Argument and Contribution

At the national level, the United States struggled to effectively respond to the COVID-19 pandemic: federal policy was delayed and inconsistent, supply shortages were widespread, and political pressure undermined accurate public health guidance. At the state and local levels, however, there was a great deal of variation in terms of the capacity to respond to COVID. While indicators of state capacity often focus on “formal” indicators like institutional resources, staffing, and finances, translating formal capacities into effectively implemented policies is neither a simple nor an automatic process. 

In “Building the Plane While Flying,” Didi Kuo and Andrew S. Kelly draw our attention to the importance of informal indicators of public health capacity. These include strong relationships within and across government agencies, the embeddedness of health officers in local communities, and prior experience with responding to disasters, among other factors. The authors argue that local governments with strong informal capacity were better able to communicate with and learn from one another, as well as to gain the trust of community members, during the pandemic. Conversely, localities with otherwise strong formal capacities often failed to respond to the challenges at hand. This is because they were unable to effectively leverage their relationships and organizational networks.
 

Kuo and Kelly’s paper is informed by qualitative analysis of California’s public health institutions as well as in-depth interviews with health officers across seventeen Northern, Central, and Southern California counties. The interviews illuminate the concrete processes by which local governments responded (or struggled to respond) to the COVID-19 pandemic. One of the paper’s key contributions is to push us to conceptualize state capacity more broadly and to focus on the factors that drive not just policy development, but policy implementation. 

The Importance of Informal Capacity

The bulk of the paper disaggregates informal capacity into its various mechanisms and processes. Each of these proves to be crucial in explaining different pandemic outcomes at the local level. One such mechanism is coordination within local governments. To illustrate this, consider public health officers, who enjoy broad legal powers to protect public health as well as financial resources and personnel at their disposal. By law, officers possess significant capacities to mitigate health crises. Yet across the interviews, health officers reported that effectively implementing COVID-19 policy required their cooperation and communication with a host of actors, including the County Counsel (the county’s top lawyer), Chief Administrative Officer, and Board of Supervisors, which is charged with appointing health officers.
 

Closely related to intra-governmental coordination is the importance of autonomy, particularly in the face of political pressure. For example, boards of supervisors sometimes undermined the public guidance provided by health officers. (This guidance could range from the need to close schools to officers simply communicating truthfully with localities about COVID-19 risks.) Overcoming efforts by board members to ignore or muzzle officers required coordination between those actors who were more insulated from political pressure.

Another key component of informal capacity was prior experience responding to emergencies and California’s myriad of natural disasters, such as fires, floods, or mudslides. Health officers from more experienced counties noted their ability to draw upon established emergency procedures and partnerships. For example, some counties had previously cooperated with each other, as well as with independent agencies like the Red Cross, to provide aid and shelter to those affected by wildfires. These experiences — for which no amount of financial resources or personnel can substitute — served as templates to help coordinate COVID-19 policy responses.

Informal capacity also depended upon health departments effectively communicating with the public. Many departments initially lacked the infrastructure to do this, and therefore relied on cooperation with other actors like school superintendents, sheriffs, and community leaders. Some counties created toolkits to improve their community’s understanding of personal protective equipment (PPE) or even produced local TV shows. Still others scheduled conference calls with local hospitals, faith leaders, and nursing homes. Given that many of these communication efforts were improvised, public health officers stressed the importance of formalizing coordination between state and nonstate actors so as to improve emergency preparedness in the future.
 

In addition to coordination within local governments, effective policy-making and communication required coordination across governments. One such institution was the Association of Bay Area Health Officers (ABAHO), founded in the 1980s during the HIV/AIDS epidemic. ABAHO members had also coordinated policy responses to the H1N1 outbreak. These cross-county partnerships enabled early, rapid, and unified responses to the COVID-19 pandemic. By contrast, the authors find that regions without such networks faced greater challenges in developing and implementing public policy.

A final aspect of informal capacity is the social embeddedness of health officials in their communities. This includes partnerships with leaders of businesses and faith groups, teachers, and restaurant owners. Not only did these partnerships increase the scope of outreach, but they also often established relationships that had not existed beforehand. Gaining a foothold in local communities thus increased the likelihood that community members would support policies and enabled local governments to access hard-to-reach populations.
 

Kuo and Kelly’s analysis of informal capacity should give us pause when considering existing indices of public health preparedness; some of these have ranked the United States quite high despite its often ineffective responses to the COVID-19 pandemic. That this mismatch occurs is arguably a function of observers prioritizing formal capacities. For federal, decentralized countries like the US, informal capacities and relationships are essential not only for delivering services but for generating legitimacy and trust among those receiving services.

*Research-in-Brief prepared by Adam Fefer.

The Walter H. Shorenstein Asia-Pacific Research Center (APARC) is pleased to invite applications for a suite of fellowships in contemporary Asia studies to begin in fall quarter 2026.

The Center offers postdoctoral fellowships that promote multidisciplinary research on Asia health policy, contemporary Japan, and contemporary Asia broadly defined, as well as postdoctoral fellowships and visiting scholar positions with the Stanford Next Asia Policy Lab and a visiting fellow position on contemporary Taiwan. Learn more about each opportunity and its specific application requirements:

2026-27 Asia Health Policy Program Postdoctoral Fellowship

Hosted by the Asia Health Policy Program at APARC, the fellowship is awarded to one recent PhD recipient undertaking original research on contemporary health or healthcare policy of high relevance to countries in the Asia-Pacific region, especially developing countries. Appointments are for one year beginning in fall quarter 2026. The application deadline is December 1, 2025.

2026-27 Japan Program Postdoctoral Fellowship

Hosted by the Japan Program at APARC, the fellowship supports research on contemporary Japan in a broad range of disciplines, including political science, economics, sociology, law, policy studies, and international relations. Appointments are for one year beginning in fall quarter 2026. The application deadline is December 1, 2025.  

2026-27 Shorenstein Postdoctoral Fellowship on Contemporary Asia

APARC offers two postdoctoral fellowship positions to junior scholars for research and writing on contemporary Asia. The primary research areas focus on political, economic, or social change in the Asia-Pacific region (including Northeast, Southeast, and South Asia), or international relations and international political economy in the region. Appointments are for one year beginning in fall quarter 2026. The application deadline is December 1, 2025. 
 

2026-27 Taiwan Program Visiting Fellowship

Hosted by the Taiwan Program at APARC, the fellowship is awarded to one mid-career to senior-level expert with extensive experience studying contemporary Taiwan. The fellowship research focus is on issues related to how Taiwan can meet the challenges and opportunities of economic, social, technological, environmental, and institutional adaptation in the coming decades, using a variety of disciplines, including the social sciences, public policy, and business. The application deadline is March 1, 2026.  
 

Alzheimer’s disease and related dementias (ADRD) are putting a significant strain on families and healthcare systems worldwide, and with increasing life expectancies, they pose an escalating global challenge. As one of the world’s fastest aging economies, South Korea’s efforts to address the burden of care for people living with ADRD offer valuable lessons for other nations grappling with the social and economic pressures of the demographic transition.

A new comprehensive review of Korea’s programs and policies to promote healthy aging and diagnose, treat, and care for people living with ADRD sheds light on progress and ongoing challenges. Published in the May 2025 issue of Alzheimer's & Dementia: The Journal of the Alzheimer's Association, the review offers insights from Korea’s strategies that resonate far beyond its borders.

The co-authors – Stanford health economist Karen Eggleston, the director of APARC’s Asia Health Policy Program (AHPP), and Daejung Kim, an associate research fellow at the Korea Institute for Health and Social Affairs – focus on recent policies supporting “aging in place” for independent seniors and palliative care for those needing greater support.

Eggleston and Kim used a mixed-methods review of dementia care in Korea over the past 25 years, combining a critical analysis of peer-reviewed social science and health policy studies in both English and Korean, quantitative analysis of Korean statistical agency data compared with other OECD countries, and interviews with local policymakers and welfare administrators in a region with a high proportion of elderly population.

• Sign up for APARC newsletters to receive our scholars' research updates >
• Learn more about Dr. Eggleston's related research project, "Innovation for Healthy Aging" >  

Social and Policy Pressures in a Rapidly Aging Economy

Korea is aging fast, and the prevalence of ADRD among older adults is expected to surge, as is the projected social and economic toll of dementia care. Demographic and economic projections suggest that the annual cost of ADRD in Korea would increase from 0.9 percent to almost four percent of GDP from 2019 to 2050.

“Korea’s demographic transition, like its economic development, has been compressed into just a few generations,” Eggleston and Kim explain. “As a result, its triumph of longevity and current extra-low fertility engender social strains and policy pressures to address the burgeoning needs for long-term services and support – including prevention of ADRD, investing in early detection, and providing appropriate care for people with ADRD, which often involves addressing the broader social issue of financial support for older adults and detecting cognitive decline in those still engaged in the labor force.”

A Foundation for Dementia Care Service Delivery

Korea has taken decisive steps to build a comprehensive system for dementia care, leveraging its national health insurance and long-term care insurance (LTCI). This dual insurance framework aims to reduce unnecessary hospitalizations and shift social care away from medical settings.

Research shows that “the adoption of LTCI in 2008 helped to address regional disparities by providing nationwide risk pooling for long-term care services,” but the system still faces hurdles. Within Korea’s private-dominated service delivery system, the public-private balance varies significantly across different services, coordination between healthcare and long-term care services remains fragmented, and there is a need for better integration of community-based support.

Furthermore, “social insurance is no panacea for mitigating disparities and securing financial support for the most vulnerable citizens, such as people with ADRD and their families,” Eggleston and Kim note. Out-of-pocket payments for medical care still constitute a substantial portion of Korean household consumption.

Livelihood and Workforce Challenges

In light of Korea’s limited sources of financial support for its older citizens, the country has relatively high labor force participation, especially among older men. This high level of employment of older Koreans may bode ill in an economy where many of the “senior employment” positions – primarily low-paying roles in the service sector – are not age-friendly.

Giving elderly persons a reason to get up in the morning has its benefits, Eggleston and Kim note, but having them perform service jobs is not a sustainable way to support livelihoods and healthy aging. “How decision-making by cognitively impaired individuals affects health and financial well-being can be considered the defining feature of the economics perspective on ADRD and its social impacts,” the co-authors say.

The growing demand for professional dementia care strains Korea’s caregiving workforce in other ways. Amid the shortage and aging of caregivers, much of dementia care falls on unpaid family members, often women in their 50s, lowering their rates of labor force participation in prime age. The burden on these informal caregivers is profound.

The authors note that “Korea needs more strategies to recruit, retain, and empower a knowledgeable and resilient caregiving workforce.”

Prevention and Early Diagnosis: A Mixed Picture

Early detection is critical for planning care and support for people with ADRD, and Korea is taking steps to design programs and incentives for healthy aging habits and early ADRD detection. These efforts, however, require stronger staffing and funding to offer more personalized and coordinated care.

Another set of challenges stems from the underuse of existing long-term services and support programs and the need to diversify them. Currently, providers have weak incentives to offer palliative care, while families and patients often struggle to choose comfort care over ongoing medical treatments.

Policymakers must also expand the target group of beneficiaries and diversify long-term services and support for daily life, including promoting a reduction in risk factors associated with dementia, such as low educational attainment, smoking, physical inactivity, uncontrolled chronic diseases, and depression. Eggleston and Kim call for developing “additional care service types such as hospital companion and nutrition support services” and integrating new technologies as part of a diversified, long-term aging-in-place care system.

Expanding Care Options 

The demographic transition has been accompanied by shifting social norms regarding responsibilities and caregiving, meaning significantly fewer Koreans believe care for older parents is the sole responsibility of family members. Accordingly, Korean policies aim to strengthen home- and community-based services (HCBS). Yet, the country’s share of at-home care recipients remains lower than in many peer economies.

“Making the vision of quality HCBS a reality involves multiple dimensions of financing and service delivery, tailored to local and individual circumstances while supporting equitable access nationally for those in need,” write Eggleston and Kim.

Institutional care in residential facilities remains a necessity for frail older people with ADRD and multiple comorbidities. While the supply of such service providers has greatly improved and long-term care insurance coverage has enhanced their affordability for families, wide disparities in quality of care for those in residential facilities persist. Meanwhile, hospice and palliative care remain largely an underdeveloped care option for people with ADRD in Korea.

Lessons for Aging Economies

South Korea’s dementia care journey illustrates the complex balancing act of addressing the multiple dimensions of a rapid demographic transition. The country’s efforts to promote healthy aging and diagnose, treat, and care for people with ADRD offer valuable insights for other economies that must prepare to provide long-term support for their aging populations.

One major imperative in Korea and elsewhere is ensuring that dementia care policies and programs are based on robust evidence. “To utilize limited resources most effectively, it will be critical to design and collect policy-relevant evidence about what works for people with ADRD and their care partners,” Eggleston and Kim write.