarak's cronies. And the military's core interests are not freedom and democracy for the people, but preserving their own power, wealth, privilege, and impunity. The core lesson of numerous prior transitions is the need for a negotiated way out of this potentially fatal impasse. Democrats want democracy with no guarantees to autocrats. Autocrats want guarantees, with no real democracy.

There is an obvious generic compromise, and every successful negotiated transition-from Spain and Brazil to Poland, South Africa, and Indonesia-has settled on a version of it. The old order gets to hang on to most of its wealth and privilege, along with military autonomy at least for a time. Few, if any, henchmen of the old order are prosecuted for their past crimes, unless it is for the last, desperate excesses of a few diehards trying to hang on during the transition. Real accountability waits for a later day. Democrats get democracy. Autocrats (mostly) retain their wealth and influence, but they cannot bid for power unless they play the democratic game. The Yale political scientist Robert Dahl coined a term for this type of bargain. He called it "mutual security." From the Spanish transition on, the generic bargain became known as a political pact.

Only a negotiated pact between Egypt's surviving authoritarian regime and its emergent democratic forces can steer the transition through the current treacherous straits to calmer and freer waters. For that to happen, Egypt's disparate democratic forces must unify in a broad negotiating front that unites the "outside" opposition of the youthful movements with the "inside" opposition of the "wise persons" and established parties who have so far dominated, on an ad hoc basis, the discussions with the old order.

Opposition unity will give Egypt's democrats strategic leverage; if negotiations stall due to regime intransigence, then the unified opposition can more credibly threaten to turn out people by the millions again in protest. But, if negotiations move forward to ensure the essential conditions for a democratic transition-an end to emergency rule; freedom of organization, expression, and assembly; judicial independence; and new and fair electoral administration-then a unified opposition can guarantee social peace and political stability. Opposition coherence enables clear negotiating priorities to level the playing field and ensure a democratic transition. It will also give the old order a clear set of interlocutors who can credibly commit to deliver popular support behind a difficult compromise agreement. No condition is more important for a successful transition.

The role for the United States and other international actors is not to dictate terms for the transition or structures for the new political order. That is not our place, and Egyptians of every political stripe will resent it. But international actors should offer training to political parties and technical and financial assistance to the new civil society organizations and state institutions needed to make democracy work. For the United States., this will mean millions of dollars in new assistance for democracy in Egypt-but that is a trifle compared to the $68 billion we have invested in dictatorship (even if it was to buy peace). No less importantly, other democracies (including leaders of recent democratic transitions) can encourage Egypt's opposition groups to coalesce and share lessons of the strategies and choices that have led to democratic outcomes. And the Obama administration can make it clear to Egypt's military rulers that nothing less than a real transition to democracy-with broad consultation, serious negotiations, and a new climate of freedom-will return Egypt to stability and a lasting partnership with the United States.

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Elias Muhanna is a PhD candidate in Near Eastern Languages & Civilizations at Harvard University and the author of QifaNabki.com, a blog devoted to Lebanese political affairs. He has written extensively on contemporary cultural and political affairs in the Middle East for several general-interest publications, including The Nation, Foreign Policy, The Guardian, The National, Mideast Monitor, World Politics Review, Bidoun, and Transition, and is regularly quoted in media outlets such as The New York Times, The Washington Post, The Financial Times, The Los Angeles Times, National Public Radio, The Christian Science Monitor, Slate, and Al-Jazeera International.

Encina Ground Floor Conference Room

Elias Muhanna Author of Lebanese political blog qifanabki.com Speaker
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An equilibrium search model of the Malawian HIV/AIDS epidemic is presented. Individuals engage in di¤erent types of sexual activity, which vary in their riskiness. When choosing a sexual activity, such as short-term sex without a condom, a person rationally considers its risk. A simulated version of the model is parameterized to match some salient facts about the Malawian epidemic. Some topical policies (e.g., male circumcision, treatment of other STDs, and promoting marriage) are studied and found to have potential to back…re: Moderate interventions may actually increase the prevalence of HIV/AIDS, due to shifts in human behavior and equilibrium e¤ects.

Assistant Professor Michele Tertilt is one of three Stanford scholars awarded a two-year Sloan Research Fellowship.  The Sloan Research Fellowships support the work of exceptional young researchers early in their academic careers.  Michele's research focuses on  family economics, consumer credit, growth and development, and demography.  The Economics department congratulates Michele on the prestigious fellowship.

Encina Ground Floor Conference Room

Michele Tertilt Assistant Professor Speaker the Department of Economics, Stanford University
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Michael Watts, PhD, is a Professor of Geography at the University of California at Berkeley. His interests include the political economy and ecology in Africa and South Asia, US agriculture, and Islamic social movements. Less specifically, Watts is also interested in development, peasant societies, and social and cultural theory.

His recent publications include Afflicted Powers, 2005 and Liberation Ecologies: Environment, Development, Social Movements, 2004, as well as many journal articles and invited papers.

Ed Kashi, is a photojournalist, filmmaker and educator dedicated to documenting the social and political issues that define our times. A sensitive eye and an intimate relationship to his subjects are the signatures of his work.

Kashi’s images have been published and exhibited worldwide. His innovative approach to photography and filmmaking produced the Iraqi Kurdistan Flipbook. Using stills in a moving image format, this creative and thoughtprovoking form of visual storytelling has been shown in many film festivals and as part of a series of exhibitions on the Iraq War at The George Eastman House. Also, an eight-year personal project completed in 2003, Aging in America: The Years Ahead, created a traveling exhibition, an award-winning documentary film, a website and a book which was named one of the best photo books of 2003 by American Photo. Along with numerous awards, including honors from Pictures of the Year International, World Press Foundation, Communication Arts and American Photography, Kashi’s editorial assignments and personal projects have generated four books. In 2008, his latest books will be published; Curse of the Black Gold: 50 Years of Oil in the Niger Delta and Three.

CO-SPONSORED BY CENTER FOR AFRICAN STUDIES

» http://www.powerhousebooks.com/blackgold.pdf
» http://www.curseoftheblackgoldbook.com/
» http://curseoftheblackgold.blogspot.com/

Oksenberg Conference Room

Michael J. Watts Professor of Geography Speaker University of California at Berkeley, co-sponsored by Center for African Studies
Ed Kashi Photo journalist, filmaker Speaker
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