The world’s population is aging at a faster rate and in larger cohorts than ever before. In countries like Japan that have low fertility rates and high life expectancy, population aging is a risk to social sustainability. Developing policies and healthcare infrastructure to support aging populations is now critical to the social, economic, and developmental wellbeing of all nations. As the COVID-19 pandemic has repeatedly shown, accurate projections of future population health status are crucial for designing sustainable healthcare services and social security systems.

Such projections necessitate models that incorporate the diverse and dynamic associations between health, economic, and social conditions among older people. However, the currently available models – known as multistate transition microsimulation models – require high-quality panel data for calibration and meaningful estimates. Now a group of researchers, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston, has developed an alternative method that relaxes this data requirement.

In a newly published paper in Health Economics, Eggleston and her colleagues describe their study that proposes a novel approach using more readily-available data in many countries, thus promising more accurate projections of the future health and functional status of elderly and aging populations. This alternative method uses cross‐sectional representative surveys to estimate multistate‐transition contingency tables applied to Japan's population. When combined with estimated comorbidity prevalence and death record information, this method can determine the transition probabilities of health statuses among aging cohorts.

In comparing the results of their projections against a control, Eggleston and her colleagues show that traditional static models do not always accurately forecast the prevalence of some comorbid conditions such as cancer, heart disease, and stroke. While the sample sets used to test the new methodology originate in Japan, the proposed multistate transition contingency table method has important applications for aging societies worldwide. As rapid population aging becomes a global trend, the ability to produce robust forecasts of population health and functional status to guide policy is a universal need.

Read the full paper in Health Economics.

Learn more about Eggleston’s research projects >>

To celebrate its May Release, the Stanford China Program hosted a virtual book launch event for Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press) on June 2^nd. Joining co-authors Thomas Fingar (Shorenstein APARC Fellow, Stanford University) and Jean C. Oi (Director, Stanford China Program; William Haas Professor of Chinese Politics, Stanford University) were contributors Karen Eggleston (Senior Fellow at FSI; Director of the Asia Health Policy Program, Shorenstein APARC, Stanford University), Barry Naughton (Sokwanlok Chair of Chinese International Affairs, School of Global Policy and Strategy, UC San Diego), and Andrew Walder (Senior Fellow at FSI; Denise O'Leary and Kent Thiry Professor, Stanford University). As Fingar and Oi point out in their volume, despite China’s extraordinary growth over the past 40 years, the country’s future is uncertain. China has enjoyed optimal conditions for development since the 1980s, but new hurdles including an aging populace, the loss of comparative economic advantage, a politically entrenched elite, and a population with rising expectations will test the country’s leaders. With each focusing on a different facet of China’s challenges, the panelists gathered to share their expertise and provide the audience with a glimpse into what the future might hold for this important country.

Available Now: Fateful Decisions: Choices That Will Shape China’s Future

Following an introduction from Professor Jean Oi, the program kicked off with Professor Barry Naughton of University of California, San Diego, who discussed his chapter entitled “Grand Steerage.” Professor Naughton argued that, as it plans for the future, China’s policymaking is becoming increasingly technology-focused, particularly in the realm of economic policy. Naughton further notes that China’s economy is becoming simultaneously more state-guided and more centered around technology. This decision is a gamble, though: China is investing heavily in high-tech industries, advancing massive, centrally steered projects like the Greater Bay Area initiative and the Xiong’an New District. If they are successful, says Naughton, this will indeed be an incredible success. But, if they are not, China’s losses will be major: “There’s not really a middle ground.”

After Professor Naughton was Professor Karen Eggleston, an expert on health policy in Asia. Professor Eggleston’s chapter, “Demographic and Healthcare Challenges,” deals with emerging obstacles for China’s healthcare system, including population aging and the problems that come with it, like chronic diseases and elder care. Although China’s healthcare system has improved dramatically in recent decades, it has done so unevenly, notes Eggleston: life expectancy has greatly increased, but with disparities according to income, region, and urban vs. rural status; universal healthcare is available, but the benefit level is low, effectively limiting the standard of care many can receive. The ratio of health spending to GDP is also increasing, yet it is still modest compared to high-income countries. The COVID-19 crisis has, of course, introduced even more challenges: Will China be able to distribute future vaccines equitably? Will this crisis negatively affect young people’s decisions to choose healthcare as a career? Will telemedicine, which has seen a surge under the pandemic, improve or exacerbate existing disparities? China faces a multitude of constraints and choices going forward if it hopes to meet its population’s healthcare needs.

The audience then had a chance to hear from co-editor Thomas Fingar, speaking on his chapter, “Sources and Shapers of China’s Foreign Policy.” Fingar noted three key takeaways from both his chapter and his talk: Firstly, China’s foreign policy is a fundamental part of its national policy. Secondly, the global political environment plays an important role in shaping both foreign and domestic policy which, thirdly, plays an important role in shaping foreign policy. The conditions that allowed China to flourish over the past 40 years, emphasized Fingar, are very different from those of the present. In the 1970s and 80s, China was able to take advantage of Cold War bipolarity, globalization was in its infancy, and “China was the only significant developing country willing to embark, at that time, on the export-led path of development.” In recent years, though, China’s behavior internationally has alienated other countries; there are many competitors pursuing its style of development; and its needs and aspirations have changed, requiring more raw materials and depending upon multi-national economic agreements. Fingar suggests two potential foreign policy options: China could continue with its wolf warrior diplomacy, which has “alienated essentially all China’s neighbors to some degree,” or it could return to a style more similar to that of the 1980s and 90s Reform and Opening era. It remains to be seen which style will win out.

Finally, Professor Andrew Walder concluded the program with his discussion of China’s political future at large. His chapter, “China’s National Trajectory,” follows China’s remarkable advancement in recent years and “tr[ies] to divine what a lower growth era will mean for China’s political future.” The last 40 years of rapid growth have generated support for China’s political system, more patriotism, the near eradication of democracy movements, and an elite unity not seen in the 1970s and 80s. However, low growth rates could mean a reversal for many of these trends, says Walder. While the aforementioned support for and stability of the Chinese government was maintained by ever-improving living standards and upward mobility, a low growth period (coupled with an aging population) means the government will no longer be able to rely on these trends for popular support. Rather, it will need to improve its provision of public services to address present-day challenges. Regardless, argues Walder, the low growth era will undoubtedly lead to “dynamic changes underneath the façade of stability of Chinese politics….”

For more insights on the modern obstacles China faces and what they mean for the country’s future, check out Fateful Decisions: Choices That Will Shape China's Future, available for purchase now.

This interview was originally produced by the Oliver Wyman Forum.

Coronavirus has dramatically increased the use of technology as governments, healthcare providers, and businesses tackle the pandemic and its devastation. But even before the crisis, Japan, a country long at the forefront of robot production and usage, had begun to use this technology in many of its nursing homes.

About 60 percent of the country’s nursing facilities now use robots. The proliferation of machines has had a relatively minor impact on turnover or wages of caregivers because of strong demand for care, an aging working population, and government subsidies for robot implementation, according to research by Karen Eggleston, the deputy director of the Shorenstein Asia-Pacific Research Center and director of the Asia Health Policy Program (AHPP), Yong Suk Lee, a center fellow and the deputy director of the Korea Program, and Toshi Iizuka, professor at the University of Tokyo and former visiting scholar with AHPP. Robot-adopting nursing homes, the researchers found, had between eight to 11 percent more staff than those who didn't adopt robots.

Caregiving is a physically demanding task. Staff frequently lift residents in and out of bed, and many suffer from back pain. Many of the robots deployed in Japan either help caregivers perform physical tasks or facilitate movement by the residents themselves.

The research couldn’t be timelier. Nursing homes have taken a heavy toll from the coronavirus. The disease has claimed the lives of more than 28,000 residents and workers of care facilities in the United States – approximately 35 percent of all deaths in the nation as of May 11. By contrast, Japan’s overall death toll stands at a little over 900 in early June.

Professors Eggleston and Lee discussed the implications of their research in a Zoom interview with Partha Bose, a partner at Oliver Wyman and a leader of the Oliver Wyman Forum, as well as Jilian Mincer, managing editor of the Oliver Wyman Forum, and Dan Kleinman, the Forum’s digital editor.

[Like what you're reading? Sign up for our newsletters to get content like this delivered directly to your inbox.]

From a labor economics point of view, Japan has been struggling with staffing in these care facilities. What made it much more acceptable for robots to be used in their situation versus other sectors?

Karen Eggleston: Japan has an extreme demography that it’s dealing with. The demand for long-term care is going up quite a bit while the overall population is declining. Although they're relaxing some immigration, there are issues with that. Some of the policy goals were to support robotics and to understand how it complements or substitutes for specific tasks in long-term care — to bring down back pain among care workers, for example — and to explicitly set a target for percentage of healthcare providers and long-term care clients who say it's acceptable to have a robot involved in their care.

They went into it well aware that robots weren't going to completely push out the workforce, but it's all a question of what type of tasks they can be involved with and how they can get an early read on that and start developing appropriate robots and re-engineering the care processes to meet that surge in demand.

What kinds of tasks are robots being used for in Japan right now?

Yong Suk Lee: There are these wearable transfer-aid robots that can actually help care workers lift persons and move around. There are similar types of robots that are non-wearable. And there are robots that directly assist the elderly in their care: They can use these to move around, and related to that, bathing activities, going to the bathroom, and so on.

The main type of robots are monitoring robots. They’re basically a camera system. They signal to the nurses or caregivers in an aid station if there seems to be abnormal movement so that they can actually go there — especially during the night when there's less staffing to actually go and check how the residents are doing. Those are the highest in terms of rate of adoption. And then there are those cute communication types of robots to help patients with dementia communicate with their families and caregivers.
 
What sort of facilities are using these robots? Do they tend to be urban facilities, or can they be anywhere in the country, like rural areas?

Lee: Based on preliminary results, adoption is higher in urban areas, but it's not significantly different. In China, it could differ drastically because there's a huge urban-rural divide in China of public health systems or public service in general. Robots are capital intensive. In South Korea, there are private homes that are wealthier and those could adopt new technologies earlier, but still, adoption in general is not widespread due to sufficient immigrant labor providing care. There could be an urban-rural divide for sure. Because of government subsidies in Japan, it equalizes distribution across regions.
 
Eggleston: We find more part-time or irregular nurses in urban areas. That may seem counterintuitive, but when you think about it, having that concentration of human capital in urban areas might facilitate that kind of part-time work and so on. There are differences we can see in our data between urban and rural homes, but we don't see large differences in terms of robot adoption and use.

Are there kinds of conditions that robots are better suited for than others?

Lee: In general, most robots are related to mobility issues. The biggest consequences of the elderly staying in homes are pressure ulcers on their skin because of their extended time in bed and low levels of mobility. Robots could provide a major contribution if they help residents move about and reduce pressure ulcers.

Communication robots are helpful for patients with dementia. The adoption of those isn't high compared to monitoring robots, but I think it's becoming more accepted and especially helpful for certain types of patients.
 
Do you think robots will be helpful for medical care?

Eggleston: That's the hope. For example, night monitoring reduces the probability of a severe fall which requires hospitalization and so on. There are contentious issues with nursing homes about physical restraints for patients, which are not allowed. And so, adding robots might deal with some of the outcomes. Both the producers and users of robots are hoping this will have a significant impact on the quality of care. 

As you look at how the coronavirus has affected long-term care facilities, do you wonder what the outcomes might've been had some of these facilities had robots?

Lee: Yes. What our findings indicate is that robots are not replacing workers in Japan. They're allowing firms to adopt more nurses — the skilled type of caregivers, which is an important finding directly related to the quality of care. Allowing critical personnel to actually focus more on patients. If there were certain technologies in place, caregivers could have spent their time more efficiently. I believe that's going to be a discussion going forward in the US and in many other countries that have suffered drastically. 

Eggleston: Particularly the communication and monitoring robots would help to some extent. They can save caregivers from having to go room-to-room and enable communication between people at the facility, and also with their households.

We do know that there's a potential there, and it might affect future adoption in nursing homes in the US and elsewhere. But given the huge financial hit the industry has taken as a whole, it might be a while before that plays out.

Given the coronavirus’s prevalence in nursing homes, people may be wary of taking jobs there. Can these robots be used in a recruiting capacity for nursing homes?

Lee: Certified nursing assistants in the US are not well-paid and it’s a physically demanding job. Now there's an extra concern of, "What will happen to me when I work here?" A lot of nursing homes had enormous difficulty recruiting people. They were paying extra for nurse aids, but they weren't able to recruit given the situation.

Potentially, nursing home facilities that have the capacity to adopt robots may be able to advertise this as not only being able to improve the quality of care for the residents but providing better work conditions for the caregivers. What we're finding in our research is those that adopt these robots tend to have better management practices.

What has surprised you most in your research?

Lee: We didn't find that robots replaced care workers. They’re being used to supplement the workers and maybe have better outcomes in quality of care. This is having an overall net positive effect both on jobs and productivity.

Mongolia, a nation bordered by China and Russia, does not usually attract much public attention. Its success so far in containing COVID-19, however, is well worth considering.

Any of several factors could make Mongolia highly vulnerable to COVID-19: its weak healthcare system, its proximity to China, the first epicenter of the coronavirus, and its close ties to South Korea, which experienced one of the largest initial outbreaks of COVID-19 outside China and which is home to a relatively large population of Mongolian migrant workers. Yet Mongolia’s strategy in fighting the pandemic seems to have worked well thus far for its 3.2 million people.

In the following post, Dr. Gendengarjaa Baigalimaa, a gynecological oncologist at the Mungun Guur Hospital in Ulaanbaatar, Mongolia’s capital, discusses the country’s response to the pandemic and its implications. Baigalimaa was a 2013-14 postdoctoral fellow on developing Asia health policy with APARC’s Asia Health Policy Program.

This is the second installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. You can read the first part in the series, featuring reflections by several former Global Affiliates Program Fellows.

[To get stories like this delivered directly to your inbox sign up for our newsletters]

---

Dr. Gendengarjaa Baigalimaa

As of May 17, 2020, the number of new coronavirus infections in Mongolia has reached 136. All of them are imported cases, including four foreigners and 132 Mongolians who came from abroad. They have been treated by the National Center for Communicable Diseases and some have been discharged as totally recovered. Most notably, there have been no reports of community transmission.

Following the World Health Organization's recommendation of January 22 that countries begin considering containment measures, Mongolia immediately activated its inter-agency State Emergency Commission in support of the Ministry of Health as a lead agency in the response against the coronavirus outbreak. The Mongolian government made an unprecedented decision to close all schools and kindergartens starting January 25. All classes are now being conducting via TV and the internet.

Already in mid-February, with the pandemic's spreading in China, the Mongolian government’s strategy was to adopt decisive preventative measures, including the cancelation of the national holiday Tsagaan Sar, the Mongolian lunar new year, and closure of all travel between Ulaanbaatar and provinces outside the capital. Mongolia also closed its borders with China and Russia, stopping the inflow and outflow of people, and banned international flights from all airlines. The government has been mobilizing its citizens to return home from countries like South Korea, Japan, Turkey, and Russia. Those arriving are quarantined for an extended 21-day period, with multiple coronavirus screenings.

The use of masks, especially from early November, when flu season starts and air pollution worsens, is already familiar to Mongolians. This season, the government has enforced mask-wearing in public places. In the capital city of Ulaanbaatar, the requirement that all employees at government offices, banks, shops, and markets wear masks was imposed as early as January 25. The State Emergency Commission would issue fines of 150,000₮ (54 USD) for violating the order. At the same time, health professionals and community leaders conveyed the importance of mask-wearing and handwashing and worked to increase sanitation at all public places.    

These steps have helped immensely to contain the spread of COVID-19. They have also had the added benefit of sharply reducing the number of flu infections. At the start of the flu season last year, almost 12.7 percent of all hospital visits were flu-related, compared to 1.8 percent this year. Another unexpected benefit was the drop in gastrointestinal infections among children. Children were staying home and washing their hands properly. As a result, there have been no cases of gastrointestinal infections registered this year so far.

“Not only did Mongolia close its borders early and move promptly, but also did a great job at quarantining evacuees from overseas immediately upon arrival and taking safety measures,” said Mr. Sergey Diorditsa, the WHO representative to Mongolia. He praised the country’s economic stimulus measures and noted that prolonged restrictions may adversely affect its social and economic sectors and that WHO Mongolia is conducting a study on the in-country impacts of COVID-19. Indeed, data provided by the National Statistical Office shows that the country’s economy is expected to decline sharply due to the adverse effects of the pandemic.

Mongolia’s urgent response to COVID-19 offers lessons for vulnerable communities on containment of the coronavirus and prevention of its spread. The country is also a relevant case study for the economic repercussions of the pandemic.