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CDDRL Postdoctoral Scholar, 2021-22
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I am a political scientist (PhD degree expected in July 2021 from Harvard) working on political parties, social welfare policies and local governance, primarily in the Middle East and North Africa. My dissertation project focuses on secular parties in the region and explores why they could not form a robust electoral alternative to the Islamist parties in the post-uprisings period. In other projects, I explore voters' responses to executive aggrandizement (focusing on Turkey), and social welfare in the context of ethnic and organizational diversity (focusing on Lebanon). Prior to PhD, I worked as an education policy analyst in Turkey, managing several research projects in collaboration with the Ministry of Education, World Bank and UNICEF. I hold a BA degree in Political Science from Boğaziçi, and Master's degrees from the LSE and Brown. 

Department of Political Science
Stanford University
Encina Hall West, Room 307
Stanford, CA 94305-6044

(650) 725-7987
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CDDRL Affiliated Faculty
Associate Professor, Political Science
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Adam Bonica is an Associate Professor of Political Science. His research is at the intersection of data science and politics, with interests in money in politics, campaigns and elections, the courts, and political methodology. His research has been published in journals such as the American Journal of Political Science, Political Analysis, Journal of Economic Perspectives, Journal of Law, Economics, and Organization, and JAMA Internal Medicine. His book The Judicial Tug of War: How Lawyers, Politicians, and Ideological Incentives Shape the American Judiciary (with Maya Sen) examines the politicization of the American judiciary. 

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In the time of COVID-19, the attention of physicians and policymakers alike has largely been focused on responding to the immediate needs of people experiencing the fallout from the novel coronavirus. For Radhika Jain, a postdoctoral fellow with the Asia Health Policy Program (AHPP) at APARC, the pandemic has further highlighted the importance of advancing policies that support effective and equitable public health systems.

We sat down with Jain to discuss her work and recent research into the ways the COVID-19 pandemic has affected the efficacy of India’s healthcare services for people living with chronic, non-communicable diseases. Listen to the full conversation above or via our Soundcloud channel.

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Jain’s research focuses on the role of the private sector in health systems, frictions in health care markets, the extent to which public health policies serve the needs of target populations, and health policy design in lower-income countries. In particular, she studies India's health care system, probing into data sets and administrative records to identify the factors that contribute to poor health outcomes and determine what interventions increase the effectiveness of public health insurance.

In the case of India, the private healthcare sector is highly fragmented and made up of a collage of small and independently-run hospitals and service providers with varying levels of oversight and administrative regulation. Gathering data on patient costs, insurance use, and benefit allocation for different cohorts of people using private healthcare in the world's second-most populous nation is a central pillar in Jain's efforts to better understand and document how health systems are used and how they can be improved to better serve vulnerable populations.

COVID-19 Lockdown Impacts on Non-COVID Health Care and Outcomes


For Jain, the ongoing effects of the COVID-19 pandemic have re-emphasized the crucial role that a well-functioning public, government-backed health system plays in providing care to citizens during times when the private sector experiences sudden and severe disruptions. Working in collaboration with Pascaline Dupas, the faculty director at the Stanford King Center on Global Development and a senior fellow at the Stanford Institute for Economic Policy Research, Jain has documented the adverse effects of COVID-19 on accessibility to health services for patients needing treatment for chronic, non-communicable diseases.("The Effects of India’s Covid-19 Lockdown on Critical Non-Covid Health Care and Outcomes: Evidence From a Retrospective Cohort Analysis of Dialysis Patients"

Jain's and Dupas' recent working paper (published in AHPP's Working Paper Series) shows that the abrupt, severe lockdown instituted by the Indian government as a preventive measure against the spread of the coronavirus had widespread impacts on individuals' ability to receive care for non-COVID-related healthcare needs such as dialysis. Their findings indicate that, among patients needing dialysis, the death rate between April and July 2020 was 25 percent higher than the death rate for a comparable cohort in the same months in 2019.

During something like a pandemic, the importance of having a social safety net and a strong public health system that the government can deploy to protect households experiencing medical hardships becomes all the more clear.
Radhika Jain
Postdoctoral Fellow, Asia Health Policy Program

This increase in mortality is directly related to disruptions to critical health service delivery and accessibility caused by the lockdown measures. Sixty-three percent of those surveyed by Jain and Dupas reported experiencing disruptions to their care, with travel barriers and hospital closures or refusals cited as the most common causes. As a cohort, vulnerable populations were affected most by both the lockdown and ensuing disruptions to healthcare access.

Discrepancies like this between how a health system performs on paper and what happens in real-world practice is something Jain has a deeper appreciation for in light of the pandemic. “There were many policy prescriptions about how to respond to the lockdown, but what was done in India was a poorly conceived political response,” she cautions. “That’s something we who work on health policy need to keep in mind and contend with: What is the role of the political system, what is the role of the health system, and how does our research interact with all of that?”

Looking ahead, Radhika intends to continue researching and writing recommendations on how to make health systems viable and usable for all populations, including the most vulnerable. In particular, she is interested in investigating strategies to close engagement gaps and accessibility challenges women in India experience in utilizing healthcare services. She will continue working at APARC as a postdoctoral fellow with the Asia Health Policy Program through the end of the 2021-22 academic year.

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“Co-Bots,” Not Overlords, Are the Future of Human-Robot Labor Relationships

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Radhika Jain, a postdoctoral fellow with the Asia Health Policy Program, shares insights on her research into India’s health care system and how it is responding to both the COVID-19 pandemic and standard healthcare needs of citizens.

Shorenstein APARC Stanford University Encina Hall E301 Stanford, CA 94305-6055
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Visiting Scholar at APARC, 2019-20
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Ph.D.

Jinlin Liu joined the Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) as visiting scholar during the 2019-2020 academic year from Xi'an Jiaotong University, where he serves as a researcher for the XJTU Research Center for the Belt and Road Health Policy and Health Technology Assessment.  His research focuses on public health services and healthcare governance and reform in China.  Dr. Liu obtained his Ph.D. in Public Administration from Xi'an Jiaotong University in 2018.

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China started comprehensive health system reforms in 2009. An important goal of China’s health system reforms was to achieve universal health coverage through building a social health insurance system. Universal health coverage means that all individuals and communities should get the quality health services they need without incurring financial hardship. It has three dimensions: population coverage, covering all individuals and communities; service coverage, reflecting the comprehensiveness of the services that are covered; and cost coverage, the extent of protection against the direct costs of care.
 
The authors examine China’s progress in enhancing financial protection of social health insurance and identify the main gaps that need to be filled to fully achieve universal health coverage. They find that, after a decade of comprehensive health system reforms, China has greatly increased access to and use of health services, but needs to further enhance financial protection for poor populations to fully achieve its commitment to universal health coverage.
 
This article is part of a BMJ collection with Peking University that analyzes the achievements and challenges of the 2009 health system reforms and outlines next steps in improving China's health.
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BMJ
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Hai Fang
Karen Eggleston
Kara Hanson
Ming Wu
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Noa Ronkin
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Asia Health Policy Program Director Karen Eggleston and colleagues examine China’s progress in enhancing financial protection under its social health insurance to achieve universal health coverage.

In 2009, China launched comprehensive health system reforms to address challenges such as increasing rates of non-communicable diseases and population aging, problems with health financing and healthcare delivery, and overall growing health expectations of its people. Promoting universal health coverage by building a social health insurance system was a central pillar of the reforms.

After a decade of system reforms, has the Chinese government made good on its commitment to bolster universal health coverage? In a new article published in a BMJ collection, a team of four co-authors including Karen Eggleston, APARC’s deputy director and director of the Asia Health Policy Program, evaluates China’s progress towards enhancing financial protection of social health insurance and identifies the main gaps that need to be filled to achieve universal health coverage. Their article is part of a special BMJ collection with Peking University that marks the tenth anniversary of China’s health system reforms by analyzing their accomplishments and challenges ahead.

The 2009 reforms aimed to cover the entire Chinese population with one of three (since 2012 one of two) basic social health schemes. To provide added financial protection to patients with critical illnesses, catastrophic medical insurance was initially launched in 2012 and implemented nationally in 2015. Eggleston and her co-authors determine that the expansion of health insurance has had several major successes. First, it improved access to and use of healthcare. In 2011, China achieved near-universal health insurance coverage, with more than 95% of the Chinese population covered by health insurance. Moreover, the annual inpatient hospital admission rate increased from 3.6% in 2003 to 17.6% in 2017, and admission rates for outpatient services were much higher than the global average.

Second, the expansion of health insurance coverage reduced the share of out-of-pocket heath expenses in total health expenditure, thus raising the level of financial protection. Third, catastrophic medical insurance was also effective in supplementing the basic social health insurance schemes and provided extra financial protection to a range of vulnerable groups. By 2017, more than a billion people in China were covered by such insurance.

However, much remains to be done. Out-of-pocket health expenditures remain fairly high and are one of the main reasons for catastrophic health expenses and low financial protection in China, which disproportionately affect deprived populations. Catastrophic medical insurance currently does not target underprivileged people, while medical aid is relatively small in scale and covers only a minority of patients with catastrophic health expenses.

Eggleston and her colleagues conclude that the Chinese government should focus on underprivileged populations within the current insurance system and enhance their financial protection as an important element of targeted poverty alleviation. Such targeting, the researchers emphasize, requires a clear and integrated policy encompassing the basic social health insurance schemes, catastrophic medical insurance, medical aid, and improved healthcare efficiency.

 

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We examine the effect on service delivery outcomes of a new information communication technology (ICT) platform that allows citizens to send free and anonymous messages to local government officials, thus reducing the cost and increasing the efficiency of communication about public services. In particular, we use a field experiment to assess the extent to which the introduction of this ICT platform improved monitoring by the district, effort by service providers, and inputs at service points in health, education and water in Arua District, Uganda. We find suggestive evidence of a short-term improvement in some education services, but these effects deteriorate by year two of the program, and we find little or no evidence of an effect on health and water services at any period. Despite relatively high levels of system uptake, enthusiasm of district officials, and anecdotal success stories, we find that relatively few messages from citizens provided specific, actionable information about service provision within the purview and resource constraints of district officials, and users were often discouraged by officials’ responses. Our findings suggest that for crowd-sourced ICT programs to move from isolated success stories to long-term accountability enhancement, the quality and specific content of reports and responses provided by users and officials is centrally important.

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World Development
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Guy Grossman
Melina R. Platas
Jonathan Rodden
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Noa Ronkin
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People who are acquainted with the work of Shorenstein APARC’s Asia Health Policy Program (AHPP) may be aware of the Innovation for Healthy Aging collaborative research project led by APARC Deputy Director and AHPP Director Karen Eggleston. This project, which identifies and analyzes productive public-private partnerships advancing healthy aging solutions in East Asia and other regions, encompasses an upcoming volume, co-authored by Eggleston with Harvard University professors Richard Zeckhauser and John Donohue, about public and private roles in governance of multiple sectors in China and the United States, including health care and elderly care. This volume, however, is not the first collaboration between Eggleston and Zeckhauser.

Zeckhauser, the Frank P. Ramsey Professor of Political Economy at Harvard University’s Kennedy School, is known for his many policy investigations that explore ways to promote the health of human beings, to help markets work more effectively, and to foster informed and appropriate choices by individuals and government agencies. In 2006, Eggleston and Zeckhauser co-wrote a paper about antibiotic resistance as a global threat, an issue that has since received much attention as it has become a critical public health and public policy challenge. Zeckhauser was a pioneer in framing antibiotic resistance as a global threat.

On October 20, 2018, Eggleston was among some 150 colleagues, students, and friends who participated in a special symposium at the Kennedy School to celebrate Zeckhauser’s 50th anniversary of teaching and research, and to anticipate what the next 50 years might bring in the multiple fields he has influenced throughout his long career.

Eggleston joined the first of two panels in that symposium, where she spoke about Zeckhauser’s impact on health policy and about what academics and policymakers should be tackling next on the path to addressing the global threat of antibiotic resistance.

The panel was moderated by Harvard Professor Edward Glaeser. In addition to Eggleston, it included Jeffrey Liebman, Daniel Schrag, and Cass Sunstein.

A video recording of the panel is made available by the Kennedy School. Listen to Eggleston’s remarks (beginning at the 8:42 and 36:20 time marks):

 

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Purpose – The purpose of this paper is to produce a high-quality measure of the nature of healthcare resources available in China’s Township Health Centers (THCs), paying particular attention to equity between high- and low-income areas.

Design/methodology/approach – This study makes use of data from a nearly nationally representative survey in rural China conducted by the Center for Chinese Agricultural Policy at the Chinese Academy of Sciences in 2011. The samples of towns were selected randomly from 25 counties located in five provinces from different regions of China. Data were collected through questionnaires and direct observation.

Findings The THCs located in rich areas have higher levels of human resources than poor areas. THCs in rich areas also have more fixed assets than those in poor areas. In fact, even though the Chinese Ministry of Health mandates that all THCs have certain basic levels of medical equipment and facilities, many THCs in poor areas do not have them. The allocation of mandated equipment is unequal.

Practical implications These findings suggest that Chinas government should pay more attention to THCs located in poor areas, especially in light of new initiatives to improve health care in poor rural areas.

Originality/value – This is the first nationally representative study to employ rigorous empirics to investigate the extent of inequality in allocation of resources within THCs across China.

Keywords China, Health, Inequality, Rural development, Medical resources, Township health centers

Paper type Research paper 

 

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China Agricultural Economic Review
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Yue Ma
Matthew Boswell
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Research by Stanford Health Policy’s Michelle Mello looks at what happens when a group of hospitals started systematically acknowledging adverse outcomes in care by apologizing and proactively offering compensation where substandard care caused serious harm. 

Hospitals have traditionally “crouched in a deny-and-defend posture when things go wrong in medical care,” said Mello, a professor of law at Stanford Law School and a professor of health research and policy. The new approach, called “a communication-and-resolution program,” or CRP, is being adopted by an increasing number of health-care facilities.

“None of the hospitals experienced worsening liability or trends after CRP implementation, which suggests that transparency, apology, and proactive compensation can be pursued without adverse financial consequences,” Mello and her co-authors write in the study published Monday in Health Affairs. However, despite the growing consensus that CRPs are the right thing to do, concerns over liability risks remain.”

Stanford Health Policy asked Mello some questions about the research:

Could this new approach to resolving patient conflict be a thing of the future?

Hospitals that adopt CRPs believe they will help improve patient safety and are consistent with the ethical obligation to disclose medical errors; they also hope they will reduce liability costs. However, there is a lot of uncertainty about their effects on costs. On the one hand, being honest with patients could avoid the anger that prompts patients to sue, and compensating injured patients early on saves on litigation expenses. On the other hand, in the traditional system, very few patients injured by substandard care ever get compensated. Offering up admissions of error and early compensation could mean a lot more patients receive payment, raising total costs. Uncertainty about this issue continues to be a barrier to widespread adoption of the CRP approach.

What were the key findings in your study?

We evaluated the liability effects of CRP implementation at four Massachusetts hospitals by examining before-and-after trends in malpractice claims, volume, cost, and time to resolution. We then compared those to trends among similar hospitals in the state that did not adopt CRPs. We found that CRP implementation was associated with improved trends in the rate of new claims and legal defense costs at the two big hospitals that implemented these programs — favorable developments that were not seen at comparison hospitals with no communication-and-resolution programs in place. CRP implementation was not associated with significant changes upward or downward in trends of new claims receiving compensation, compensation costs, total liability costs, or average compensation per paid claim, nor was it associated with a significant change in time to resolution.

So then why are the findings important?

The study helps resolve uncertainty about the liability effects of admitting and compensating medical errors, especially since the study design was much stronger than that of previous studies. We found that the CRP approach does not expand liability risk and may, in fact, improve some liability outcomes. Therefore, hospitals can “do the right thing” — be honest about errors, apologize, and compensate patients who are injured by negligence — without adverse financial consequences.

Who began the CRP approach and what is the average payment proactively made to patients who did not receive proper care?

The approach dates to the late 1990s and was first publicized by a Veterans Affairs hospital in Kentucky and then by the University of Michigan Health System, both of which reported very positive outcomes.  Stanford was also an early adopter.

The model calls for patients to be compensated at about what the hospital estimates their claim would be worth in traditional litigation. In our study in Massachusetts, the median payment to patients was $75,000. That’s a lot lower than the median payment in the tort system, but the mix of injuries is different. In traditional litigation, 85 percent of claims involve very serious injuries or deaths, because smaller claims aren’t attractive to plaintiff attorneys. They just go uncompensated. In CRPs, it’s easier for patients with moderate-severity injuries to have access to justice.

 

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