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Global Health Economics, China, & the Science of Health Care Delivery in the Digital Age


Advances in artificial intelligence, use of "big data", digital platforms enabling mass collaboration, automation, the "internet-of-things" and other so-called "4th Industrial Revolution" (4IR) technologies are enabling a radical shift in how healthcare is delivered. Few places are attempting to integrate these technologies into healthcare as rapidly as China. This talk will discuss China's comparative advantage in the adoption of these technologies and lay out a research agenda for the economics of digital health. While these technologies bring potential to produce massive improvements in access to high-quality care and lower costs, this result is far from certain. Beyond mere technical uncertainty, 4IR technologies are likely to produce profound changes in healthcare markets by altering the nature of incentives in the health system and relationships between patients, providers, payers. Evidence on these issues is needed to inform policy and regulation aiming to maximize social value and mitigate unintended consequences. Specific applications will be drawn from online research in China and other middle-income countries.


About the Speaker

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Sean Sylvia headshot.

Sean Sylvia is an Assistant Professor of health economics at UNC. His primary research interest is in the delivery of healthcare in China and other middle-income countries. Working with multidisciplinary teams of collaborators, he conducts large-scale population-based surveys and randomized trials to develop and test new approaches to provide healthcare to the poor and marginalized. His recent work focuses on the use of information technology to expand access to quality healthcare. 


For more information, please visit his personal website.


This event will be held in-person at Stanford University, masks are not required but strongly encouraged.

Questions? Contact sccei-communications@stanford.edu


 

Philippines Room, C330, Encina Hall, Stanford University

Sean Sylvia
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Rose Gottemoeller
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Just days into Russia’s invasion of Ukraine, Dmitri Medvedev, the former president and prime minister of Russia, took to social media to post a chilling message. He raged against Western sanctions on his country and suggested darkly that Russia could rip up some of its most important agreements with the West. He mentioned the New START treaty, the nuclear arms reduction agreement signed with the United States over a decade ago, but the threat was broader still: the sundering of all diplomatic ties with Western countries. “It’s time to hang huge padlocks on the embassies,” he wrote.

Read the rest at Foreign Affairs

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With Russia Going Rogue, America Must Cooperate With China

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After months of watching hundreds of new nuclear missile silos being dug in the dirt northwest of Beijing, it is welcome news that President Joe Biden and Chinese President Xi Jinping seemingly agreed at last week’s summit on the need for strategic stability talks. Strategic stability — the idea that nuclear-armed countries should not be able to gain decisive advantage over one another — has taken on new importance as China expands and modernizes its nuclear arsenal.

China is expected to quadruple its number of warheads in the next decade, and is upgrading its nuclear capabilities with new missiles, submarines and bombers. Over the summer, it reportedly fired a missile from a hypersonic glide vehicle while testing its fractional orbital bombardment system (FOBS) — a technical advance that, if true, means the Chinese can attack targets from space with nuclear weapons. Although China insists it will never be the first to use nuclear weapons, this claim has less credence than in the past, when the country’s nuclear force was much smaller.

Read the rest at Politico 

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After months of watching hundreds of new nuclear missile silos being dug in the dirt northwest of Beijing, it is welcome news that President Joe Biden and Chinese President Xi Jinping seemingly agreed at last week’s summit on the need for strategic stability talks.

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One out of every three children under age 5 in developing countries lives in conditions that impede human capital development. In this study, we survey the literature on parenting training programs implemented before age 5, with the aim to increase parental investment in human capital accumulation in developing countries. Our review focuses on the implementation and effectiveness of parenting training programs (i.e., training in child psychosocial stimulation and/or training about nutrition). We emphasize the mechanisms that drive treatment-induced change in human capital outcomes and identify the demand- and supply-side behaviors that affect efficacy and effectiveness. Although the literature includes evidence on program features that are associated with successful interventions, further evidence on the dynamics of human capital formation, documentation of medium- to long-term persistence of treatment impacts, and research on the implementation and evaluation of programs at scale are needed to delineate a scalable and inclusive program that provides long-term treatment impacts.

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Annual Review of Resource Economics
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Scott Rozelle
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This paper examines the impact of parental beliefs on child development outcomes (for both cognitive and social–emotional skills) based on a three-wave longitudinal survey in rural China. The survey waves were conducted when the sample children were 18–30 months, 22–36 months, and 49–65 months, respectively. A total of 815 children and their primary caregivers who participated in all three wave surveys were enrolled in this study. Using difference-in-differences and propensity score matching approaches, the results indicate that strengthened parental beliefs have a positive and significant impact on child social–emotional development. Specifically, between the periods of the Wave 1 survey (when children were 18–30 months old) and the Wave 3 survey (when children were 49–65 months old), and between the Wave 2 survey (when children were 22–36 months old) and the Wave 3 survey, strengthened parental beliefs were causally associated with more favorable child social–emotional scores by 0.44 SD (p < 0.01) and 0.49 SD (p < 0.01), respectively. No significant impact, however, was found between the period of the Wave 1 survey and the Wave 2 survey. In contrast, weakened parental beliefs had a negative and significant impact on child social–emotional development. Specifically, weakened parental beliefs were causally associated with worse child social–emotional abilities by 0.35 SD (p < 0.01), 0.30 SD (p < 0.01), and 0.22 (p < 0.05) for the time period of the Wave 1 to Wave 2, Wave 1 to Wave 3, and Wave 2 to Wave 3, respectively. No significant impact of parental beliefs, however, was found on child cognitive development. In addition, the findings of the mediation analysis show that only a marginal impact of parental beliefs on child social–emotional development can be indirectly explained by parental beliefs through parenting practices. This study calls on policy makers to improve parental beliefs and parenting practices in the hope that it will lead to better child development in rural China.

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International Journal of Environmental Research and Public Health
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Michael Breger
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For as long as policymakers and scholars of international relations have sought to understand the actions of actors on the global stage, they have also debated the intentions of governments and the role those intentions play in statecraft. In a new article in the Journal of Chinese Political Science, Center Fellow Oriana Skylar Mastro proposes a new research agenda for deciphering Chinese intentions. She argues that the current treatment of intentions in international relations is not granular enough to allow for a nuanced understanding of what China wants, how it plans to achieve it, and what the implications will be for the United States and the U.S.-led world order.


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Mastro suggests that there are theoretical and empirical issues with how existing scholarly accounts have defined, measured, and operationalized intentions in the context of understanding China’s rise. She presents five propositions that should drive research moving forward. 

Her first point in advancing a theory of intentions requires a definition distinct from aspirations, motives, preferences, objectives, goals, and grand strategy. She argues that “intentions consist of purposefully designing or manipulating means to achieve some end,” implying “clear formulation and deliberateness.”

Second, a theory of intentions should analytically separate ends from means but include both process intentions and outcome intentions, says Mastro. Process intentions refer to “the preferred methods and the factors that influence how a country thinks it is best to achieve its goals,” outcome intentions to “what one wants to bring about, accomplish or attain.” Scholars thus need to differentiate between what China wants and how it plans to achieve those goals. For example, some argue that China is a “revisionist” power seeking to increase its influence by changing aspects of the international order to further its interests, not a “revolutionary” power intending to upend the system entirely. But more accurately, Mastro notes, “China has revisionist outcome intentions, not process intentions, with respect to international institutions; countries are revolutionary powers when they have both.”

Chinese intentions to control more of the South China Sea are detrimental to U.S. interests, even if China pursues those interests without using force
Oriana Skylar Mastro
Center Fellow

Another problem is that existing measurements of intentions tend to rely on values that are largely subjective and uninformative in explaining what a country is doing and how others should respond. For example, scholars often see revisionist intentions as bad and status quo intentions as good. But Mastro points out that the United States was revisionist after WWII: it set up the network of international institutions that make up the current international system. Why, then, should we ascribe a negative label to China’s revisionist efforts to leverage those institutions for its benefit? According to Mastro, it is more accurate to assess whether intentions are detrimental or beneficial for specific actors. For example, “Chinese intentions to control more of the South China Sea are detrimental to U.S. interests, even if China pursues those interests without using force." 

Fourth, Mastro contends that states’ intentions vary not only by issue area but also within a particular issue area, and therefore it is empirically problematic to analyze one variable describing everything a state wants. She argues that a state’s intentions can vary even within specific spheres of activity, such as security, and in many cases, a particular issue cannot be dissected cleanly into economic or security tropes like China’s One Belt, One Road initiative.

Her fifth proposition addresses a debate in the literature about uncertainty and intentions: while there may be uncertainty about intentions, that does not make them unknowable. Mastro suggests that, in practice, “current intentions are knowable to a great degree... future intentions are less knowable, as states have yet to formulate them — but how the pursuit of current intentions unfolds largely shapes future intentions.”

The study of China and its intentions must be more granular and deeply data-driven, Mastro concludes. The view that “China is revisionist/bad and the United States is status quo/good” risks creating a series of assumptions that hamper good policy, she warns. Embracing the five propositions she lists will allow for a more productive research agenda and policy recommendations based on data instead of “wishful thinking.” For Mastro, this new framework is an important launching pad from which U.S. policymakers not only can better consider China’s intentions but also think innovatively about how to win over partners and build new types of power.

Read the article by Mastro

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Deciphering China’s intentions is a pressing task for U.S. scholars and policymakers, yet there is a lack of consensus about what China plans to accomplish. In a new study that reviews the existing English and Chinese language literature on intentions and revisionism, Center Fellow Oriana Skylar Mastro offers five propositions to allow for a more productive and data-driven approach to understanding Beijing’s intentions.

Paragraphs

What are intentions and how should states decipher them? For scholars, the debate about uncertainty and intentions lies at the heart of international relations. And yet there are theoretical and empirical issues with how scholars have defined, measured, and operationalized intentions to date in the context of understanding China’s rise.

This article reviews the English and Chinese language literature on intentions and revisionism and presents five propositions that should drive research moving forward. First, a theory of intentions requires a definition distinct from aspirations, motives, preferences, objectives, goals, and grand strategy. Second, states’ intentions about ends should be analyzed independently from those about means. Third, assessments of whether a country’s intentions are good or bad are subjective and vary based on from which country’s perspective the analysis is undertaken. Fourth, states’ intentions vary not only by issue area, but also within a particular issue area, just as international institutions, or territorial disputes. And lastly, while there may be uncertainty about intentions, that does not make them unknowable.

Embracing these five propositions allow for a more productive research agenda and policy recommendations based on data-driven research instead of wishful thinking.

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Oriana Skylar Mastro
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Noa Ronkin
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When U.S. Secretary of State Antony Blinken, in a major China policy speech on May 26, 2022, outlined the Biden administration's strategy to outcompete China, he noted that China “has announced its ambition to create a sphere of influence in the Indo-Pacific and to become the world’s leading power.” But what exactly is China's influence, and how do we know it when we see it? These are some of the questions Dr. Enze Han seeks to answer.

Han, an associate professor at the University of Hong Kong's Department of Politics and Public Administration, joined APARC as a Lee Kong Chian NUS-Stanford Fellow on Contemporary Southeast Asia for the 2022 spring quarter. The fellowship, which is hosted jointly by APARC’s Southeast Asia Program (SeAP) and the Faculty of Arts and Social Sciences at the National University of Singapore, enabled Han to advance his research into Southeast Asia’s relations with China. He recently discussed his work in a seminar hosted by SeAP.

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Conceptualizing China as an Unconventional Great Power

Most studies on China’s presence in Southeast Asia tend to focus on China’s power dynamics and how it wields it to gain influence within the region. The emphasis is on intention and causation: how China willingly uses its power to coerce, coopt, or persuade Southeast Asian states to behave in particular ways. This characterization, Han argues, ignores the contemporary Chinese state as fragmented, decentralized, and internationalized. Han goes beyond this conventional approach to explore the variety of actors and the intended versus unintended outcomes associated with China’s presence in Southeast Asia. It is necessary to understand such nuance and complexity, he claims, if we are to make sense of China’s relations with Southeast Asian states.

China’s presence in Southeast Asia is by no means monolithic, notes Han. Rather, it takes numerous everyday forms and involves not only state actors, such as diplomatic missions and state-owned enterprises, but also non-state actors that may or may not be closely associated with the Chinese state. These include civil society organizations, private businesses, and ordinary Chinese citizens who reside in Southeast Asia for work, study, or retirement, in addition to Chinese tourists. The actions of these multiple stakeholders can have intended and unintended consequences, Han argues. In particular, the effects of non-state Chinese actors’ daily encounters with local communities in Southeast Asia deserve attention, he says.

Shadow Economy and Offshore Gambling in Eastern Myanmar

Consider, for instance, the case of the “new city” of Shwe Kokko in Myanmar’s Southeastern Kayin State (known as 'Karen State' among the ethnic-Karen population living there), on the border with Thailand. The emerging “Chinatown” project in Shwe Kokko began attracting international attention as capital investment flowed into the former farmland on the banks of the Moei River and residential complexes, hotels, shops, Chinese restaurants, and glitzy casinos sprang up. Allegations of Chinese mafia involvement have plagued the massive city project, and media outlets and Western observers attributed culpability to the Chinese government, portraying the project as part of the Belt and Road Initiative.

However, Han points out that empirical details show that the new city project was led by a company headed by a fugitive Chinese businessman fleeing the Chinese government’s crackdown on illegal offshore gambling. Therefore, Shwe Kokko is not quite a case of Chinese Belt and Road Initiative expansionism using complex networks of PRC citizens and ethnic Chinese in a neighboring country to fuel dangerous activities colluding with Chinese officials and government agencies. Instead, it demonstrates how shadow economies like the online gambling industry are responding to regulatory attempts by the Chinese state. According to Han, to make sense of the Shwe Kokko story, one must understand who the non-state actors are and how they interact with local communities in Southeast Asian borderlands.

Market Demand and Agricultural Transformation in Northern Myanmar

Now turn to Northern Myanmar, where Han conducted fieldwork in 2019. Over the past decade, he explains, Northern Myanmar has undergone accelerated deforestation due to rising agricultural production in response to increasing demand for grains such as maize and their elevated global commodity market prices. In Myanmar’s Shan State, which borders China, the expansion of maize cultivation is closely related to a surge in Chinese demand for animal feed resulting from the rising domestic consumption of meat. However, a Chinese state ban on maize import from Myanmar had created rampant smuggling coupled with irregular enforcement of border inspections and schisms between the commodity production cycle and financing for local farmers.

One may draw a correlation between the rising demand for meat consumption in China that seemingly created a ripple effect in Myanmar, leading to the expansion of maize cultivation, deforestation, and economic precarity for local farmers. But then again, is this a case of Chinese influence operations? There is no evidence pointing to such deliberate attempts by the Chinese state to influence its neighboring country, although the resulting economic and environmental consequences are related to conditions in China.

Thus, Han argues, understanding an increasingly globalized China and its variegated impacts around the world requires conceptual flexibility. In particular, when referring to China's presence and influence in Southeast Asia, one must not assume a monolith with hegemonic designs for its neighboring states but rather differentiate between multiple types of actors with long histories and multifaceted consequences, both intended and unintended.

Enze Han

Enze Han

Lee Kong Chian NUS-Stanford Fellow on Contemporary Southeast Asia, 2021-2022
Full Biography

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Departing from international relations scholarship and popular media accounts that tend to portray China as a great power intent on establishing a sphere of influence in Southeast Asia, Lee Kong Chian NUS-Stanford Fellow on Southeast Asia Enze Han argues for conceptualizing China as an unconventional great power whose diverse actors, particularly non-state ones, impact its influence in the region.

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The Hoover Project on China’s Global Sharp Power and the Stanford Center on China's Economy and Institutions invite you to Banking on Beijing: The Aims and Impacts of China’s Overseas Development Program on Tuesday, June 7 from 2 - 3PM PT.

Is China a “rogue donor” that uses its largesse to prop up corrupt and authoritarian regimes? Does Beijing bankroll politically motivated and economically inefficient ‘‘white elephants”? What are the risks of borrowing from Beijing? The existing debate about China’s overseas lending and grant-giving activities is largely guided by opinion and conjecture rather than rigorous evidence. In this talk, Dr. Parks will set the record straight with a new dataset of international development finance from China that captures 13,427 projects worth $843 billion across 165 countries over an 18-year period.


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Banking On Beijing: The Aims And Impacts Of China’s Overseas Development Program even speaker line up.

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Oriana Skylar Mastro
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This opinion piece first appeared in the New York Times.


President Biden’s recent trip to Asia nearly went off without a hitch — until Taiwan came up. Mr. Biden was asked whether the United States would respond “militarily” if China sought to retake the self-ruled island by force.

“Yes,” he said. “That’s the commitment we made.”

It was one of the most explicit U.S. defense guarantees for Taiwan in decades, appearing to depart from a longtime policy of “strategic ambiguity.” But it’s far from certain that the United States could hold off China.

I have been involved in dozens of war games and tabletop exercises to see how a conflict would turn out. Simply put, the United States is outgunned. At the very least, a confrontation with China would be an enormous drain on the U.S. military without any assured outcome that America could repel all of China’s forces. Mr. Biden’s comments may be aimed at deterring a Chinese attack, and hopefully they will.

After a decades-long military modernization, China has the world’s largest navy and the United States could throw far fewer ships into a Taiwan conflict. China’s missile force is also thought to be capable of targeting ships at sea to neutralize the main U.S. tool of power projection, aircraft carriers. The United States has the most advanced fighter jets in the world but access to just two U.S. air bases within unrefueled combat radius of the Taiwan Strait, both in Japan, compared with China’s 39 air bases within 500 miles of Taipei.

If China’s leaders decide they need to recover Taiwan and are convinced that the United States would respond, they may see no other option but a pre-emptive strike on U.S. forces in the region. Chinese missiles could take out key American bases in Japan, and U.S. aircraft carriers could face Chinese “carrier killer” missiles. In this scenario, superior U.S. training and experience would matter little.


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The need to project power across vast distances also makes U.S. forces vulnerable to China’s electronic and cyberwarfare capability. China could disrupt networks like the United States Transportation Command, which moves American assets around and is considered vulnerable to cyberattacks. China may also have the ability to damage satellites and disrupt communications, navigation, targeting, intelligence-gathering, or command and control. Operating from home turf, China could use more-secure systems like fiber-optic cables for its own networks.

Under a best-case battle scenario for the United States, China would attack only Taiwan and refrain from hitting American forces to avoid drawing in U.S. military might. This would allow the United States time to bring its forces into the region, move others to safety and pick where and when it engages with China.

If the United States did ever intervene, it would need regional allies to provide runways, ports and supply depots. But those partners may be eager to stay out of the crossfire.

I’m not the only one who’s worried. A 2018 congressionally mandated assessment warned that America could face a “decisive military defeat” in a war over Taiwan, citing China’s increasingly advanced capabilities and myriad U.S. logistical difficulties. Several top former U.S. defense officials have reached similar conclusions.


Mr. Biden’s remarks were made in the context of Ukraine, and America’s failure to prevent that war may be driving his thinking on Taiwan. Mr. Biden may be calculating that Russia’s setbacks in Ukraine will give China pause and that guaranteed U.S. intervention in a conflict over Taiwan would cost Beijing too much, even if it took the island.

But comparing Ukraine and Taiwan is problematic. Beijing views Taiwan — self-ruled since 1949 — as an integral part of Chinese territory since ancient times, a significantly deeper attachment than Vladimir Putin’s obsession with Ukraine. Reunifying the island with the mainland is one of the Chinese Communist Party’s most cherished goals, and China would see U.S. intervention as a bitter betrayal of the “one China” principle — the idea that China and Taiwan belong together, which Washington has acknowledged since the 1970s.

China’s military is bigger and more formidable than Russia’s, and its economy far larger, more resilient and globally integrated. Rallying support for economic sanctions against Beijing during a conflict — China is the biggest trading partner of many countries — would be more challenging than isolating Russia.

The White House is once again walking back Mr. Biden’s comments, saying official policy has not changed.

If so, then Mr. Biden should stop rocking the boat and focus instead on strengthening America’s position in the Taiwan theater. This doesn’t just mean more weapons for Taiwan and a more robust U.S. military presence in the region, though the former would help the island hold out if China attacked, and both would boost deterrence.

It also means shrewd diplomacy. Mr. Biden needs to stand firm against Chinese intimidation of Taiwan, while working to ease Beijing’s anxieties by demonstrating a stronger U.S. commitment to a peaceful resolution of the Taiwan issue. Mr. Biden should also persuade regional friends to provide more bases for the United States to use. This not only increases U.S. operational flexibility but also heightens deterrence.

Whatever Mr. Biden’s calculations, departing from the “strategic ambiguity” that has helped keep peace for decades misses the point. The main question for President Xi Jinping must be not whether the United States would join in, but whether China could beat the United States in a battle for Taiwan. Twenty years ago, China’s poorly trained army and largely obsolete naval and air forces had no chance. But that was then.

Many will applaud Mr. Biden for standing up for democratic Taiwan in the face of Chinese threats. But he could be putting the island in greater danger, and the United States may not be able to come to the rescue.

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Many will applaud Mr. Biden for standing up for democratic Taiwan in the face of Chinese threats. But he could be putting the island in greater danger, and the United States may not be able to come to the rescue.

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