Stanford Report: The First Lady of the United States, Michelle Obama, spoke at SCPKU today and said study abroad allows students to realize that countries all have a stake in each other's success.  Following her remarks, she held a conversation with students on the Stanford campu via SCPKU's Highly Immersive Classroom. Read more.

In countries far along in the demographic transition, rapidly aging populations are colliding with a severe shortage of health care and elder care workers. Japan may be the most pertinent case study of this and other impacts of demographic disruption. The country’s fertility rate is decreasing faster than projected, and as of 2025, 30% of its population was aged 65 or older. These trends have contributed to a persistent gap between surging demand for elder care and a shrinking care workforce.

To cope with this crisis, the Japanese government has implemented several programs to promote the use of robots in nursing home care. These care robots (or “kaigo robots”) assist care workers and support residents with daily needs. But how does their adoption affect workflows, staff retention, and overall staffing of long-term care facilities? Few studies have empirically examined these questions.

Shedding light on the debate surrounding new automation technologies and their impact on workers, a recent study, published on August 6 in the inaugural issue of the journal Health Affairs Review, finds that care robots help address challenges posed by population aging and care-labor shortages without necessarily displacing workers or lowering care quality.

The study, titled Robots and Labor in the Service Sector: Evidence from Nursing Homes, is part of a collaborative effort driven by the Asia Health Policy Program (AHPP) at the Walter H. Shorenstein Asia-Pacific Research Center. The study’s co-authors are Stanford health economist Karen Eggleston, the director of AHPP; Toshiaki Iizuka of the University of Tokyo’s Graduate School of Economics, a former AHPP visiting scholar; Yong Suk Lee of the University of Notre Dame’s Keough School of Global Affairs, formerly the SK Center Fellow at Stanford’s Freeman Spogli Institute for International Studies; and Ellie Xi, a rising junior at Stanford studying biomedical computation on the pre-med track and a former research assistant to Dr. Eggleston.

“One of the aspects of the paper that I found most interesting is its attempt to move beyond simply documenting where robots are being adopted and instead ask what their adoption may actually do to the long-term care workforce, especially given the sector’s high turnover rates and physically demanding working conditions,” says Xi.

Sign up for APARC's newsletters to receive our scholars’ research updates > 

Lessons from Early Diffusion of Robotics in the Long-Term Care Sector

The researchers grouped the robots prevalent in Japanese nursing homes into three main categories:

• Transfer aids: Wearable and non-wearable devices that assist staff with lifting frail residents from beds to wheelchairs, significantly reducing back strain, a leading cause of caregiver burnout.
• Mobility robots: Assistive systems that help residents move, use the restroom, or bathe more independently.
• Monitoring and communication systems: Sensors that alert staff when a resident has slipped out of bed or fallen, as well as social robots designed to offer companionship and cognitive stimulation.

To examine early diffusion of these robots, the researchers used 2017 survey data on long-term care work across approximately 860 Japanese nursing homes. A second source of data is their compilation of prefecture-level care robot subsidy availability, using regional variation in robot subsidies as an instrumental variable. Think of this as a natural experiment driven by a “geographic nudge.” Starting in 2015, Japan’s central government began providing prefectural governments with funds to subsidize the cost of adopting care robots. Because different prefectures introduced these subsidies at different times and with varying levels of generosity, nursing homes in some regions had a much easier path to acquiring and deploying robots than those in neighboring areas.

By comparing staffing trends between nursing homes that received this external, subsidy-driven "nudge" to adopt robots and those that did not, the researchers could confidently isolate the technology’s causal effects on the caregiving workforce.

The results indicate that nursing homes that adopted robots saw a significant decrease in staffing retention problems. Robot adoption was also associated with a 28% increase in care workers and a 39% increase in nurses, resulting in approximately 26% higher total employment at the facility level. Importantly, this employment growth occurred entirely among non-regular employees – that is, staff members on flexible, often part-time, contracts. The findings also suggest that robot adoption may improve continuity and quality of care while mitigating careworker shortages.

“Using nationally representative data from Japan and an instrumental-variable strategy, the study provides evidence suggesting that robots can complement rather than simply replace care workers, including by alleviating retention difficulties in a sector facing persistent labor shortages and potentially supporting quality of care,” explains Xi. “The paper’s central finding is that robot adoption is associated with reduced retention difficulties and increased employment of care workers and nurses under flexible contracts.”

A Human-Robot Collaborative Future for Elder Care

Caregiving is a physically demanding and high-stress occupation. The study’s findings indicate that, by introducing robots to ease staff burdens and monitor residents, nursing homes were able to promote more flexible work, either by increasing the tasks performed by non-regular employees or potentially encouraging part-time work. This type of work structure is encouraged by the Japan Nursing Association as a means for reducing stress, preventing burnout, and promoting a healthier work-life balance.

“Given recent debates about AI use in healthcare and the future of work, I found it especially interesting that this research highlights the potential for technology to augment caregivers, particularly by supporting physically demanding or indirect tasks, while preserving the human aspects of care that are more difficult to reproduce,” says Xi.

The study's findings are relevant for policymakers seeking evidence on the social value of collaborative robots and their impacts on staffing and care delivery, particularly as aging societies facing demographic pressures similar to Japan consider how to meet growing demand for long-term care.

A Mentorship Story

The study is part of Eggleston’s Innovation for Healthy Aging research track, which investigates how East Asian economies adopt and adapt to emerging technologies, design incentives, and adjust their workforces to support older adults. It builds on an earlier research project focused on the impact of robots on nursing home care in Japan.

For Xi, co-authoring the paper represents an academic milestone. "As someone deeply interested in geriatrics, I first began working with Dr. Karen Eggleston as a research assistant during the summer after my freshman year," Xi recalls. "Last spring, we decided to continue working together through a directed reading."

During that directed reading, Xi was invited to help revise and update a project that had previously circulated as an Asia Health Policy Program working paper. She worked to update the research, framing the original findings within the rapidly shifting landscape of care robotics and artificial intelligence in long-term care.

"I worked on situating the original findings within more recent research and developments in care robotics and considering what Japan’s experience can tell us about the role of these technologies in aging societies today," Xi says. "It was an incredible opportunity to work closely with Dr. Eggleston, Professor Toshiaki Iizuka, and Professor Yong Suk Lee. I was especially grateful to see firsthand how a collaborative project evolves and to contribute to that process as the paper moved from a working paper toward publication.”

Introduction and Contribution

Nearly half of the world (46%) lives in authoritarian regimes that hold regular elections — compared to 28% who live in autocracies without elections and 26% who live under democracy. In these “electoral autocracies,” the ruling party can theoretically lose power, but its ability to repress and co-opt its opponents makes defeat unlikely. Incumbent executives and parties in electoral autocracies have become increasingly sophisticated in their repressive techniques and increasingly connected to other regimes that share similar fears of democracy. “How can electoral authoritarianism be resisted?” is thus a pressing question for domestic opposition parties and civil society organizations (CSOs) as well as international actors seeking to promote democracy, including governments, nonprofits, think tanks, and academics. 

In “Opposition strategies and electoral challenges under autocracy,” Oren Samet analyzes five strategies opposition parties use to fight electoral authoritarianism during campaigns, on election day, and after polls have closed. These are: joining multiparty coalitions, strengthening their party organization, mobilizing mass protests, boycotting elections, and seeking international assistance. Samet shows that each strategy entails tradeoffs, increasing opposition competitiveness while making authoritarian repression more likely or efficient. For example, joining a multiparty coalition can both increase the incumbent’s likelihood of defeat and increase his propensity to repress — insofar as he perceives the opposition as popular and threatening.

Samet offers several prescriptions for international democracy promoters. First, they must collaborate with domestic opposition parties, because only they — and not CSOs — can win elections. Yet many international actors avoid this approach; for instance, some opposition parties may care more about power than democracy, or collaborating with them may invite criticism that democracy promotion is partisan. While these risks cannot be ignored, neither can political parties.

A second prescription follows from the fact that oppositions have at least five tools at their disposal: there can be no single “best practice” in democracy promotion; it requires flexibility, adaptability, and an integrated approach. Finally, because autocrats continue to become more sophisticated, democracy promoters must take steps to prepare for the repression of their partners. 

Five Approaches and Their Pitfalls

Otherwise effective strategies for winning democratic elections — such as running savvy campaigns on primetime television that are informed by public opinion polling — will not work for opposition parties under electoral autocracy. This is because the system is structurally biased toward incumbents. As such, one common approach has been for individual opposition parties to join together in a coalition: sharing policy platforms, endorsing joint candidates, and merging their party organizations. And indeed, multiparty coalitions are statistically associated with higher vote shares and a higher likelihood that autocrats are defeated. At the same time, however, such coalitions are difficult to form and sustain due to ideological differences and polarization. In especially repressive electoral autocracies, such as Ethiopia or Cambodia, incumbent parties are often able to neutralize or eliminate coalitions. Finally, when coalitions pose a serious challenge on election day but without winning, autocrats may repress even harder.

A second strategy involves strengthening party organization, for example, by improving its geographic reach or recruiting more professional candidates. These efforts can increase competitiveness and popular appeal, but they risk providing the incumbent with a large amount of information that he can use to more efficiently target his opponents. This includes formal lists of members, candidates, and party branch locations. Meanwhile, more organized opposition parties may inadvertently legitimize the system by affording it some semblance of democracy.

Encouraging mass protests is a third strategy available to opposition parties. As the number of protesters grows, authoritarian repression becomes more costly and more likely to backfire, while the incumbent’s allies become more likely to defect and join the opposition. Parties help with this process by translating protester demands into coherent party platforms. However, and especially after the 2010-12 Arab Uprisings, electoral authoritarian regimes have become highly sensitive to and ready to combat protests. This may be accomplished via surveillance or assistance from powerful third parties such as China or Russia.

A fourth, common strategy has been for parties to boycott the autocrat’s electoral facade. Doing so signals to the international community that the playing field is skewed and the system illegitimate. Yet boycotts can lead to missed opportunities for the opposition to build electoral strength, influence policy change as legislative minorities, or monitor the autocrat from inside government. In addition, they rob oppositions of the chance to take advantage of the autocrat’s miscalculations, which may even lead to his defeat. 

Finally, opposition parties can reach out to international actors for support. This may involve requesting that they sanction the regime or intervene in the name of democracy. International pressure can indeed encourage political openings and is especially useful for oppositions with low visibility. However, autocrats are adept at demonizing those who use this strategy as agents of malign foreign influence. These appeals can strengthen the autocrat’s domestic support base among those who see him as protecting the nation. In all, these tradeoffs suggest that effective democracy promotion requires a deep understanding of the political context in which oppositions operate.

*Brief prepared by Adam Fefer.