Since the period of rapid development in the People’s Republic of China (PRC) after the reforms initiated by Deng Xiaoping in the late 1970s, the world is experiencing a new wave of Chinese migration. Loosely defined as Chinese people who are outside of China to conduct business, work, study or join their family overseas, these new Chinese migrants—also known as xin yimin 新移民—have had a profound impact on their host countries. Their influence on local societies, economies and politics has been complicated by Beijing’s dynamic policy towards the Chinese overseas in general and towards the xin yimin in particular.

Before we proceed further, it is important for us to put Chinese migrants in a proper historical context.

A Brief Outline of Chinese Migration

The earliest contact between China and Southeast Asia can be traced back to the Han dynasty. However, significant migration to this region started during the Song dynasty of the twelfth century. The first period was from the Song dynasty in the twelfth century until the first half of the sixteenth century of the Ming dynasty. It lasted for about 400 years. During this period, the feudal economy in China was at its peak and the number of Chinese abroad also increased. This coincided with the period that Admiral Zheng He (Cheng Ho 郑和) embarked upon his seven expeditions to the West Ocean (later known as Nanyang 南洋). Groups of Chinese merchants and sailors ventured overseas and some of them remained in various sites from their voyages. Those who stayed long married local women; the number of the Chinese overseas in Southeast Asia during this period was between 150,000 and 200,000.

The second period started in the second half of the sixteenth century when there was a sea embargo for the ethnic Chinese until the eruption of the Opium Wars. This period lasted about 300 years. During this period, China experienced the rise of capitalistic elements, and the West began to colonize Southeast Asia. More Chinese left China for Southeast Asia. According to one study, there were about a million Chinese in Southeast Asia.

The Chinese language has become one of the most attractive foreign languages—it ranks only second to English in Cambodia. The demand for the Chinese language is driven by the influx of Chinese tourists and investments, especially after 2010 when Cambodia and China signed their comprehensive strategic partnership. China has invested a significant amount of resources in promoting the Chinese language in Cambodia, especially under the cooperation framework of the Confucius Institute, intending to enhance people-to-people ties and project a positive image of China. The Chinese language has become a critical source of China’s public diplomacy and soft power projection.

This chapter discusses the supply and demand of the Chinese language in Cambodia and the relationship between language education and acquisition with the political and social values of the learners. The chapter seeks to understand how language education and acquisition affect Cambodian learners’ perception of China. The research does not aim to provide a comprehensive Cambodian perception towards China—it only targets those who learn the Chinese language. There are two assumptions here. First, there is a relationship between the acquisition of the Chinese language and the learners’ perception of China. Second, the learners play an important role in promoting bilateral ties, especially under social and cultural cooperation. The chapter has three main parts: supply-side analysis, demand-side analysis and learners’ perception analysis.

Research Method

The study uses a mixed research method and data collection to understand the perception of Cambodian learners of the Chinese language towards China, including desk review, semi-structured interviews and an online survey. The online questionnaire includes questions relating to learners’ perceptions of the New Chinese, Chinese investments, the Chinese government, and China in general. The semi-structured interviews also focus on the informants’ perception of these issues. The informants are also Chinese language learners, but they did not participate in the online survey. The online survey and interviews were administered from 1 November 2020 to 10 December 2020.

Concerning the online survey, 250 online questionnaires were sent out to Chinese learners in Cambodia using the snowballing approach. As a result, 87 survey responses were collected.

On 7 April 2010, the Lao government signed an agreement with China that sets out the financing and the construction of a high-speed railway line (420 km) linking the capital Vientiane to southwestern China. The construction was initially set to commence on 25 April 2011 to celebrate the fiftieth anniversary of diplomatic relations between China and Laos. However, the project was postponed after the corruption scandal that led to the removal of China’s Minister of Railways in February 2011. Afterwards, the Chinese construction companies pulled out of the venture fearing the rail link would not generate enough profit. After several years of numerous setbacks and rumours of cancellation, the construction of the controversial China–Laos railway was officially launched on 25 December 2016, but labour issues and compensation for people displaced still linger (Radio Free Asia 2017). The railway is valued at US$6 billion, and is expected to be completed within five years. China holds a 70 per cent stake in the rail project, while Laos holds the remaining 30 per cent.

Should this megaproject materialize, China would be fully connected to Southeast Asia, from Beijing to Singapore. The rail project is part of the Belt and Road Initiative, which aims to develop infrastructure networks across the ancient Silk Road trading routes. It would join the multiples lines of communication that have been built by China over the past few years. The navigation on the Mekong River and the North–South Economic Corridor (NSEC) seemed unrealistic just a decade ago, given the very difficult terrain of this region. These Herculean works are rather emblematic as the Chinese are on track to achieve the mise en valeur of Laos that the French only dreamed of during their colonial rule but failed to implement (Stuart-Fox 1995).

French interest in Indochina was mainly to gain access to the Chinese market to the detriment of the British. That was why building railways and a water road along the Mekong River was crucial to the colonial government. A century later, the same scenario is being replayed, but this time the Chinese have become the dominant players, and they are considering the Greater Mekong Subregion (GMS) as the centrepiece of their “charm offensive” (Kurlantzick 2007, p. 10) in Southeast Asia.

Xin yimin (新移民), or new Chinese migrants, have continued to be a hot topic for discussion for the last three decades. In fact, it is now often difficult to distinguish which group of Chinese migrants and what period of entry can be considered xin yimin. This large-scale migration of the Chinese started in the early 1980s after China’s opening up when opportunities to study abroad, travel, do business overseas, and join families became more prevalent. In Southeast Asia, xin yimin refers to those who came in during the new millennium or the beginning of the twenty-first century. For the purposes of this chapter, I use the common practice in the Philippines to differentiate the laoqiao (老僑), jiuqiao (舊僑), xinqiao (新僑), and the xin yimin who are migrants who came in during the 1990s to date. I will focus on those who came to the Philippines in the new millennium, but particularly highlight new developments, issues and new organizations formed starting 2016, the beginning of President Rodrigo Duterte’s presidency.

Historically, there have been Chinese migrants to the Philippines since Spanish colonial rule. However, the contemporary influx of Chinese migrants into the Philippines started in the 1970s, especially after the establishment of Philippines diplomatic relations with China in 1975. It escalated in the 1980s with the market reforms instituted by Deng Xiaoping and the opening up of China to foreign markets. This influx increased even more considerably after President Duterte was elected in 2016.

The influx of new Chinese migrants to the Philippines for the last two decades has been contentious, and President Duterte’s pivot to China has brought the problem to the forefront. Philippines-China bilateral ties have reached new heights and brought an increase in investments and infrastructure development and other much welcome economic benefits, but have also triggered an escalation of anti-Chinese sentiments due to many factors, founded and unfounded.

One of the key challenges is the fact that seventy per cent of the newcomers in the work force are hired in POGOs (Philippine offshore gaming operations) or are employed in the online gambling and downstream businesses related to them.

The boatman perches precariously on one end of a long bamboo raft, his hands clutching the long pole that guides the raft to the opposite bank. A traveller hops gingerly from the bank on to the other end of the raft, his right arm stretched out by his side to balance the weight of a heavy suitcase in the other. Stabilized, the boatman pushes off from the edge with his pole, artfully drifting across the river eddies and edging carefully to the other bank. It is dry season, the river is barely thirty metres wide, and the currents are gentle. The traveller strolls from one end of the raft to the other, hands the boatman some money, and hops off at the other end. This crossing of an international boundary has taken all of forty seconds.

This river is the international border between Yunnan Province, China and Shan State of Myanmar. And this illicit crossing has taken place in full view of the official border bridge just 200 metres upstream. The Chinese banks of the river are filled with gravel and larger rocks, dumped here as part of ongoing construction to build up its embankments. On the other side, sits Myanmar, but not really. It is a place called Wa Region, territorially part of Myanmar, but almost completely de facto autonomous, governed by the United Wa State Army (UWSA), an Ethnic Armed Organization (EAO) at odds with the Myanmar military (Tatmadaw) and Myanmar state. A ceasefire signed in 1989 when the UWSA was formed has never been broken, and an uneasy truce has held for thirty years. There are no Myanmar government representatives on the border; movement is regulated by the Chinese state and the UWSA.

Dozens of crossing points like this exist along the China–Myanmar border, perhaps somewhat surprising for two states which so jealously guard their national sovereignty. But such crossings are the sustenance of the borderland economy integral to China’s ‘going out’ policy: it circumvents the bureaucratic hassle of passports and documents; it provides commercial opportunities and livelihoods for border crossers, and eases pressures on the Chinese labour market.

The character of immigration is often shaped by the conditions of departure. Why and how people leave their country, as well as the state of the country they leave behind, influence their attitudes and the relations they share with host societies. In the case of Southeast Asia, Chinese immigration over the centuries has been characterized by different levels of settlement and integration. There have generally been four waves of Chinese immigration into the region. The first wave saw scattered flows of Chinese merchants and traders between the tenth and fifteenth centuries into parts of Southeast Asia such as Sumatra, Cambodia and Campa, and later, Malacca from the fifteenth century. Many of these merchants and traders settled down to marry local women and integrated into local communities.

The second wave was triggered by conflict, wars, starvation, and corruption in the hinterland from the nineteenth century to 1949. This wave, also known as the “coolie pattern”, was made up of “large numbers of coolie labour, normally men of peasant origin, landless labourers and the urban poor” (Wang 1991, p. 8). During this wave, many migrants spread to different parts of the globe, including the United States, Canada, Latin America, Australia, Malaya and Indonesia, less as traders and merchants but more as indentured slaves and coolies to provide menial labour. Again, like the previous wave, many did not return to China but instead settled down in their destination countries and, in the case of Southeast Asia, to engage in the struggle to be recognized as members of newly formed nations. These waves of Chinese immigration came at a time when China was not the power it is today. Centuries of economic insulation and the ‘100 years of humiliation’ during which China was subjugated to Western powers, together with famines and war, had shaped the character of Chinese immigration and the way immigrants engaged and settled in host societies.

China’s 1978 open-door policy kick-started the third wave in Chinese immigration. Seen by some as the ‘New Chinese Migration’ (Wong 2012), this wave differed in scope and character from the previous two waves.

A Confucius Institute (CI), essentially, is a language school that teaches Mandarin (the standard form of modern Chinese) and operates outside China. It functions as a partnership between a Chinese university and a host university of the country (or administrative district) in which it operates. The former will provide teaching materials and instructors as well as an administrator known as the Chinese Director. Whereas the latter supports the running of the institute by providing infrastructure such as teaching facilities and local connections as well as an administrator known as the Foreign Director, who usually is a faculty of the host university and whose duty is to ensure the institute complies with the academic, administrative and fiscal statutes and regulations of the university.

The effort in establishing CIs worldwide was initiated by the government of the People’s Republic of China (PRC) to assist the international community to develop a capacity for teaching Chinese language and culture in their own nations, a facility which was very much non-existent or scarce in most of the countries in the world. In the early 2000s, the Chinese government set up a bureau called Hanyu Guoji Tuiguang Xiaozu Bangongshi (汉语国际推广小组办公室), or Office of Chinese Language Council International, to realize this initiative. This office, located in Beijing, was to become the central agency overseeing the CIs that had proliferated rapidly over the globe in the one and a half decades since 2004. It was more widely known by its acronym ‘Hanban’ (汉办), or the Confucius Institute Headquarters.

The first CI in the world was established in Seoul, the capital city of South Korea, in 2004. Ten years later, 475 CIs were operating in 126 countries. By 2018, the number had further increased to 548 CIs in 154 countries. The phenomenal growth of CIs, coupled with the rising economic power of China, however, is viewed by some as alarming. These institutes, entrusted with the primary duty of teaching Chinese language and culture, have come to be seen as a platform for the PRC to exercise its ‘soft power’.

On 7 January 2014, a bulldozer was sent by a Chinese firm—the Kings Romans Company, which runs the Golden Triangle Special Economic Zone—to clear land to construct an international airport in Ton Phueng district. An area of 236 hectares of rice fields had already been taken by the company from forty-one families, but the villagers refused to accept the offered compensation as it was well below market value. Though the original land dispute was not yet settled, Kings Romans demanded an additional 6 hectares of land to complete its construction. Refusing to comply with the perceived unfair deal, a group of farmers who had cultivated the area for several generations protested in front of the bulldozer, prompting the company to seek intervention from the Lao police. Policemen armed with AK-47 assault rifles were sent to enforce the order by Kings Romans, resulting in a stand-off between villagers and government officials. This was a rare protest by citizens against a developmental project in post-Socialist Laos.

The case of Ton Phueng is just one among many throughout the Lao PDR of local communities similarly affected by the government’s Special Economic Zones (SEZs), defined as the creation of large-scale zones of fenced-in industrial estates to attract foreign direct investments. Since the 2000s, Laos has followed its Chinese neighbour in creating SEZs to serve as a new economic engine where special economic policies and flexible governmental measures conducive for business can be implemented.

We would like to begin this chapter by recalling an important message related to maternal health as quoted by the United Nations Secretary-General during the High-Level Forum on Accelerating Millennium Development Goals (MDGs-5) on 24 September 2013. He quoted a statement from Professor Mahmoud Fathalla, an international campaigner for safe motherhood and a founder of the Safe Motherhood Initiative. The key message of this quote is that no one should be left behind in health matters, including women and mothers. Our main question is then ‘What about the progress of maternal health in Indonesia today?’.

This chapter attempts to answer that question by assessing how maternal health in Indonesia has changed over time and its potential trends in the future.

Maternal health commonly refers to the health of women during motherhood, starting from pregnancy, through to childbirth and the postnatal period. These are the most important stages during the parenthood experience. In actuality, maternal health starts when a woman enters adolescence, long before her motherhood period, and remains throughout a woman’s reproductive life and beyond menopause. Moreover, maternal health does not stand alone. It is influenced by many factors, including women’s living conditions, their early-age health status, as well as support from their family and partner. Therefore, maternal health–related issues should be a concern of societies at every level: micro (individual and family), meso (community) and macro (national and global).

At the macro level, maternal health has been a global priority as indicated in the United Nations MDGs (2000–2015) and subsequent Sustainable Development Goals (SDGs). Before then, the Safe Motherhood Initiative was introduced in 1987 at the Safe Motherhood Conference in Nairobi, Kenya (Sai and Measham 1992). Maternal health was covered in the fifth MDG, specifically a goal to ‘reduce maternal mortality by 75 percent by 2015’. Most recently, maternal health is covered in the third goal—ensure healthy lives and wellbeing for all—of the seventeen SDGs.

Since the fall of Suharto’s New Order in 1998, Indonesia’s political elite has made significant changes to Indonesian law affording greater recognition to the right to health (R2H). Between 1999 and 2002, the People’s Consultative Assembly amended the 1945 constitution to introduce new rights to ‘obtain health services’, ‘have a good and healthy living environment’, have access to social security and ‘develop oneself through the fulfilment of basic needs’. In accordance with these new rights, it also imposed a new obligation on the state to provide ‘health service facilities’ and declared that the state would develop a social security system for all people. In the midst of and following these amendments, the national parliament (DPR) enacted a number of laws that reaffirmed—and in some cases expanded upon—these rights and obligations (Rosser 2017: 6–7). These included Law No. 36/2009 on Health which stipulates, among other things, that the government has obligations to provide health services, ensure resources for the health sector, and try to realise the highest possible standard of health (Pūras 2018: 5).

These legal commitments have been accompanied by health policies and programs that have sought to promote R2H in various ways. As the United Nations’ (UN) special rapporteur on R2H, Dainius Pūras, noted in a 2018 report, the Indonesian government has ‘made considerable progress with regard to the realization of the right to health, particularly by expanding universal health coverage’. It has also promoted R2H by increasing health expenditure as a share of the government budget. However, many commentators have suggested that the government has stymied progress vis-à-vis R2H by failing to address discrimination and inequality in access to health services, improve the quality of health services, address the growing burden of non-communicable diseases, enhance access to clean water and sanitation, control addictive and harmful substances, ensure healthy environmental conditions, and— particularly since the onset of the COVID-19 pandemic in 2020—ensure the country is protected from emerging infectious diseases.

The purpose of this chapter is to shed light on the reasons for this outcome and the likely future trajectory of health policy in Indonesia by examining the political dynamics that have shaped health policy in post–New Order Indonesia.

Mental illness has historically dwelt in the shadows of global health and international development. Only recently has it moved from the margins to become a central priority in both research and policy. Mental disorders account for a significant proportion of the worldwide non‑fatal and overall disease burden, which includes death and disability. By 2030 the annual cost to the global economy is estimated to be as high as US$6 trillion (Ferrari et al. 2022; Marquez and Saxena 2016). Large middle- and low-income countries like Indonesia continue to confront a plethora of challenges in delivering adequate mental health care. This chapter is a brief introduction to how, and how well, Indonesia has met, and is currently meeting, that challenge. Specifically, using two vignettes (which are composite portraits based on actual experience), we clarify the current state of knowledge on mental health needs in association with existing infrastructure, including a preliminary sketch of the current legislative framework. We touch on the impact of the COVID-19 pandemic and conclude with a firm call to action. Without urgent reform, Indonesia’s mental health system will continue to risk failing tens of millions of Indonesians with mental health issues.

Please note, although the following vignettes are not actual cases, they are composites of real people either met directly by the authors or appearing in recent Indonesian media. We caution readers that the following chapter contains confronting themes, and we urge our readership, if you experience any subsequent distress, to contact your local mental health care provider. Some links are provided at the end of this chapter. The other people included in the vignettes, together with their current roles in Indonesian mental health care and the institutions mentioned, are real and can also be contacted for mental health assistance.

Ahmed

Ahmed is 43. He farms a small plot of land in Kebumen, Central Java. He lives in a separate household to his wife and two children, who are currently attending junior secondary school. This separation is a result, he tells us, of ‘his episodes’. They start the same time every year, in July, his birth month.

Law No. 9/1960 on Basic Health declared that all Indonesians had the right to be physically, mentally and spiritually healthy, while Article 8 declared the government responsible for ensuring that all Indonesians had access to health services. Four decades then passed before President Megawati Sukarnoputri, in her last act as head of state, signed legislation supporting universal health insurance. Although her successor did little to advance the health care agenda nationally, initiatives at the district level established that the provision of ‘free’ health care played very well at the ballot box (Rosser et al. 2011). One of the beneficiaries was Joko Widodo. As governor of Jakarta, he enthusiastically rebranded a city health insurance scheme inherited from his predecessor, taking credit for the popular Jakarta Health Card (Kartu Jakarta Sehat, KJS). When Widodo ran for president in 2012 under the banner of Sukarnoputri’s Indonesian Democratic Party of Struggle (Partai Demokrasi Indonesia-Perjuangan, PDI-P), he promised to extend the scheme nationwide should he win, thus cementing universal health coverage as a PDI-P legacy (Pisani et al. 2017).

When Indonesia’s mandatory, universal, single-payer insurance system (Jaminan Kesehatan Nasional, JKN) was formally launched in 2014, it was thus freighted with political importance. Many vested interests were involved in preparing for that launch, including those of the powerful state insurance firms which preceded JKN’s implementer, Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS-K). The details of the scheme’s implementation were thus hammered out largely on the anvil of political expedience rather than through careful technical calculus (Aspinall 2014). The result was a generous insurance program that could not cover its costs. For Rp 25,500 a month (covered by the government for the poor and near-poor), all Indonesians had a right to full coverage for a wide range of care, including sophisticated procedures such as hip replacements. Many hospitals provided private rooms for patients paying ‘first class’ premiums of Rp 80,000 per month. The price of diagnostic tests and all 300-odd medicines on the national essential medicines list was included at all levels, with no co-payments required (Mboi 2015).

Unsurprisingly, the scheme ran at a deficit from its inception until premiums rose in 2020.

The global burden of dengue

Dengue, a systemic viral infection transmitted from person to person by the Aedes mosquitoes, presents a persistent and escalating problem in many parts of the world. Globally, the dengue infection has been predicted to reach 100 million cases in more than 110 countries, and the incidence rate, death and disability-adjusted life years (DALYs) lost have all increased during the past two decades (Zeng et al. 2021). Although dengue transmission occurs mainly in tropical regions, it has been highest in Asia (Simmons et al. 2012), where more than 75% of the world’s population infected with dengue live. Eight countries in the Southeast Asian region are classified as hyperendemic areas, including Indonesia (Murray et al. 2013). Recent studies indicate that dengue has the highest DALYs lost in Southeast Asia compared to other neglected tropical diseases such as schistosomiasis, leprosy, trachoma, hookworm and ascariasis (Shepard et al. 2013).

In addition to the morbidity and mortality, evidence shows that dengue significantly impacts the economic burden. A systematic review estimated the global cost of dengue illness was US$8.89 billion annually, consisting of 46% non-fatal cases admitted to hospital, 33.6% non-fatal ambulatory patients, 8.5% non-fatal non-medical cases and 11.9% fatal cases (Shepard et al. 2016). Asian countries experienced productivity losses of US$6.7–$1,445.9 for inpatients and US$3.8–$1,332 for outpatients per dengue episode. The cost of productivity losses associated with fatal dengue episodes in Asia is around US$12,035–$1,453,237 (Hung et al. 2020).

Dengue also affects quality of life, mainly psychological and social functions. From the quality of life perspective, dengue infection causes discomfort and nervousness. During the acute phase of the disease, the physical symptoms of dengue have several effects on personal mobility and social activities that persist into the late-acute stage of the disease. The most common symptoms sometimes last beyond the period of fever. These disorders often worsen, especially in those who do not seek treatment (Elson et al. 2020).

Environmental conditions and community behaviour can also affect the development of dengue, which affects the prevalence of dengue yearlong. All age groups are vulnerable to this disease.

Ensuring timely access to quality health services is a basic human right. All people, regardless of their social location, race, economic circumstances, cultural background, sexual orientation or gender, should have equitable access to essential health services (WHO 2015a). From a government perspective, safeguarding responsive and appropriate access to essential health services is one of the key objectives of health systems (WHO 2000, 2007). In most instances, people interact with health systems as patients who require expert opinion and treatments about their health concerns. People’s access to such services is influenced by at least three key dimensions of access: availability, affordability and acceptability (WHO 2015b). Availability refers to the physical presence and reach of the health facilities, workforce and services, whereas affordability refers to the ability of patients or communities more broadly to pay for the health services (ibid.). Acceptability deals with the sociocultural components of health services to ensure the delivery of quality, appropriate, timely and responsive health services (ibid.).

Inequitable access to health care is a recurring health system challenge in Indonesia, given the country’s demographic, geographic, economic, sociocultural and political characteristics. The emergence of the COVID‑19 pandemic in March 2020 has amplified existing access and health inequities within communities and between different population groups across Indonesia. As observed in other countries, the pandemic has led to disproportionate consequences, both mortality and morbidity, among socially and economically disadvantaged populations (Bambra et al. 2020; Dorn et al. 2020). The inequitable access to health care during the pandemic is exacerbated further by the interconnected systemic risks such as inequities in wealth, lack of social protection, unfair employment structure, food insecurity, and maldistribution of health infrastructure and resources (Bambra et al. 2020). For instance, existing government priorities and decisions embedded in sociopolitical infrastructure and economic forces have allowed the pandemic to discriminate against marginalised groups.

Ensuring access to affordable and comprehensive health services, therefore, requires interventions beyond the individual level to include these interrelated structural and political determinants of health. Designing new institutions and mechanisms to address the structural causes of access inequities requires critical examination of how problems and their solutions are framed.