ANALYSIS

THE QUAD: NEO-CONTAINMENT OF CHINA?

THE IDEA OF QUADRILATERAL COOPERATION OF THE U.S., JAPAN, INDIA AND AUSTRALIA DATES BACK TO 2007

BY TAMÁS MAGYARICS

Arguably the single most important question nowadays is the relationship between the United States and the People’s Republic of China. The U.S. was pursuing the ’two-China’ policy for decades in the Cold War; that is, recognizing the Republic of China (on Taiwan) as the legitimate representative of the Chinese people. Richard Nixon shifted this American approach to the Chinese with his historic trip to Beijing in February 1972, and, ultimately, Washington gave up its former policy and moved official diplomatic recognition from Taipei to Beijing. Mao Zedong’s death opened new opportunities for Communist China, and it embarked on the process of fast economic modernization – even if the political structure remained in place.

A growing economic power

After the collapse of the Soviet Union in 1991, China was increasingly becoming a sort of peer competitor for the U.S. – at least in the economic field. The rather aggressive economic expansion (One Belt One Road or Belt and Road Initiative) has recently been coupled with a dynamic expansion of the Chinese security agenda as well. The areas affected include the South China Sea, the East China Sea, and the Himalayas; the countries affected around these seas range from Vietnam through Indonesia to Japan, while the history of the border disputes and clashes with India go back to the early 1960s. Though Beijing’s official defense posture is basically defensive, it has been busy building a strong blue-water navy, and is having a vigorous missile technology program with offensive capabilities. At the same time, it is trying to make use its economic might as much as possible; China is Australia’s and India’s largest trading partner, while Chinese trade is representing a fifth of Japan’s total trade. And Beijing is not squeamish about using its economic might as a political weapon either.

Playing by selective rules

The U. S. tried different strategies to coopt China into the liberal world order which it has been keen on establishing since the conclusion of World War II. Thus, it facilitated China’s accession to the World Trade Organization hoping that Beijing would play by its rules. However, it seems that China has taken advantage of the rules from which it benefits, while ignoring those – including the ban of dumping, excessive government subsidies, market distortion techniques, currency manipulation and the like – which may slow down its economic development and make China less competitive on the world market. Strategically, the bilateral relationship has been characterized, in turn, as strategic partnership or strategic competition.

Balancing the Chinese challenge

The countries concerned with the rapid rise of China as an economic (and, to some extent, a military) superpower endeavored to find a regional framework for balancing the Chinese challenge. Several different ideas were floated; one of these was the Quadrilateral Security Dialogue (Quadrilateral Initiative) between the U.S., Japan, India, and Australia by then Japanese Prime Minister Shinzo Abe in December 2007. The Obama administration also sensed the potential threat to U.S. positions in the Asia-Pacific region with its ’pivot/rebalancing to Asia’, which had an economic dimension in the first place (in the form of the stillborn Trans-Pacific Partnership, TPP), but its security implications were also quite obvious. The members of the Quad met five times between 2007 and 2019 on ministerial level. In reality, none of the members was too keen on taking on China very forcefully – to a large extent because of the economic interdependence mentioned above. A certain new life was breathed into the informal groupings by the Trump administration when Secretary of State Mike Pompeo raised the idea of transforming the Quad into a kind of Asian NATO – which, by the way, does not have any real chance because of the diverging regional interests of Australia, India, and Japan.

Reviving a multilateral approach

The idea of working through and with the Quad is one of the major issues that have been taken over by the Biden administration. Presidential candidate Biden repeatedly criticized Donald Trump for neglecting multilateral approach to major outstanding questions in the world – among others, the future of the U.S.-China relations and, by extension, that of the AsiaPacific or Indo-Pacific region. The Biden administration’s own ’rebalancing to Asia’ is demonstrated by the meeting of the Quad members on February 18, 2021 in which they agreed to strongly oppose any attempt by China to change the status quo in the IndoPacific region by force. Then, on March 12, the first (virtual) summit took place of the Quad members, where a number of working groups were set up – in the ’soft’ areas of climate change, vaccine experts, and critical and emerging technologies. The participants also warned of the dangers of great power rivalry, massive military investments, social inequality, and territorial disputes – in fact, ’code words’ for challenges emanating primarily from China.

Undeclared neo-containment

The Biden administration has another incentive to keep this undeclared neo-containment policy towards China on the agenda. There are very few things in which the great majority of the Democrats and the Republicans in the U.S. agree; being tough with the Chinese is one of them. They share this common strategy; what difference is between them in this question is tactical. Donald Trump preferred bilateral relations over multilateral ones; President Biden, most probably correctly, believes that the U.S. is able to handle the challenges posed by a rising and ever more aggressive China in a multilateral framework most successfully. It does not seem to be enough for the U.S. to rely on the other three partners in the Quad in this endeavor; Washington should also counterbalance the massive Chinese investments in the economies of the countries in the Asia/Indo-Pacific region and, among others, should reconsider the establishment of a regional free-trade bloc instead of the aborted TPP to lure countries away from the China-led Regional Comprehensive Economic Partnership (RCEP). In fact, hard- and soft-balancing China would require a close relationship between the U.S. and the EU too besides working closely with Washington’s regional partners.

private healthcare

FOR A HEALTHY PARTNERSHIP

ASSOCIATION CALLS FOR PRIVATE HEALTHCARE INSURANCE AND MORE PUBLIC-PRIVATE COOPERATION

The PRIMUS Private Healthcare Providers Association was established in March 2017 by twelve key members of the domestic private healthcare sector with the intention of promoting the emergence of an ethically functioning, private healthcare sector that fully complies with patient safety requirements.

BY SÁNDOR LACZKÓ

“When PRIMUS was established, our primary objectives were to clean up the sector,” the Association’s President György Leitner recalls to Diplomacy&Trade. “The big players formulating PRIMUS realized that there was an ‘uneven battlefield’ and set the objective of encouraging others to play by the regulations. They established a kind of certification process in which the operation of these companies is closely monitored (e.g. by surprise visits or audits) by third party firms, it is examined how patient-orientated they are, what service quality and professionalism they provide,” he adds. While witnessing major changes in Hungarian healthcare, György Leitner believes it is important that the Association have a say in these matters and they can express their views, for instance, on how state provision and private care should supplement each other “because we believe there is synergy between these two rather than competition. We have already expressed our opinion on new taxation rules, like the changes this January in the KATA taxation, which influences our relationship with our contracted doctors very negatively.”

A changing private sector

The private healthcare sector provides for about 50% of the outpatient care in Hungary. Approaching this issue from the patients’ point of view, the President points out that more than 60% of the patients have visited private healthcare providers in

private healthcare

the past two years. So, it is quite a widespread phenomenon, unlike 10-15 years ago when these kinds of services were the privilege of the rich – nowadays it is for ordinary people also. “In terms of money, we are talking about HUF 400-420 billion on an annual basis. It is a very fragmented sector: there are thousands of smaller or bigger providers and 60% of this turnover is generated by small ‘apartment clinics’ where there is only a single practice like gynecology or dermatology. In the past couple of years, there have been major developments with a lot of bigger providers emerging. These companies are now controlling roughly 25% of the total market. Over the next five years, we can expect a much more balanced private healthcare sector. There has also been a major change in terms of what services are provided. We all remember that 15-20 years ago, it was primarily gynecology, dentistry, dermatology and also some beauty care, including plastic surgery, provided by the private actors. The situation is not like that anymore. In the past ten years, basically all sorts of outpatient specialists like diagnostic imaging have appeared on the scene. Moreover, it is not only outpatient care but also inpatient services, like one day surgery or even more complicated types of even oncology or orthopedic surgery, are provided by the private sector, so, now it is more widespread and more integrated vertically,” he highlights.

More changes needed

Statistical data show that the Hungarian government is spending less and less of the country’s GDP on public healthcare. As to how much and in what areas private healthcare service providers can take advantage of this underfinancing, the PRIMUS President says that “yes, indeed, this state spending is one of the lowest proportions in the European Union, with below 5% of the GDP. Another 2-2.5% is spent privately, which is not so healthy from the point of view of accessing services. In the past years, especially since this January, there have been some changes in terms of salary increases for nurses and doctors – something that I think should be further increased. On the other hand, how Hungarians are spending their money on private healthcare is unhealthy as well because it is on an out-of-pocket basis and not on a sort of insurance basis where you pay a monthly fee and thus save for the time when you are really in need of services from a private healthcare provider.”

In need of private health insurance

As György Leitner notes, private health insurance in Hungary is in an embryonic stage. “All in all, the private Hungarian health insurance market is pretty small compared to the size of the country. Only corporate private insurance has achieved a certain level, so, it would be very much needed and required that a more mature individual private health insurance market emerges. There would be several criteria for that: first of all, there should be incentives by the state with tax holiday, for instance, for those who engage in private health insurance. There should also be developments from the supply side, although, it is a chicken or egg story: the medical service sector should also catch up, create a countrywide coverage and a nationwide product for private individuals. I hope that those in government will realize that this would be great supplement in terms of funding of the entire healthcare system in this country,” he explains.

The impact of the pandemic

“Many of the bigger actors in this sector play a part in providing healthcare for the public during the pandemic, including my company Affidea, a diagnostic imaging company, providing publicly financed services in several hospitals. We are basically operating under pandemic conditions in these institutions, so we take our share in this regard. The other element is how much burden we can take off the shoulders of the public health system during this unfortunate situation when patients are in need of care other than COVID-19. It is natural and understandable and the private sector offers its help and support to the state care system, sharing some of the burden by offering personnel and infrastructure,” György Leitner stresses.

Public-private partnership

Last November, it was raised at a healthcare conference in Budapest that there is an urgent need to rethink the role of private healthcare providers and the framework for their cooperation with the public health system. The PRIMUS President is of the view that there is certainly a willingness on the part of the government to have a clearer situation concerning a more transparent provision of public and private healthcare services. “However, there definitely are some areas where they mix. It happens when a doctor is taking his or her private patients into the public system and uses public infrastructure for the benefit of his or her own. That is not good. New regulations try to target and ban such activities. This is very positive. Another, more difficult area is when big private care companies are providing – and have provided for decades – services like diagnostic imaging, an accredited laboratory or dialysis, partnering with the state healthcare system on the basis of transparent regulations on prices set by the state. I do think that in these examples, this is a very positive and progressive partnership that we are hoping to maintain and even develop further.”

private healthcare

Located in the heart of Budapest, in one of the most modern buildings in the city center with spacious interior, roof terrace and an elegant office environment, the Dr. Rose Private Hospital provides high standard services for its patients, standing out from among other private healthcare service providers in many areas since the beginning.

Investments for better care

HEALING BODY AND SOUL

BUDAPEST’S OLDEST PRIVATE HOSPITAL CONSTANTLY DEVELOPS SERVICES AND PATIENTS’ CARE

The Dr. Rose Private Hospital in the Hungarian capital dates back to almost one and a half decades. As Managing Director Dr. Kornél Papik explains to Diplomacy&Trade, the hospital was founded in 2007 with the aim of providing a unique experience for well-to-do Hungarian and foreign patients living in Budapest, in addition to reliable, high-quality healthcare services. The choice of location, Széchenyi Square, with a panoramic view of the Chain Bridge and the River Danube, already served this purpose, but the exclusive interior design solutions, the spacious interior, the modern equipment, the service provided for the patients and the employment of renowned doctors together created the premium quality. “Over the years, the standard has not changed, but we have expanded our services according to the needs of our patients. The institution, which initially provided outpatient care, opened its inpatient department more than ten years ago, where more than 10,000 medical interventions have now been performed. In the three operating rooms and the 28-bed inpatient ward, patients undergo plastic surgery, orthopedics, obstetrics-gynecology and surgery interventions. We are proud of our obstetrics department, where all the conditions are in place for a safe, peaceful birth and for spending the first days together in our family apartments. The more complicated interventions are no problem, either, the excellent specialists working here perform surgeries from orthopedic endoprosthetic surgeries to breast reconstruction or colon surgery thanks to the 7/24 hour on-call system and the high-level equipment.” He emphasizes that the demand for inpatient and hospital surgical care is constantly growing in all fields, especially in orthopedics, general and plastic surgery, obstetrics and gynecology. “In 2020, the Dr. Rose Private Hospital performed nearly 2,000 major surgeries, which is outstanding in private healthcare,” he adds.

For all ages

The institution has a strong pediatric department but that is not the only reason Dr. Rose is called the family hospital. Obstetrics and gynecology are traditionally important divisions here but they can also provide 14 specialized pediatric care, and for patients in adult medical care, they have a team of specialists in all fields supported by highquality equipment. There is actually a family in which all members have been cared for at Dr. Rose for ten years, so, generations are healing with this institution from babies to grandparents, the Managing Director says, adding that they have an annual fee for such constructions. “Dr. Rose created a market 14 years ago, and now, there are several private hospitals here. We have strong competitors, which also inspires us to continuously improve.” In addition to the best professional conditions, the unique experience, the environment and the attention ensure that the soul also heals, providing the feeling that every detail is taken care of at Dr. Rose. Personality and professionalism are important so that all patients feel a priority. This is complemented by unique customer service, an experience-friendly, premium environment and transparency.

COVID-19 safety

As to how much, and in what way, the current epidemic has affected daily patient care at the Dr. Rose Private Hospital, Dr. Papik points out that “the COVID-19 epidemic is a constant challenge for all healthcare providers, including us. Epidemic care, such as testing, and routine patient care are very difficult to perform safely in parallel. Enhanced safety standards are mandatory throughout the hospital. To isolate those arriving for testing, we established a COVID-19 screening center completely detached from the hospital, where all known testing methods are available, from officially priced PCR testing to rapid antigen testing and antibody level determination. We work with laboratories that have the necessary accreditation and produce the fastest results. Our quick tests come from American and European manufacturers. Negative test results are sent to our patients on weekends immediately upon receipt, and positive results are reported by a doctor in each case so that further action can be discussed and taken. In our hospital, screening is mandatory before all surgeries and other interventions, even examinations with increased exhalation. Our patients are continuously tested and almost all of our staff have now been vaccinated. With these measures, we managed to achieve that although we find many positive cases during the screenings, no infected patient was admitted to the hospital.” Another impact of the new coronavirus epidemic was that it steered patients towards the private health sector. Unsurprisingly, private service providers responded quickly to new customer needs, offered new services, and began improvements. Dr. Papik says that after the first wave of COVID-19, there was a clear increase in the number of patients and the growth has continued ever since as it has become very important for patients to have quick access to safety and full service. He adds that they responded to the needs by increasing their supply capacity, further expanding the range of professions available and developing new products, including the investigation and treatment of post-COVID patients in both adult and pediatric patients.

Many private healthcare providers are looking to the future positively and are making further investments in the post-epidemic period to provide high-quality, comfortable and quickly accessible care to be able to retain their clients and attract more in this multi-player market. As the Managing Director stresses, the Dr. Rose Private Hospital is now available to a wider audience and their prices are in line with those of leading private care providers. They are constantly adapting to emerging needs and place great emphasis on development. “We believe that if our customers are satisfied, we should not be afraid of competitors,” he says, adding that in 2021, an investment worth more than HUF 600 million have been made, the institution having been expanded with additional wards and operating rooms, the obstetrics department have been rebuilt and the client rooms have also been increased. The hospital is constantly adapting to emerging needs and place great emphasis on development. "Medical device investments affect almost all professions. For patient safety and increased sterility, we have purchased a new plasma sterilizer and a UVC disinfector, which is also effective against the new coronavirus. In addition to operating rooms, the rooms are disinfected before receiving each patient. The radiology department has been expanded with new digital X-ray equipment and the latest state-of-the-art mammography available today. We place great emphasis on obstetric and neonatological care: our new ultrasound equipment supports diagnostics, while the integrated neonatological equipment supports the care of newborns,” he highlights, adding that their philosophy is based on premium care: services are provided in a way that adapts to the needs of the patient, without waiting, in a discreet manner – that will continue to receive special attention this year at Dr. Rose Private Hospital.

private healthcare

A REFERENCE HUB IN GASTROENTEROLOGY

The Affidea Gastroenterology Center in downtown Budapest awaits patients with the continent’s most modern diagnostic equipment, the excellence of the national gastroenterology profession – trained experts with many years of experience – and a pleasant environment.

The number of newly discovered cancers dropped significantly in 2020 since the start of the pandemic, presumably due to the late and delayed conduct of various cancer screenings and other routine health examinations. One of those highly-trained professionals at Affidea Gastroenterology Center, Dr. Richárd Schwab tells Diplomacy&Trade that “we cannot really talk about capacity decrease. For quite a long time – it was a ministerial decree in Hungary (as in many other countries) that only emergency medical procedures were allowed. It means that preemptive screening examinations for patients without complaints were not allowed. To put it simply: this has been the case over the past 12-13 months. Postponing tests due to the pandemic, a worldwide tendency, is likely to increase cancer cases both in the number of patients and in the severity and frequency of the cases, unfortunately. The healthcare system was forced to postpone examinations but this also coincided with the perceptions of the population as nobody wanted to get into a hospital or even have a test if it was not something urgent. As a result, we encounter more and more neglected cases, patients who apply for tests because of long-standing health complaints.” A reference hub of HD quality

The Affidea Gastroenterology Center awaits patients with Europe’s most modern GI endoscopy equipment. As Dr. Schwab explains, it is the Central European reference hub for the world renowned and most prestigious GI endoscopic equipment manufacturer, Olympus. “All in all, I can say that all the pieces of equipment at the Affidea Gastroenterology Center is of the latest technology available not only concerning endoscopy but also patient logistics, the service environment, making available a high level of treatment and service. For instance, it is unique in Hungary that all tests are recorded in HD quality and all patients receive the entire video material. It is important for later direct comparisons, 2nd opinions, referrals. HD recording is also important from the quality control perspective. So, it was a constructive step from Affidea partner EndoExpert Ltd., a Group Practice of Gastroenterologists, who brought all this expertise, international experience and combined with the solid capital strengths and market access of Affidea.” He adds that although the pandemic also puts limitations on this activity but the cooperation with Olympus is intended to extend to a preceptorship program for training gastroenterologists on how a properly equipped private healthcare service center should look like and organized as a business. Everything is according to strict standards starting from the arrival experience to the quality of beds and patient comfort to the highest level of patient safety during the exams. This center is the first in the country to use ‘Scope Guide’ in the routine setting, a 3D-Image-Navigation System providing real-time 3D image of the position and configuration of the endoscope inside the colon. Navigation through the colon becomes easier and patients experience less discomfort as loops can be identified more quickly. Appeasing the nervousness about testing

By nature, many of the gastroenterology examinations are (or are believed to be) uncomfortable and/or painful. As to what is done, what new technologies are used to appease the nervousness of the patients, the doctor highlights that these beliefs may come from experience in the past. It is now for at least ten years that examinations in anesthesia have become widespread practice. “We also do some 90% of the diagnostic tests in propofol anesthesia, same standards as anywhere of the highest ranking centers of excellence globally.”

Experienced professional staff

Doctors working at the Center have extensive international experience, which adds to the quality of work and to the comfort of the patient. According to Dr. Schwab, the fact that Europe has become such an open space in the past twenty years has greatly improved the level of professional experience of physicians. “There are more and more doctors who had the opportunity to take part in post-gradual trainings and work abroad. In addition, in today’s online world, trainings have become so simple. Language proficiency is another important factor as those who have spent years abroad working or graduated in a foreign country will express themselves in a given language with much more confidence.” Citing his own example, Dr. Schwab says it basically does not matter for him if needs to speak to a patient in English, German or Hungarian. He himself had part of his medical training at the Universities of Vienna, London and later had work experience in Basel, Switzerland and received his MBA degree at a joint program of CEU and Purdue University in the United States.

Do not miss your check-up!

Many future illnesses are not symptomatic in the early years, and the question also arises that despite the difficult situation due to the pandemic, what tests are the ones that should definitely be carried out. When someone had cancer of the GI tract in the past, regular follow-up exams cannot and should not be postponed. Same applies for advanced benign tumors that need thorough and regular check-ups, or for inflammatory bowel diseases (IBD), Dr Schwab says, giving a list of the most important examples. “We have recently had a patient who has had minimal invasive surgical procedures multiple times in the past ten years due to recurrent advanced rectal polyps. She was supposed to show up for the next control examination last December but she postponed it due to the pandemic. I managed to convince her to come and it really paid off: we have indeed found new polyps of advanced stage. It is very important that check-ups in such cases should not be put off – it is not worth the risk!”