Nearly forty-four percent of Indonesia’s population is living on less than $2 a day, making it near impossible for some to seek proper health treatment. One way to improve this situation is through Indonesia’s conditional cash transfer (CCT) programs, Margaret Triyana says.

The CCT program, first piloted by the World Bank in 2007 and expanded from 2009–10, encourages Indonesia’s most destitute to pursue health-seeking behaviors by reducing barriers to health care through cash incentives. Payment is given for receiving treatments at a local clinic. Essentially, the poor are reimbursed simply for “showing up” for health services.

Triyana, a Jakarta native and postdoctoral fellow in the Asia Health Policy Program, has been in residence at the Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute for International Studies studying the effects of the CCT program on Indonesia’s poor. She has been evaluating the household CCT program’s two-year implementation, focusing on the maternal and child health initiatives.

She plans to produce multiple papers that focus on issues related to CCT interventions and its impact on mothers and children. Triyana will continue this research after leaving Shorenstein APARC this July, accepting an academic teaching position at Nanyang Technological University in Singapore. 

Recently, Triyana discussed her research with Shorenstein APARC. 

What types of health initiatives does the CCT program sponsor, and for whom?

The CCT program targets Indonesia’s most poverty-stricken by selecting approximately the bottom 30 percent of the poorest households, with preference toward households with pregnant women or school-aged children. Eligibility depends on socioeconomic factors per district such as expenditure, education and asset ownership. The program stretches the rural-urban divide, covering people in and off Java (this is the main island where 60 percent of the population resides). Many initiatives in the household CCT program are focused on child and maternal health. For mothers, they include a series of prenatal care visits, an iron tablet prescription, childbirth assistance and postnatal care. For children, they cover vaccinations, monthly height and weight measurements at the clinic and vitamin A pills. Overall the CCT program is a combination of poverty reduction and human capital investments, attempting to induce good behavior that instills long-term health in low resource settings.

Who is the typical primary care provider in Indonesia?

The primary care provider is often a midwife. This is because Indonesia doesn’t have enough trained doctors to support the growing demand. Clinics operate at the sub-district level, which comprise of 10-15 villages each. Every village is assigned one midwife. Midwives can perform most procedures just short of surgery. For example, midwives offer typical delivery services but refer patients to a district-level hospital for a Caesarean section. This system, for the most part, functions well, but midwives do have an expanded scope of care that can be unsettling. Children have their cuts taken care of by midwives; adults can get antibiotics through them. This diffused system is perhaps more efficient, but it can call into question the legitimacy of their authority. Midwives receive only three years of training for their certification. This is something the Indonesian government intends to inspect and will likely restructure.

What behavior changes do you see as a result of the CCT program?

My initial findings show there is increased utilization of health care programs. The CCT program incentivizes certain behaviors – attending the clinic for a test or retrieving medication – which then, in theory, leads to better health. “Showing up” doesn’t automatically correlate with improved health, but if we think about the population at hand, it would in most cases. People who weren’t using health services before now are. Everyone that was offered the program signed up. Monthly attendance to CCT-linked programs is reported at a rate of 85 percent. In particular to maternal health, I noted a 10 percent increase in delivery fees. This trend follows what we would expect to see – because of increased utilization, there is a natural rise in price for the service. On the demand-side, I found a 40 percent increase in the use of midwives, and a rise in fees paid to providers for maternal and child services. These factors indicate with a high level of certainty that the CCT program lowers barriers to health care. 

Since health is effectively its own market, will increased demand for services cause a rise in price?

Yes, health care is its own market so the supply-demand relationship is relevant. My research looks at the local market because it depends upon the price being offered at the local clinic. Indonesia’s health care system is a public-private mixture, therefore public fees are regulated while private fees are less so. Indonesia now offers universal care, but people can pay a few for services beyond basic coverage. I saw a change in the private domain in terms of demand for services. The “demand shock” caused a bit of a higher price for services. It costs about $80 to meet all of the program requirements. Payment to midwives increased, while a slight decrease occurred for traditional birth attendants. I find no significant change in birth outcomes, and the quality provided by midwives does not appear to be affected by the program. These outcomes are exactly what we’d expect to see; it is consistent with the puzzle in the literature and economics, showing more women and children in the CCT program are seeking care from health care providers, but no change in health outcomes.

Can we expect increased utilization of health services in the long-run?

I anticipate there will be long-term increased utilization. The CCT program seeks to create habit formation by focusing on youth and pregnant mothers. For example, we can see this when expectant mothers attended the clinic for prenatal care, delivery assistance and postnatal care. With cost and travel barriers eliminated or reduced, participants should find it easier to initially come and then return. I did see repeat visits in my research as a positive outcome of the CCT program. A technique used to encourage commitment is a public education program as part of the program. Participants get a group briefing on how the program works, so that they are fully introduced to the incentives and guarantees of the program. 

Does Indonesia plan to extend this into a national program?

Yes, the CCT program is planned to go national later this year. The research shows that the benchmark of high attendance was met, program participants did “show up.” Next steps are to analyze health outcomes in maternal and child health, and then look at policy implications. Indeed, the Indonesian government is seeking ways to better target and deliver health services; it will be interesting to see the long-term effects of this program.

At the May 13-15 symposium on Fisheries and Food Security in China, 27 leading scientists and scholars from around the world gathered in Beijing to share research on the role of ocean fisheries, aquaculture, and marine ecosystems for improving food security in China.

Given China’s demographic changes, evolving nutritional requirements and dominant role in global fisheries, the key question of the symposium was whether marine ecosystems can be managed adequately to support the country’s future vision for domestic food security.

The symposium highlighted new research on the provision of wild fish for human consumption and for animal feeds. Scholars also shared insights on China’s aquaculture sector, including the tradeoffs involved in using wild fish in aquaculture feed.

The three-day meeting focused on critical questions about the future of fisheries and food security in China:

• How will China's seafood consumption evolve with a population that is growing in both size and wealth?
   
• How can China manage its seafood industry to maximize its own food security now and in the future?
   
• Can aquaculture take pressure off of wild fisheries, or does the inclusion of wild fish in aquaculture feed put more pressure on wild fish stocks?
   
• Can marine ecosystems be managed to protect both ocean health and food security?
   
• How does the global fish trade, including demand for luxury and medicinal seafood products, shape China's fish production industry, and vice versa?

Among the 26 participants were researchers and policy experts from Stanford University, Ocean University of China, University of Stirling, Shanghai Ocean University, University of Maine, South China Sea Fisheries Research Institute (CAFS), Yellow Sea Fisheries Research Institute (CAFS), Sustainable Fisheries Partnership, Stony Brook University, Xiamen University, Hainan University, Shandong University, Asia Pacific Fish Watch, Hong Kong University, International Institute of Sustainable Development, James Cook University, China Policy, Shanghai Jiao Tong University, and University of British Columbia Fisheries Centre.
 

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In between meetings held at the Stanford Center at Peking University, participants traveled to Beijing's largest fish market, where they observed local offerings and discussed trends in the global seafood trade with fish vendors. 

The symposium, funded by the Lenfest Ocean Program and chaired by FSE director Rosamond Naylor, kicks off a multi-year series of research papers and international meetings aimed at advancing the science around Chinese fisheries and food security. This ongoing international project will be coordinated by Professor Naylor and by Dr. Ling Cao, a postdoctoral fellow at FSE.

 

 

 

President Barack Obama announced this week that the United States would complete its pullout of troops from Afghanistan by the end of 2016, leaving 9,800 troops by the end of this year and cutting that in half by 2015. A small force will remain to protect the U.S. embassy in Kabul and help with local security. The president said this would free up combat troops for emerging terrorism threats in the Middle East and North Africa and effectively put an end to the longest war in U.S. history.

Ret. U.S. Army Lt. Gen. Karl Eikenberry, who was U.S. ambassador to Afghanistan from 2009-2011, answers a few questions about the way forward. Eikenberry is the William J. Perry Fellow in International Security at CISAC.

Critics say the drawdown is too dramatic and rapid and could seriously diminish the progress NATO and its allies have made in the country. What is your view?

I think the drawdown schedule is militarily sound and responsible. First, the commander on the ground has indicated his support for the timelines. Second, by the end of 2016 – the announced target date for completion of the military drawdown – our armed forces will have operated in Afghanistan for over 15 years. It will be time for the Afghan government, with continued U.S. and international material and security assistance support, to take full responsibility for the defense of its country. In fact, the president's announcement represents the culmination of combined U.S., NATO, and Afghanistan planning that began in 2010.

Third, militant extremists in distant lands often effectively exploit the presence of U.S. armed forces serving in their county to rally support for their cause. At some point, large scale U.S. military deployments can become counterproductive, undermining efforts to develop accountable responsible governance and security forces.     

 

Are the Afghans ready to take over the security operations in their country?

U.S. and NATO military forces have been complimentary about the performance of the Afghan National Army and Police since they began in 2012 to assume greater responsibility for securing their country. Certainly, the Afghan security forces did well protecting the recent April 5th presidential election. Their major challenges will be ensuring adequate international monetary support (perhaps $3 billion a year for some years to come) and adapting to a tactical environment in which they will not have access to U.S. and NATO firepower, logistics, communications, and intelligence. Combat against the Taliban will be more equal contests.

There are concerns that the Taliban is sitting in the wings, just waiting for the withdrawal of American troops. Are those concerns valid?  

I have heard this argument since I first served in Afghanistan in 2002. I don't buy it. By 2016 we'll be in the 15^th year of a military mission that began in 2001. Will another 15 years be adequate to prove we can "wait them out?" It is time for the Afghans to take charge of their own destiny. Furthermore, the Taliban are not a cohesive movement; there is not a centralized Taliban command "waiting in the wings." Last, the Taliban are not the primary threat to Afghan stability.The greater challenges are Pakistan's policies towards Afghanistan, Afghanistan national political reconciliation, and massive government corruption. 

What is the legacy that the United States leaves behind?

Most Afghans have told me over the years that the greatest U.S. legacy will be democracy and all that has brought. If Afghanistan is able to strengthen its political institutions and stabilize the country in the years after foreign forces return to their homes, I would agree that the introduction of democracy will be what we are remembered for. 

 

Sociologist Xueguang Zhou is no stranger to Stanford. He studied here as a doctoral student and returned to campus in 2006. He is now the Kwoh-Ting Li Professor in Economic Development and a senior fellow at the Freeman Spogli Institute for International Studies.

Zhou says it is a joy to be teaching in the very place he himself was intellectually trained. Recently, he spoke with the Shorenstein Asia-Pacific Research Center about his route to the Farm and his research focus on China’s urbanization and bureaucracy. 

How did you come to Stanford and the Center?

I completed my PhD in sociology at Stanford so it was a very easy and natural decision to come back as a professor. After graduating, I went to Cornell University and Duke University as well as spending two years in Hong Kong University of Science and Technology, but I always missed the exciting intellectual environment at Stanford. I have a lot of admiration for the faculty and research that takes place here. In 2006, the sociology department and Shorenstein APARC recruited me. I began to focus on China as a major research area after I had completed my Ph.D. My dissertation was actually centered on American universities. My joint appointment as a professor and as a senior fellow at Shorenstein APARC has been very complimentary. I teach in my trained area of sociology and explore my substantive interests in Chinese bureaucracy. I combine my teaching and research nicely to bridge the two sides. Additionally, this year, I will teach a summer graduate seminar at Stanford Center at Peking University.

What are the most pressing issues of China’s urbanization?

Urbanization processes in China have been underway for the last 10-20 years, in particular, the government is pushing very hard to accelerate this process. Suddenly, people have been pushed from rural to urban areas. Many are being forced to abandon their land and assume a new life away from their farming activities. This process raises many important questions, and is a main area of what I study. Chinese culture (way of life, organization, problem solving) is heavily drawn from rural tradition. Inherently urbanization has created tensions between tradition and the modern idea of Chinese society. Now we see a lot of contentious politics in China. Resistance, revolt and social movements are in part caused by this disruption of the social norms and tradition that had historically held the Chinese society together. Patterns of interaction between social groups have changed. So, what does this mean for society? And further to that, what is the new governance structure that emerges out of this? In rural China, governance in the past was based on kinship and local institutions, but the future is unclear. We need to research and understand the emergent governance structure in China. 

What impact has recent bureaucratic restructuring had on Chinese society? 

Right now, it is hard to say what effects the recent changes put forth at the Third Plenum will have on society. It is too soon to see any major effects on the long-term trend. My research focuses on the fundamental basis of Chinese structures and bureaucracies. Over the past two years, I have pursued analyzing Chinese bureaucracy through a historical lens. If we take a step back and observe these recent policy shifts in a greater timeline, we can see that local-level fluctuations are only temporary phenomena. For example, China’s new leadership recently launched a huge anti-corruption campaign. As a result, people in local-level bureaucracies have suddenly become much more careful about their behavior. But, how long will this behavior last? It is unlikely to last for very long. If we look at it from a longer perspective, we can see clear policy rhythms between centralization and decentralization over time. There may be short-term policy efforts to strengthen the central authority, but systematic institutional shifts are less likely.

Can you tell us about your methods and approach to your research on Chinese personnel structures?

I analyze archival data and conduct fieldwork in China to understand changes in bureaucracy. A primary way I conduct my fieldwork is participatory observations in a township-level government in China. When I visit this township government, I stay in a guestroom in the government building, and interact with local officials on a daily basis, observe their work and eat meals with them. Basically, I get to know them, their views and way of life. I also go to the nearby villages to interact with locals to gather their opinions about bureaucracy and the policy implementation processes. I also meet with other Chinese colleagues who conduct research on government behaviors, and we share and discuss our observations. Often times, they take me to different localities to visit government bureaus and to chat with local officials. All of these interactions give me great opportunities to learn about the Chinese bureaucracy. Close observations are key for me to identifying current issues in governance and bureaucratic structures, which I then compare to the historical legacy. This line of research is also connected to a project in collaboration with graduate students, analyzing the flow of bureaucrats in an entire province using public data. 

Tell us something we don’t know about you.

One aspect of my personal experience that I cherish is that, like many in my generation, I was sent to work in rural China after high school during the Cultural Revolution.  There I became a “team leader” in a village, responsible for organizing collective activities of over 200 villagers (about 50 households) and several hundreds “mu” of farming land, when I was only 17. This experience gave me a much deeper understanding of rural life in China.

The Faculty Spotlight Q&A series highlights a different faculty member at Shorenstein APARC each month giving a personal look at his or her scholarly approaches and outlook on related topics and upcoming activities.

Rod Ewing, chairman of the federal Nuclear Waste Technical Review Board, recently led a delegation of five board members and staff to China to learn about Beijing’s efforts to develop a deep-mined geologic repository for high-level radioactive waste.

During the visit to Beijing, the delegation met with officials at the China Atomic Energy Authority (CAEA) and the Ministry of Environmental Protection (MoEP). They also met with scientist and engineers at four scientific organizations and research institutes: the Chinese National Nuclear Organization (CNNC), Beijing Research Institute for Uranium Geology (BRIUG), the China National Nuclear Engineering Company (CNPE), and the Chinese Institute for Atomic Energy (CIAE).

“We had very complete summary presentations of the Chinese approach to nuclear waste management and the status of their present research and siting program for a geologic repository for high-level nuclear waste,” said Ewing, who is a senior fellow at FSI and CISAC’s Frank Stanton Professor in Nuclear Security.

Ewing was appointed by President Barack Obama in 2012 to serve as the chair of the Nuclear Waste Technical Review Board, which is responsible for the technical review of Department of Energy activities related to transporting, packaging, storing and disposing of spent nuclear fuel and high-level radioactive waste.

The delegation had an extended discussion with Xu Dazhe, Ewing’s counterpart as chairman of the CAEA. The visit in Beijing ended with a full-day technical exchange between scientists and engineers from both countries, as well as participants from institutes outside of Beijing and members of the NWTRB

The U.S. delegation visited a museum of uranium mineral, including a specimen of the first uranium ore discovered in Guangxi in 1954. The specimen had been presented to Chairman Mao Zedong and Zhou Enlai – marking the beginning of China’s nuclear industry.

The delegation heads to the remote northwestern region of Beishan to see China's proposed site for a nuclear waste repository. Photo Credit: Rod Ewing

The delegation then traveled to Beishan to examine the granite host rock in the remote northwestern Gansu Province, which is a potential site for an underground research laboratory and geologic repository for nuclear waste.

“Both countries can learn from one another, saving time and money for each country,” said Ewing, a professor of Geological and Environmental Sciences in the School of Earth Sciences at Stanford. “Nuclear waste management is an international effort in which cooperation is essential.”

China is pursing an aggressive campaign to expand its nuclear energy capacity and as part of an effort to meet growing energy demands, as well as to reduce air pollution from coal-fired plants. There are some 20 nuclear power reactors in China and another 28 under construction, according to the World Nuclear Association.

China has a policy of reprocessing its nuclear fuel and will be disposing of vitrified, high-level radioactive waste. The U.S. delegation was particularly interested in work on the properties of the vitrified waste in a disposal environment and understanding the Chinese strategy for disposal of HLW in a granitic host rock.

The Chinese are investigating a number of sites in granite in the Beishan region, located along the ancient Silk Road. Once a suitable site is located, the first step would be to establish an underground research laboratory for detailed scientific and engineering studies that will be required for a final geologic repository.

Mary Lou Zoback, a seismologist and consulting professor in the Geophysics Department at Stanford, was one of five board members on the trip. She was impressed that China intends to take five years to build an underground research laboratory and then conduct 20 years of testing before opening a repository.

The United States has been stalled for years in its proposed plan to build a similar deep geological repository for spent nuclear reactor fuel and radioactive waste at Yucca Mountain, adjacent to the Nevada Test Site. Environmentalists and local residents have opposed the project – factors that China routinely ignores.

“I think the most valuable thing in making the visit to China and visiting the site is really to gain an understanding of their program and also their general philosophy toward siting what, in this country, has been an extremely controversial project,” Zoback said. “They chose a remote area and they really haven’t even consulted with any of the surrounding towns – and that’s not what we do here. But I was extremely impressed that they recognized the need for this lab and would allow 20 years for all the scientific investigation that would be carried out to make sure it was safe.”

The Beishan region has five granitic sites that are being investigated as potential host rocks for the underground laboratory and possible repository. Board members discussed the geology and characteristics of the site with Chinese scientists and examined rock core and data that have been generated by their research program.

In addition to detailed investigations of granite, the Chinese also consider clay as a medium for a geologic repository and very deep borehole disposal, reaching proposed depths of up to 3 miles. One of the important issues is the methodology for the comparison of sites within a single type of geology or across different types of geology. The U.S. has a wide variety of geologies that may be suitable for disposal, including granite, clay, salt and volcanic tuff.

“The U.S. approach can be informed by the Chinese strategy,” Ewing said.

You can see more photos on the CNNC website.

Military interventions have traditionally been a source of controversy in the United States. But America’s appetite for the dispatch of armed forces has been diminished greatly by factors that have primarily emerged in the 21st century. These include, most painfully, the protracted campaigns in Afghanistan and Iraq that have made US political and military leaders more cautious about waging wars to end tyranny or internal disorder in foreign lands.

Debates on military intervention are complicated by the network of political, security and economic interests that must be balanced when contemplating this option. In this IISS commentary, Karl Eikenberry, the William J. Perry Fellow in International Security at CISAC, talks about how four factors have heavily influence the current calculus.

Military interventions have traditionally been a source of controversy in the United States. But America’s appetite for the dispatch of armed forces has been diminished greatly by factors that have primarily emerged in the 21st century. These include, most painfully, the protracted campaigns in Afghanistan and Iraq that have made US political and military leaders more cautious about waging wars to end tyranny or internal disorder in foreign lands.

Debates on military intervention are complicated by the network of political, security and economic interests that must be balanced when contemplating this option. In this IISS commentary, Karl Eikenberry, the William J. Perry Fellow in International Security at CISAC, talks about how four factors have heavily influence the current calculus.