Introduction Primary healthcare (PHC) serves as the cornerstone for the attainment of universal health coverage (UHC). Efforts to promote UHC should focus on the expansion of access and on healthcare quality. However, robust quality evidence has remained scarce in China. Common quality assessment methods such as chart abstraction, patient rating and clinical vignette use indirect information that may not represent real practice. This study will send standardised patients (SP or healthy person trained to consistently simulate the medical history, physical symptoms and emotional characteristics of a real patient) unannounced to PHC providers to collect quality information and represent real practice. 

Methods and analysis 1981 SP–clinician visits will be made to a random sample of PHC providers across seven provinces in China. SP cases will be developed for 10 tracer conditions in PHC. Each case will include a standard script for the SP to use and a quality checklist that the SP will complete after the clinical visit to indicate diagnostic and treatment activities performed by the clinician. Patient-centredness will be assessed according to the Patient Perception of Patient-Centeredness Rating Scale by the SP. SP cases and the checklist will be developed through a standard protocol and assessed for content, face and criterion validity, and test–retest and inter-rater reliability before its full use. Various descriptive analyses will be performed for the survey results, such as a tabulation of quality scores across geographies and provider types. 

Ethics and dissemination This study has been reviewed and approved by the Institutional Review Board of the School of Public Health of Sun Yat-sen University (#SYSU 2017-011). Results will be actively disseminated through print and social media, and SP tools will be made available for other researchers.

Unlike performance incentives for private sector managers, little is known about performance incentives for managers in public sector bureaucracies. Through a randomized trial in rural China, we study performance incentives rewarding school administrators for reducing student anemia -- as well as complementarity between incentives and orthogonally assigned discretionary resources. Large (but not small) incentives and unrestricted grants both reduced anemia, but incentives were more cost-effective. Although unrestricted grants and small incentives do not interact, grants fully crowd-out the effect of larger incentives. Our findings suggest that performance incentives can be effective in bureaucratic environments, but they are not complementary to discretionary resources. 

Using the Bayley Scales of Infant and Toddler Development-III (BSID-III), we examine the rates of developmental delays among children aged 0–3 years in four major subpopulations of rural China, which, altogether, account for 69% of China's rural children and 49% of children nationwide. The results indicate that 85% of the 3,353 rural children in our sample suffer from at least one kind of developmental delay. Specifically, 49% of the children have cognitive delays, 52% have language delays, 53% have social emotional delays, and 30% have motor delays. The results suggest that these high rates are due to two main factors in the parenting environment. The first is micronutrient deficiencies, which are reflected in a high prevalence of anemia (42%). The second is an absence of interactive parenting inputs, such as storytelling, reading, singing, and playing. Although we find these inputs to be significantly and positively associated with better developmental outcomes, only a small share of caregivers engage in them. With this large and broad sample, we show that, if China hopes to build up enough human capital to transition to a high-income economy, early childhood development in rural areas urgently requires more attention. 

A new account of modern Iraqi politics that overturns the conventional wisdom about its sectarian divisions

How did Iraq become one of the most repressive dictatorships of the late twentieth century? The conventional wisdom about Iraq's modern political history is that the country was doomed by its diverse social fabric. But in State of Repression, Lisa Blaydes challenges this belief by showing that the country's breakdown was far from inevitable. At the same time, she offers a new way of understanding the behavior of other authoritarian regimes and their populations.

This volume draws on emerging scholarship at the intersection of two already vibrant fields: medieval material culture and medieval sensory experience. The rich potential of medieval matter (most obviously manuscripts and visual imagery, but also liturgical objects, coins, textiles, architecture, graves, etc.) to complement and even transcend purely textual sources is by now well established in medieval scholarship across the disciplines.

This study examines the impact of social engagement on elderly health in China. A two-stage residual inclusion (2SRI) regression approach was used to examine the causal relationship. Our dataset comprises 9253 people aged 60 or above from the China Health and Retirement Longitudinal Survey (CHARLS) conducted in 2011 and 2013. Social engagement significantly improved the self-rated health of the elderly and reduced mental distress, but had no effect on chronic disease status. Compared with the rural areas, social engagement played a more important role in promoting the elderly health status in urban areas. Social engagement could affect the health status of the elderly through health behavior change and access to health resources. To improve the health of the elderly in China and promote healthy aging, the government should not only improve access to effective medical care but also encourage greater social engagement of the elderly.

Risky health behaviors such as illicit drug use, smoking, overconsumption of alcohol, violence, and early sexual activity have contemporaneous and intertemporal adverse health and economic outcomes. The health-related and economic costs to individuals and to society overall are particularly pronounced when adolescents are the ones engaging in one or more of such behaviors.

This paper shows that, for mothers in Cebu, Philippines, access to electricity and the type of cooking fuel used at home affect both health outcomes and also how time is allocated, including for paid work. First, the use of fuelwood for cooking adversely affects the health of mothers, who are traditionally responsible for cooking and are often at home, taking care of their families. This result is consistent across different econometric specifications.

Cardiovascular diseases (CVDs), which are disorders of the heart and blood vessels, are the world’s leading cause of death (WHO, 2016). The transition from infectious diseases to non-communicable diseases (NCDs), primarily CVDs, as the primary cause of mortality and morbidity worldwide— combined with the economic burden associated with heart-related diseases—prompted the World Health Organization (WHO) and its regional offices to identify CVDs’ risk factors (WHO, 2016).

Background: Precise future projection of population health distribution is imperative for designing an efficient healthcare system in rapidly aging countries. Multistate-transition microsimulation models such as the US Future Elderly Model have been developed based on panel data collection, but these data may not be always available. We proposed a pseudopanel method using repeated cross-sectional representative surveys as a complementary approach, and specifically applied the model to Japan's population.

The main goal of this paper is to examine whether natural disasters and the damages they cause contribute to the international migration of Filipino workers. International migration has an important economic effect on the Philippines, which was ranked third in total remittances received (USD 15.3 billion) after India and China in 2015 (World Bank 2016; BSP 2016). The Philippines, being located in the Pacific Ring of Fire and along a typhoon belt, is frequented by natural disasters, which can cause damage to assets and properties, and can potentially displace the population.

Offensive cyber operations have become increasingly important elements of U.S. national security policy. From the deployment of Stuxnet to disrupt Iranian centrifuges to the possible use of cyber methods against North Korean ballistic missile launches, the prominence of offensive cyber capabilities as instruments of national power continues to grow. Yet conceptual thinking lags behind the technical development of these new weapons. How might offensive cyber operations be used in coercion or conflict? What strategic considerations should guide their development and use?

Crop type mapping at the field level is necessary for a variety of applications in agricultural monitoring and food security.

Oil palm expansion resulted in 2 million hectares (Mha) of forest loss globally in 2000–2010. Despite accounting for 24% (4.5 Mha) of the world’s total oil palm cultivated area, expansion dynamics in sub-Saharan Africa have been overlooked. We show that in Southwest Cameroon, a top producing region of Africa, 67% of oil palm expansion from 2000–2015 occurred at the expense of forest. Contrary to the publicized narrative of industrial-scale expansion, most oil palm expansion and associated deforestation is occurring outside large agro-industrial concessions.

Poor rural areas in China exhibit the country’s highest rates of child mortality, often stemming from preventable health conditions such as diarrhea and respiratory infection. In this study, we investigate the association between breastfeeding and disease among children aged 6–24 months in poor rural counties in China. To do this, we conducted a longitudinal, quantitative analysis of socioeconomic demographics, health outcomes, and breastfeeding practices for 1802 child–caregiver dyads across 11 nationally designated poverty counties in southern Shaanxi Province in 2013–2014. We found low rates of continued breastfeeding that decreased as children developed: from 58.2% at 6–12 months, to 21.6% at 12–18 months, and finally to 5.2% at 18–24 months. These suboptimal rates are lower than all but one other country in the Asia-Pacific region. We further found that only 18.3% of children 6–12 months old met the World Health Organization (WHO)-recommended threshold for minimum dietary diversity, defined as consuming four or more of seven specific food groups. Breastfeeding was strongly associated with lower rates of both diarrhea and cough in bivariate and multivariate analyses. As the first analysis to use longitudinal data to examine the relationship between continued breastfeeding and child illness in China, our study confirms the need for programmatic interventions that promote continued breastfeeding in order to improve toddler health in the region.

Indonesia’s oil palm expansion during the last two decades has resulted in widespread environmental and health damages through land clearing by fire and peat conversion, but it has also contributed to rural poverty alleviation. In this paper, we examine the role that decentralization has played in the process of Indonesia’s oil palm development, particularly among independent smallholder producers.

The “safety case” approach has been developed to address the issue of evaluating the performance of a geologic repository in the face of the large uncertainty that results for evaluations that extend over hundreds of thousands of years. This paper reviews the concept of the safety case as it has been defined by the international community. We contrast the safety case approach with that presently used in the U.S. repository program. Especially, we focus on the role of uncertainty quantification.

The final disposal of nuclear waste is at the interface between the technologies of the nuclear fuel cycle that produce the waste and the natural hydrologic and geochemical cycles of geologic repositories. Despite this broad interdisciplinary scope, nuclear waste management, as practiced, remains “balkanized” among the relevant disciplines.

It is commonly believed that reading challenges should be addressed early to reduce the likelihood that developmental delays will impact students over the long term. However, students in developing countries often have limited access to reading resources. In this study, the authors used a randomized controlled trial of 11,083 fourth‐ and fifth‐grade students in 120 primary schools in rural China to examine the causal effect of an in‐class library program on student reading outcomes and academic achievement in schools with poor reading resources over an eight‐month period. An in‐class library was installed in each of the selected classes in the 40 treatment schools. The authors found that the program significantly improved student affinity toward reading and student reading habits, and in these regards, it narrowed the gap between male and female students, between low‐ and high‐performing students, and between left‐behind children and children living with parents. However, the authors found no overall effect of the program on reading and academic achievement and a negative effect on student confidence in reading. There was also no effect on student, teacher, and primary caregiver perceptions toward the effect of independent reading on academic achievement, nor any effect on whether teachers and primary caregivers provided reading instructions to students. The authors propose three possible explanations for these findings: a lack of reading instruction from teachers and caregivers, a lack of reading materials specifically tailored to local needs and interests, and the relatively short duration of the intervention.

Background: There is a substantial body of evidence supporting the association between maternal active smoking during pregnancy and child development, but the association between prenatal exposure to environmental tobaccos smoke (ETS) and early child development has not been well documented. This cross-sectional study examines the association between prenatal exposure to ETS and the development of children in their first two years of life. 

The cholera response in Yemen was and remains extremely complicated and challenging for a variety of political, security, cultural, and environmental reasons. The study team recognizes these challenges and commends the government, international and national organizations, and the donors for working to find solutions in such a difficult context. There are no easy fixes to these challenges, and the conclusions and recommendations are meant to be constructive and practical, taking into account the extreme limitations of working in Yemen during an active conflict.

Abstract: A large literature has established that the International Monetary Fund (IMF) is heavily politicized. We argue that this politicization has important consequences for international reserve accumulation and financial crises. The IMF generates moral hazard asymmetrically, reducing the expected costs of risky lending and policies for states that are politically influential vis-à-vis the institution.

Our Report draws attention to a complex but understudied issue: How will climate warming alter losses of major food crops to insect pests? Because empirical evidence on plant-insect-climate interactions is scarce and geographically localized, we developed a physiologically based model that incorporates strong and well-established effects of temperature on metabolic rates and on population growth rates.