Eyeglasses boosted the standardized test scores of rural Chinese schoolchildren as much as 18 percent in just six months, according to a large-scale, ongoing study led by Stanford researchers.

"The evidence is overwhelming," said Scott Rozelle, co-director of the Rural Education Action Program (REAP), a coalition of Chinese universities and Stanford's Freeman Spogli Institute for International Studies that works to improve education and health in rural China.

The initial test scores for nearsighted students hovered around 68 percent. After receiving glasses, average scores soared to 86 percent. "You do these simple interventions and a child's whole life changes," Rozelle said. "It's fantastic."

REAP scholars partnered with Chinese ophthalmologists and scores of graduate students to orchestrate the massive project, the first to examine vision problems in rural China.

In 2012 and 2013, the team screened the vision of approximately 20,000 fourth and fifth graders in rural Shaanxi and Gansu provinces and doled out more than 4,000 pairs of eyeglasses. They discovered that 25 percent of the students were nearsighted, but only one in seven of those nearsighted students had the glasses they needed.

"There's a huge amount of unmet need," said Matthew Boswell, a REAP project manager based at Stanford.

The results may seem intuitive. Yet, helping the millions of nearsighted children in rural China is anything but easy, the REAP team discovered. Few of these rural children (and adults) know they are nearsighted – the world, to them, is naturally blurry. In addition, eye doctors are concentrated in the populous coastal corridors or regional "county towns," often dozens of miles by bus from the homes of rural Chinese families, Boswell said.

Basic eyeglasses cost between 200 and 500 yuan ($30 to $80), a price out of reach for many, he said.

The researchers also struggled to counter pervasive superstitions about eyeglasses.

For example, many rural Chinese residents believe that glasses make children's' vision deteriorate, relying on the observation that vision generally worsens with age, Boswell said. In addition, many Chinese do "eye exercises" by rubbing their eyes, cheeks and temples each morning, a practice they believe improves vision, he said.

They also face political struggles: China's rural health care program doesn't pay for vision care. "We could tell health or education officials until we were blue in the face there was a high level of need for vision care in rural communities," Boswell said. "But if your findings are not attached to something they care about, it's hard to make them listen."

Hence the connection to the test scores, a highly valued measurement by Chinese policymakers. The REAP team taps its large network of Chinese academic collaborators to translate its research results into policy reform, a process that is often successful, Rozelle said.

REAP is currently analyzing alternative ways to boost the delivery and acceptance of eye care, Boswell said. The original study assigned nearsighted students into six groups.  Researchers gave one-third of the students glasses; one-third received a voucher to purchase glasses; and another third remained untreated. Then, half of the students in each group received training about the causes and treatments for vision problems.

The training failed to significantly affect whether students wore the glasses, Boswell said.  The students who had to invest time to acquire glasses using a voucher demonstrated similar usage rates as students who received free glasses, he said.

Among a variety of other initiatives currently underway, the REAP team is training Chinese teachers to conduct simple vision tests, Boswell said.

"It's an extreme feel–good example," Rozelle said. "You put the first pair of glasses on a kid … and then a huge smile lights up their face."

Becky Bach is a writer for the Stanford News Service.

Millions of women in India give birth at home, where they don’t have easy access to medical help if things go wrong. And things go wrong often. The country has one of the world’s highest rates of maternal and neonatal deaths.

To curb this problem, the government pays eligible pregnant women to deliver their babies in an accredited medical facility. With both a financial incentive and the promise of a safer childbirth, it would stand to reason that most Indian women should choose to deliver their babies in a hospital.

But that’s not the case.

Most babies are still born in homes. Early numbers from the financial incentive programs show less than half of eligible women are choosing to participate.

Stanford researchers Grant Miller and Nomita Divi think the answer to this quandary—and so many other well-intentioned policies that fall short—needs to first be considered from the perspective of patients, doctors and other health care providers. And that, they say, is a different approach than most health interventions take.

Miller and Divi are spearheading the Stanford India Health Policy Initiative, a program that seeks to rethink health interventions based on Indian health care users’ and providers’ motivations for seeking care. And to get there, the initiative’s focus comes from the people who confront these problems every day.

The program, which is connected to the International Policy Implementation Lab at Stanford’s Freeman Spogli Institute, first brings together community leaders for an in-depth discussion of where best to focus efforts. Next, teams (including students) take these recommendations and spend several months conducting fieldwork to understand health care decision-making, both from the side of patients and providers.  From this foundation, the initiative produces reports detailing the behavioral motivations for why certain dimensions of health care are or are not working.

“To really understand why health policies succeed or fail, you have to see the world through the eyes of the providers and patients,” said Miller, an associate professor of medicine and a core faculty member of FSI’s Center for Health Policy and Primary Care Outcome Research. “A lot of programs are created because they seem logical from the outside. But if you don't understand a patient’s priorities or motives, your program may not work.”

Miller and Divi first applied this approach to the very issue of childbirth in India. Why weren’t more women giving birth in hospitals when there were seemingly logical reasons to do so?

Over the summer, Miller, Divi, their Indian partners, and Stanford graduate and medical students set out to answer this question. During seven weeks of field interviews and subsequent analysis, the students—with guidance from Miller and Divi —identified reasons for why Indian women weren’t accepting a stipend to have their babies in the hospital. Some of these reasons included hidden costs of delivering a baby (like the transportation cost to the hospital or unexpected medical expenses), pressure from mothers-in-law to follow tradition and deliver at home, and fear of unwanted medical procedures like Caesarean sections or sterilization.

This understanding of why patients and providers don’t always make seemingly logical health care decisions is exactly what the India Health Policy Initiative is after.

“So much academic research is driven by donors or journal articles that we read,” Miller said. “So it seemed like we were starting from the wrong place in identifying health policy challenges that we should work on.”

In January, Miller and Divi convened a group of Indian health policy leaders, health care workers, academics and entrepreneurs to understand the challenges they faced in their daily work, and what health care questions they would most like to know more about. From this two-day meeting, the group identified two focus areas for the India Health Policy Initiative over the coming year: understanding more deeply the motivations and activities of both formal and informal health care providers, and what Indians value about care from the informal sector. These informal providers are often doctors or nurses with little or no medical training that are used by many low-income Indians.

To help answer these questions and provide opportunities for students, the Stanford India Health Policy Initiative engages top students from across the university. “We want to provide our students with an experience that will hopefully shape the way they think in their future careers,” said Divi, the initiative's project manager. “And we try to achieve this by training our students to help make sense of urgent health delivery challenges, immersing them in an intensive field experience, and teaching them how to generate insights.”

To better understand providers’ motivations, as well as patients’ perspectives on both the informal and formal providers, Miller and Divi will work with this new team to carry out qualitative fieldwork this summer.

Miller explained that the approach is very anthropological.

”To be able to understand these issues, we all have to see the world through another person’s eyes, whether that be a formal or informal health provider or a patient,” he said. “This approach fundamentally relies on strong collaboration with Indian partners.”

The initiative’s teams will spend their weeks interviewing different health care providers and patients in a handful of Indian villages, taking copious notes and ultimately translating hundreds of interviews into findings.

Roshan Shankar, MS/MPP ’14, worked as part of the initiative’s team last summer, focusing on understanding pregnant women’s decisions about where to deliver their babies. After considering several summer internships with consulting firms and international organizations, Shankar declined these opportunities, instead opting to work with the Stanford India Health Policy Initiative.

Shankar is from New Delhi and has always planned to move back to his home country and work in government after school. He said the India Health Policy Initiative was a way to better understand his nation and the pressing challenges facing it.

“I’m used to sitting at a table and not venturing out,” Shankar said. “This experience showed me that things are much more different on the ground than on paper.”

After his work with the Stanford Health Policy Initiative, Shankar said he is now certain he wants to return to India and work in government.

“It was a humbling and enlightening experience. I think the way we did this entire analysis will affect the way I do any work there,” he said. “It will ensure that I do a more effective evaluation of the policies and programs that I work on, and start by going to see people who use them.”

The Stanford India Health Policy Initiative is supported by several organizations including the Center for Innovation in Global Health and the Office of International Affairs.

Teal Pennebaker is a freelance writer.

The favelas of Rio de Janeiro are some of the most dangerous places in the world. Havens for drug lords and their booming narcotics businesses, the urban slums that are home to 20 percent of the city’s population are notorious for soaring murder rates and a dearth of public services. Police often have little or no presence in most of Rio’s 800 favelas. And when they do, their conflicts with criminals frequently result in the killing of bystanders.

Brazilian officials have tried to bring order to the favelas with a set of policies and initiatives launched in 2008. A so-called pacification program has trained special teams of police to take a more targeted approach to fighting crime. The program has increased stability and reduced violence in about 30 favelas.

But Stanford researchers have found a hitch: When criminals are put out of business in one favela, they relocate to another. And that can lead to an increase in violence in the non-pacified slums.

“The cost of violence is disproportionately felt by the poor,” said Beatriz Magaloni, an associate professor of political science and senior fellow at Stanford’s Freeman Spogli Institute for International Studies. “Where there is violence, there is no investment. We are working with the government and the police and the community on ways to make these places safer and reduce that poverty by improving the quality of the police and devising ways to reduce the level of lethality they tend to use.”

To support the research she’s doing and the relationships she’s building in Brazil, Magaloni is working with FSI’s International Policy Implementation Lab, a new initiative that will bolster impact-oriented international research, problem-based teaching and long-term engagement with urgent policy implementation problems around the world.

Collaborating with a team of Stanford students, Magaloni is working with community groups, police organizations, government officials and other scholars to study existing policies and training procedures that could broaden the pacification program and make it more effective. The relationships have paid off with access to high-level government data, exclusive research findings and a pipeline between academics and policymakers that can improve living conditions for some of Rio’s poorest and most vulnerable people.

Her project is an example of the work being supported by the International Policy Implementation Lab, which recently awarded Magaloni’s project and those led by five other researchers a total of $210,000.

The lab, which is being supported in part by an initial $2 million gift from two anonymous donors, will grant another round of funding later this fiscal year to support projects led by Stanford faculty.

Recognizing that many Stanford scholars are engaged in international policy analysis, the Implementation Lab will help researchers who want to better understand policy implementation – a process often stymied by bureaucracy, politicking and budget constraints, but also often reflecting deliberation and experimentation by people across different countries, organizations, and cultures.

“The Implementation Lab will help us better understand health, security, poverty and governance challenges in an evolving world,” said FSI Director Mariano-Florentino Cuéllar.  “It will serve as a resource to foster communication across projects, so we can learn more about how implementation plays out in different settings and regions. Through the Implementation Lab, we can better engage faculty and students in understanding how policymakers and organizations change longstanding practices and actually execute policy.”

The Implementation Lab will support long-term projects grounded in policy-oriented research on a specific international topic. The projects must strive to connect scholarly research to interdisciplinary teaching, and will often involve long-term engagement with particular problems or international settings to better understand and inform the implementation of policy.

The first round of funding from the Implementation Lab will help shore up projects aimed at bolstering rural education in China, improving health care in India, curbing violence in Mexico and Brazil, and training government officials and business leaders in developing countries to improve economic growth and development.

And it will support a project led by political scientist Scott Sagan that uses online polling to better gauge the public’s tolerance for the use of nuclear weapons under certain scenarios – work that will lead to the collection of data that can inform how government officials craft military and diplomatic strategy.

“I can imagine two big benefits of the Implementation Lab,” said Sagan, a senior fellow at FSI and the institute’s Center for International Security and Cooperation.

“It will help pay for specific tasks that are sometimes not adequately funded elsewhere, especially in terms of student involvement,” he said. “And it will create a greater focus on policy implementation work that allows us to present our research results and see whether those results will have an impact on change.”

To encourage and support these ventures, the Implementation Lab will provide targeted funding, space for research projects and teaching, and a variety of support functions, including connections to on-campus resources that can assist with data visualization, locating interested students, and other tasks.  Those activities will be phased in during the next year based on the advice and feedback of faculty and others who are early participants.

The Implementation Lab is poised to be different from – but complementary to – other Stanford initiatives like the Hasso Plattner Institute of Design. FSI’s Implementation Lab is specifically focused on supporting long-term relationships and engaging students and faculty in the study of policy implementation in different national, organizational, and cultural settings.

Image

FSI Senior Fellow Grant Miller is working on improving health care in India.

“The Stanford International Policy Lab is creating an exciting new community that will catapult our ability to have meaningful and sustained policy engagement and impact through common learning and sharing of experiences with like-minded scholars from all corners of campus,” said Grant Miller, an associate professor of medicine and FSI senior fellow whose project on improving health care in India is being supported by the Implementation Lab.

Ann Arvin, Stanford’s vice provost and dean of research, said the International Policy Implementation Lab will help and encourage faculty to make their scholarship more relevant to pressing problems.

Demands for specialized resources, narrowly focused engagement of students, the ability to consider a long-term horizon, and an understanding of the often opaque processes of policy formulation and implementation pose considerable challenges for researchers seeking to enhance the potential of their policy-oriented research to achieve real impact.

“The International Policy Implementation Lab will help our faculty and students address these obstacles,” Arvin said. “We anticipate that this novel program will bring together Stanford scholars who seek solutions to different policy-related problems at various places around the world, but whose work is linked by the underlying similarities of these challenges. The Implementation Lab will give them the opportunity to learn from each other and share ideas and experiences about what succeeds and what is likely to fail when it comes to putting policy into practice.”

That’s what attracts Stephen Luby to the lab.

“The mistake that researchers often make is that they work in isolation,” said Luby, whose work on reducing pollution caused by the brick making industry in Bangladesh is being supported by the Implementation Lab. “Then they think they’re ready to engage in the implementation process, and realize they haven’t engaged with all the stakeholders. Policy implementation is an iterative process. You need feedback from all the right people along the way.”

Luby, a professor of medicine and senior fellow at FSI and the Stanford Woods Institute for the Environment, is working with brick makers and suppliers, as well as anthropologists and government regulators, to identify better ways to curb the pollution created by the coal-burning kilns throughout Bangladesh.

“Pneumonia is the leading cause of death among kids in Bangladesh,” Luby said. “And the brick kiln pollution is largely responsible for that. They’re using a 150-year-old technology to bake bricks, and there are better, cleaner ways to do it.”

But swapping coal-burning kilns for ones that are fired with cleaner natural gas is expensive, and there is little incentive for brick makers to change.

The government has passed regulations aimed at reducing pollution, but corruption, toothless laws and poor enforcement continue to undermine those policies.

"The country is caught in an equilibrium where people are getting cheap bricks but at a high cost to health and the environment,” Luby said. “We need to disrupt that equilibrium, and I look to the Implementation Lab to help us think this through. There’s a community of scholars who want to transform their work into implementation, and the lab will help convene them." 

The favelas of Rio de Janeiro are some of the most dangerous places in the world. Havens for drug lords and their booming narcotics businesses, the urban slums that are home to 20 percent of the city’s population are notorious for soaring murder rates and a dearth of public services. Police often have little or no presence in most of Rio’s 800 favelas. And when they do, their conflicts with criminals frequently result in the killing of bystanders.

Brazilian officials have tried to bring order to the favelas with a set of policies and initiatives launched in 2008. A so-called pacification program has trained special teams of police to take a more targeted approach to fighting crime. The program has increased stability and reduced violence in about 30 favelas.

But Stanford researchers have found a hitch: When criminals are put out of business in one favela, they relocate to another. And that can lead to an increase in violence in the non-pacified slums.

“The cost of violence is disproportionately felt by the poor,” said Beatriz Magaloni, an associate professor of political science and senior fellow at Stanford’s Freeman Spogli Institute for International Studies. “Where there is violence, there is no investment. We are working with the government and the police and the community on ways to make these places safer and reduce that poverty by improving the quality of the police and devising ways to reduce the level of lethality they tend to use.”

To support the research she’s doing and the relationships she’s building in Brazil, Magaloni is working with FSI’s International Policy Implementation Lab, a new initiative that will bolster impact-oriented international research, problem-based teaching and long-term engagement with urgent policy implementation problems around the world.

Collaborating with a team of Stanford students, Magaloni is working with community groups, police organizations, government officials and other scholars to study existing policies and training procedures that could broaden the pacification program and make it more effective. The relationships have paid off with access to high-level government data, exclusive research findings and a pipeline between academics and policymakers that can improve living conditions for some of Rio’s poorest and most vulnerable people.

Her project is an example of the work being supported by the International Policy Implementation Lab, which recently awarded Magaloni’s project and those led by five other researchers a total of $210,000.

The lab, which is being supported in part by an initial $2 million gift from two anonymous donors, will grant another round of funding later this fiscal year to support projects led by Stanford faculty.

Recognizing that many Stanford scholars are engaged in international policy analysis, the Implementation Lab will help researchers who want to better understand policy implementation – a process often stymied by bureaucracy, politicking and budget constraints, but also often reflecting deliberation and experimentation by people across different countries, organizations, and cultures.

“The Implementation Lab will help us better understand health, security, poverty and governance challenges in an evolving world,” said FSI Director Mariano-Florentino Cuéllar.  “It will serve as a resource to foster communication across projects, so we can learn more about how implementation plays out in different settings and regions. Through the Implementation Lab, we can better engage faculty and students in understanding how policymakers and organizations change longstanding practices and actually execute policy.”

The Implementation Lab will support long-term projects grounded in policy-oriented research on a specific international topic. The projects must strive to connect scholarly research to interdisciplinary teaching, and will often involve long-term engagement with particular problems or international settings to better understand and inform the implementation of policy.

The first round of funding from the Implementation Lab will help shore up projects aimed at bolstering rural education in China, improving health care in India, curbing violence in Mexico and Brazil, and training government officials and business leaders in developing countries to improve economic growth and development.

And it will support a project led by political scientist Scott Sagan that uses online polling to better gauge the public’s tolerance for the use of nuclear weapons under certain scenarios – work that will lead to the collection of data that can inform how government officials craft military and diplomatic strategy.

“I can imagine two big benefits of the Implementation Lab,” said Sagan, a senior fellow at FSI and the institute’s Center for International Security and Cooperation.

“It will help pay for specific tasks that are sometimes not adequately funded elsewhere, especially in terms of student involvement,” he said. “And it will create a greater focus on policy implementation work that allows us to present our research results and see whether those results will have an impact on change.”

To encourage and support these ventures, the Implementation Lab will provide targeted funding, space for research projects and teaching, and a variety of support functions, including connections to on-campus resources that can assist with data visualization, locating interested students, and other tasks.  Those activities will be phased in during the next year based on the advice and feedback of faculty and others who are early participants.

The Implementation Lab is poised to be different from – but complementary to – other Stanford initiatives like the Hasso Plattner Institute of Design. FSI’s Implementation Lab is specifically focused on supporting long-term relationships and engaging students and faculty in the study of policy implementation in different national, organizational, and cultural settings.

Image

FSI Senior Fellow Grant Miller is working on improving health care in India.

“The Stanford International Policy Lab is creating an exciting new community that will catapult our ability to have meaningful and sustained policy engagement and impact through common learning and sharing of experiences with like-minded scholars from all corners of campus,” said Grant Miller, an associate professor of medicine and FSI senior fellow whose project on improving health care in India is being supported by the Implementation Lab.

Ann Arvin, Stanford’s vice provost and dean of research, said the International Policy Implementation Lab will help and encourage faculty to make their scholarship more relevant to pressing problems.

Demands for specialized resources, narrowly focused engagement of students, the ability to consider a long-term horizon, and an understanding of the often opaque processes of policy formulation and implementation pose considerable challenges for researchers seeking to enhance the potential of their policy-oriented research to achieve real impact.

“The International Policy Implementation Lab will help our faculty and students address these obstacles,” Arvin said. “We anticipate that this novel program will bring together Stanford scholars who seek solutions to different policy-related problems at various places around the world, but whose work is linked by the underlying similarities of these challenges. The Implementation Lab will give them the opportunity to learn from each other and share ideas and experiences about what succeeds and what is likely to fail when it comes to putting policy into practice.”

That’s what attracts Stephen Luby to the lab.

“The mistake that researchers often make is that they work in isolation,” said Luby, whose work on reducing pollution caused by the brick making industry in Bangladesh is being supported by the Implementation Lab. “Then they think they’re ready to engage in the implementation process, and realize they haven’t engaged with all the stakeholders. Policy implementation is an iterative process. You need feedback from all the right people along the way.”

Luby, a professor of medicine and senior fellow at FSI and the Stanford Woods Institute for the Environment, is working with brick makers and suppliers, as well as anthropologists and government regulators, to identify better ways to curb the pollution created by the coal-burning kilns throughout Bangladesh.

“Pneumonia is the leading cause of death among kids in Bangladesh,” Luby said. “And the brick kiln pollution is largely responsible for that. They’re using a 150-year-old technology to bake bricks, and there are better, cleaner ways to do it.”

But swapping coal-burning kilns for ones that are fired with cleaner natural gas is expensive, and there is little incentive for brick makers to change.

The government has passed regulations aimed at reducing pollution, but corruption, toothless laws and poor enforcement continue to undermine those policies.

"The country is caught in an equilibrium where people are getting cheap bricks but at a high cost to health and the environment,” Luby said. “We need to disrupt that equilibrium, and I look to the Implementation Lab to help us think this through. There’s a community of scholars who want to transform their work into implementation, and the lab will help convene them.”

For more information about FSI's International Policy Implementation Lab, please refer to this Concept Note or contact Elizabeth Gardner.