Publications

The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.

Key policy takeaways from Didi Kuo on U.S. electoral reforms; Keith Humphreys on the opioid epidemic; Oriana Skylar Mastro on China-North Korea relations; and Michael McFaul and Francis Fukuyama on the Ukraine-Russia crisis.

In a new Lawfare piece Jim Dempsey of the Program on Geopolitics, Technology and Governance, makes a case for breaking out a critical (and often unused) tool in the cybersecurity toolbox: the leveraging of authority by federal agencies to improve the cybersecurity of private actors.

Pascaline Dupas and co-authors Agness, Baseler, Chassang, and Snowberg leverage individual choice data they generate on farmers in western Kenya to solve a general problem: do behavioral phenomena drive individual choices when trading off cash for time, or cash and time for goods?

In a new paper for the Journal of Historical Political Economy, Alberto Diaz-Cayeros and Saumitra Jha examine the conditions under which indigenous communities in Mexico were able to overcome the onslaught of disease and violence that they faced.

Background

Despite rising incomes and rapid economic growth, there remains a significant gender gap in health outcomes among rural children in China. This study examines whether the gender gap in child health is related to the behavior of caregivers when seeking healthcare, and whether healthcare subsidies help to bridge the gender gap in rural health outcomes.

Methods

Focusing on vision care specifically, we draw on data from a randomized controlled trial of 13,100 children in Gansu and Shaanxi provinces in China that provided subsidized eyeglasses to myopic children in one set of schools (henceforth, referred to as the treatment schools) and provided prescription information but not subsidized eyeglasses to myopic children in another set of schools (control schools).

Results

The baseline results reveal that while female students generally have worse vision than male students, they are significantly less likely than male students to be taken by their caregivers to a vision exam. The experimental results indicate, however, that caregivers respond positively to both health information and subsidized healthcare, regardless of the gender of their children. When prescription information is paired with a subsidy voucher for healthcare (a free pair of eyeglasses), the uptake rate rises dramatically.

Conclusions

The gender gap in healthcare can be minimized by implementing subsidized healthcare policies.

Une arme de destruction sémantique (French Edition)

On February 16, 2022, FSI Director Michael McFaul testified before the House Comittee on Oversight and Reform Subcommittee on National Security examining Russia’s destabilizing activity in Eastern Europe, including its recent buildup of approximately 130,000 troops along Ukraine’s borders.

Poor knowledge, scarce resources, and lack of or misaligned incentives have been widely documented as drivers of the irrational use of medicine (IUM), which significantly challenges the efficiency of health systems across the globe. However, there is limited understanding of the influence of each factor on IUM. We used detailed data on provider treatment of presumptive asthma cases in rural China to assess the contributions of provider knowledge, resource constraints, and provider behavior on IUM. This study enrolled 370 village providers from southwest China. All providers responded to a clinical vignette to test their knowledge of how to treat presumptive asthma. Resource constraints (“capacity”) were defined as the availability of the prescribed medicines in vignette. To measure provider behavior (“performance”), a subset of providers (104 of 370) were randomly selected to receive unannounced visits by standardized patients (SPs) who performed of presumptive asthma symptoms described in the vignette. We found that, 54% (201/370) of providers provided the vignette-based patients with prescriptions. Moreover, 67% (70/104) provided prescriptions for the SPs. For the vignette, only 10% of the providers prescribed the correct medicines; 38% prescribed only unnecessary medicines (and did not provide correct medicine); 65% prescribed antibiotics (although antibiotics were not required); and 55% prescribed polypharmacy prescriptions (that is, they prescribed five or more different types of drugs). For the SP visits, the numbers were 12%, 51%, 63%, and 0%, respectively. The lower number of medicines in the SP visits was due, in part, to the injections’ not being allowed based on ethical considerations (in response to the vignette, however, 65% of providers prescribed injections). The difference between provider knowledge and capacity is insignificant, while a significant large gap exists between provider performance and knowledge/capacity (for 11 of 17 indicators). Our analysis indicated that capacity constraints play a minor role in driving IUM compared to provider performance in the treatment of asthma cases in rural China. If similar findings hold for other disease cases, this suggests that policies to reduce the IUM in rural China have largely been unsuccessful, and alternatives for improving aligning provider incentives with appropriate drug use should be explored.

Evidence from Dialysis Patients

Abstract

We study public vs. private provision of health care for veterans aged 65 and older who may receive care provided by the US Department of Veterans Affairs (VA) and in private hospitals financed by Medicare. Utilizing the ambulance design of Doyle et al. (2015), we find that the VA reduces 28-day mortality by 46% (4.5 percentage points) and that these survival gains are persistent. The VA also reduces 28-day spending by 21% and delivers strikingly different reported services relative to private hospitals. We find suggestive evidence of complementarities between continuity of care, health IT, and integrated care.

Rural China has seen an increase in its migrant workers returning home. As a result, many of these workers’ children, who had previously boarded at school, needed to return home as well. While the existing research indicates that boarding affects the development of disadvantaged children, the effect of the switch to nonboarding on the growth of vulnerable boarding children remains unknown. Using two-stage data from 20,594 fourth- and fifth-grade students in rural Shaanxi and Gansu provinces as well as the difference-in-differences method, this study estimates the impact of switching to nonboarding on the academic performance and mental health of vulnerable boarding students. The results suggest that the shift toward nonboarding significantly reduces boarding students’ academic performance, and further testing shows that these results are robust. Additionally, the switch to nonboarding insignificantly increased the standardized mental health scores of rural primary school students but significantly increased their standardized impulsive tendency scores. Heterogeneity analysis found that boarding students whose mothers had lower educational achievement or whose families belonged to lower economic levels had poorer academic performance after switching, while boarding students whose parents had higher education achievement or myopia possessed better mental health after switching. This study offers novel, policy-relevant insights into potential strategies that would improve the academic performance and mental health of students who transition to nonboarding, especially those with low-educated parents and those belonging to poor families.

Key policy takeaways from Larry Diamond and Francis Fukuyama on the anniversary of the January 6 Capitol riot; Kathryn Stoner and Michael McFaul on the Ukraine-Russia crisis; and Alex Stamos and Matthew Masterson on ensuring election integrity and protecting election officials.

Oriana Skylar Mastro reviews Rush Doshi’s book The Long Game: China’s Grand Strategy to Displace American Order (New York: Oxford University Press, 2021).

Stanford researchers reveal how to turn a global warming liability into a profitable food security solution

Purpose

To study the factors determining spectacle-wear compliance and reasons for non-wear among students in rural China.

Methods

This study was based on a spectacle intervention trial among 162 schools in rural China. Students with refractive errors were randomly assigned to either a free or voucher group to receive spectacles at baseline. Spectacle-wear compliance was assessed through an unannounced follow-up 7 months after spectacles were distributed. Students not wearing spectacles were also asked their reasons for non-wear. The collected data underwent descriptive, bivariate, and logistic regression analyses.

Results

A total of 1904 students received spectacles at baseline, 1826 (95.9%) of whom were present at the 7-month follow-up. Among those students, 41.7% wore their spectacles. There was no significant difference in compliance rates between the free and voucher groups. Predictors of wearing spectacles at follow-up included older age (Odds ratio = 1.56, 95% CI: 1.12–2.19), the severity of refractive error (3.68, 2.23–6.07), wearing spectacles before baseline (3.91, 2.53–6.04) and having friends who wore spectacles (1.87, 1.32–2.63). When students could see the blackboard from their seats (0.68, 0.51–0.89) and thought that wearing spectacles was bad looking (0.76, 0.57–1.00), they were reluctant to wear spectacles. The two main reasons for non-wear were the widespread perception that wearing spectacles would weaken eyesight (32.8%) and the inconvenience of wearing spectacles during activities (23.6%).

Conclusions

The main reason that accounts for the low compliance of spectacle wear was misconceptions around spectacle. School-based spectacle programs should consider enhancing the compliance rates to maximize the benefits of spectacle wear.

In his final essay as co-editor of the Journal of Democracy, Larry Diamond calls this moment the darkest for freedom in a half-century. Whether democracy regains its footing will depend on how democratic leaders and citizens respond to emboldened authoritarians and divisions within their own societies.

Nate Grubman shows how the repeated failures of Tunisia’s once-promising democratic transition created a crisis ripe for exploitation by a populist outsider

Background: Social-emotional development during the first three years of life is associated with later social-emotional development and cognitive development. In rural China, research has found large shares of children under age three are developmentally delayed, yet little is known about the paths of social-emotional development before age 3 or how developmental paths predict later social-emotional skills and cognitive skills. 

Aims: To investigate the paths of child social-emotional development during ages 0–3 and examine how different paths predict social-emotional development and cognitive development at preschool age. 

Methods: Three waves of longitudinal panel data from 1245 children in rural Western China was collected. Child social-emotional development was measured by the Ages and Stages Questionnaire: Social-Emotional. Child cognitive development was measured by the Bayley Scales of Infant Development and by the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition. Four paths of child social-emotional development were classified: “never” social-emotionally delayed; “persistently” social-emotionally delayed; “improving,” or “deteriorating.” 

Results: 331 (27%) were never social-emotionally delayed; 373 children (30%) were persistently social-emotionally delayed; 149 children (12%) experienced improving social-emotional development; and 392 children (31%) experienced deteriorating social-emotional development. Children who were never social-emotionally delayed or who were on an “improving” path had higher social-emotional development at preschool age (p < .01). Children who were persistently social-emotionally delayed (p < .5) and on a deteriorating path (p < .01) had lower social-emotional development at preschool age. Children on the persistently delay path also were shown to have lower levels of cognitive development at preschool age (p < .01). 

Conclusions: Different paths of child social-emotional development before age 3 are associated with different social-emotional and cognitive development at preschool age.

Why do voters support executive aggrandizement?