Population health

The primary goal of the Guatemala Rural Child Health and Nutrition Program is to use the capacities of Stanford University to save young children’s lives in Guatemala and other areas of the world plagued by conflict and political instability.  Part of the Children in Crisis Initiative, this Stanford effort in Guatemala has been focused on young child malnutrition, the central contributor to child mortality and life-long disability in these regions.

-

About the talk: This presentation will discuss the centrality and challenges of health-specific technological progress in global health improvement. It will describe a research agenda and provide examples of specific empirical studies and findings that are part of the agenda.

About the speaker: Grant Miller is an Associate Professor of Medicine at the Stanford University School of Medicine, a Core Faculty Member at the Center for Health Policy/Primary Care and Outcomes Research, a Senior Fellow at the Freeman Spogli Institute for International Studies, and a Research Associate at the National Bureau of Economic Research (NBER). His primary interests are health economics, development economics, and economic demography.

Professor Miller’s primary focus is research and teaching aimed at developing more effective health improvement strategies for developing countries. His agenda addresses three major interrelated themes: (1) The major causes of population health improvement around the world and over time (2) Behavioral underpinnings of the major determinants of population health improvement - which factors have contributed most to population health gains, and why? (3) From insights to policy relevance: how can programs and policies use these behavioral insights to improve population health more effectively? 

CISAC Conference Room

Encina Commons Room 101,
615 Crothers Way,
Stanford, CA 94305-6006

(650) 723-2714 (650) 723-1919
0
Henry J. Kaiser, Jr. Professor
Professor, Health Policy
Senior Fellow at the Freeman Spogli Institute for International Studies
Senior Fellow at the Stanford Institute for Economic Policy Research
Professor, Economics (by courtesy)
grant_miller_vert.jpeg
PhD, MPP

As a health and development economist based at the Stanford School of Medicine, Dr. Miller's overarching focus is research and teaching aimed at developing more effective health improvement strategies for developing countries.

His agenda addresses three major interrelated themes: First, what are the major causes of population health improvement around the world and over time? His projects addressing this question are retrospective observational studies that focus both on historical health improvement and the determinants of population health in developing countries today. Second, what are the behavioral underpinnings of the major determinants of population health improvement? Policy relevance and generalizability require knowing not only which factors have contributed most to population health gains, but also why. Third, how can programs and policies use these behavioral insights to improve population health more effectively? The ultimate test of policy relevance is the ability to help formulate new strategies using these insights that are effective.

Faculty Fellow, Stanford Center on Global Poverty and Development
Faculty Affiliate, Stanford Center for Latin American Studies
Faculty Affiliate, Woods Institute for the Environment
Faculty Affiliate, Interdisciplinary Program in Environment & Resources
Faculty Affiliate, Stanford Center on China's Economy and Institutions
CV
Date Label
Grant Miller Associate Professor of Medicine; Senior Fellow, FSI Speaker
Seminars
-

Abstract
The scope and complexity of global health can be overwhelming, making it difficult to form an inspiring and unified vision for the future. Mired in this complexity, the international community defines success disease by disease‹without a clear picture of what fundamental reform would actually look like. If the aspiration of global health with justice is the right goal, then answering three simple questions may pierce the haze.

First, what would global health look like? That is, given optimal priority-setting, funding, and implementation, to what level of health should we aspire, and with what provision of health-related services? Posing these three elementary questions, of course, oversimplifies a field that is fraught with tensions and trade offs. But I want to imagine a more ideal future for world health, with bold proposals to get there. After thinking about these three basic questions, I turn to an idea for innovative global governance for health‹a Framework Convention on Global Health.

Second, what would global health with justice look like? Global health seeks to improve all the major indicators of health, such as infant and maternal mortality and longevity. Global health with justice, however, requires that we look beyond improved health outcomes for the population as a whole. Although overall population health is vitally important, justice requires a significant reduction in health disparities between the well-off and the poor. Societies that achieve high levels of health and longevity for most, while the poor and marginalized die young, do not comport with social justice.

Third, what would it take to achieve global health with justice? That is, once we clearly state the goal, and meaning, of global health with justice, what concrete steps are required to reach this ambitious objective? This raises fundamental challenges, intellectually and operationally, as the response cannot be limited to ever-greater resources, but must also involve improved governance‹at the country and international level and across multiple sectors.

Lawrence O. Gostin is University Professor, Georgetown University’s highest academic rank conferred by the University President. Prof. Gostin directs the O’Neill Institute for National and Global Health Law and was the Founding O’Neill Chair in Global Health Law. He served as Associate Dean for Research at Georgetown Law from 2004 to 2008. He is Professor of Medicine at Georgetown University, Professor of Public Health at the Johns Hopkins University, and Director of the Center for Law & the Public’s Health at Johns Hopkins and Georgetown Universities.

 Prof. Gostin holds a number of international academic professorial appointments: Visiting Professor (Faculty of Medical Sciences) and Research Fellow (Centre for Socio-Legal Studies) at the University of Oxford, United Kingdom; the Claude Leon Foundation Distinguished Scholar and Visiting Professor at the University of Witwatersrand, Johannesburg, South Africa; and the Miegunyah Distinguished Visiting Fellow and Founding Fellow of the Centre for Advanced Studies (Trinity College), University of Melbourne. Prof. Gostin serves as Secretary and a member of the Governing Board of Directors of the Consortium of Universities for Global Health.

Building 200 (History Corner)
Room 205
Stanford University

Lawrence O. Gostin O'Neill Professor in Global Health Law Speaker Georgetown University
Seminars
-

**** PLEASE NOTE CHANGE OF SPEAKER***

Dr. Susan Kasedde currently serves as Senior Advisor and Team Leader on HIV and Adolescents for UNICEF based in New York since November 2009. In this role, she has contributed towards global level evidence generation, technical guidance development, advocacy, global partnership development, and technical assistance towards the global response towards HIV prevention, treatment and care in adolescents aged 10 - 19. Since 2011, on behalf of UNICEF, Susan has coordinated a series of efforts including documentation of global practices in the care of adolescents living with HIV; mathematical modeling with the Futures Institute to assess the impact and cost of scale up of proven high impact HIV prevention, treatment and care interventions within a holistic response, on new HIV infections and AIDS deaths in adolescents; and a systematic review with the London School of Hygiene and Tropical Medicine to confirm evidence on effective approaches for programming to reduce HIV infection, illness and death in adolescents. This work has contributed to stronger advocacy and technical guidelines for programming for adolescents, a group of children previously largely neglected. In 2013, the documentation on adolescents living with HIV was a major contribution to the new WHO guidelines on HIV testing and counseling and care in adolescents. The impact modeling and systematic review are among a series of key papers that will be released in a special supplement on HIV prevention, treatment and care in adolescents at the International AIDS Society Conference in Melbourne, Australia in 2014.

 

 Susan joined UNICEF having served since 2007 as Regional Adviser with the UNAIDS Regional Office for Eastern & Southern Africa. In that role, she was responsible for coordinating analytic work on the epidemic and response and modes of HIV transmission in several high HIV burden countries, working extensively with government teams and partners in the highest HIV burden countries in the world to use an incidence model to predict the next 1000 new HIV infections and assess alignment of national strategies with the national epidemic. Susan has over 18 years of experience working on adolescents sexual and reproductive health of which 16 of those have been focused on HIV in adolescents. Susan holds a doctorate in Epidemiology and Population Health from the London School of Hygiene & Tropical Medicine, a Masters degree in Public Health from Boston University and Bachelors degrees in Biomedical Science and French. Susan is a national of Uganda and speaks English and French.

Building 200 (History Corner)
Room 205
Stanford University

Susan Kasedde Senior Advisor and Team Leader on HIV and Adolescents Speaker UNICEF
Seminars

Urbanization and obesity-related chronic diseases are cited as threats to the future health of India's older citizens. With 50% of deaths in adult Indians currently due to chronic diseases, the relationship of urbanization and migration trends to obesity patterns have important population health implications for older Indians. The researchers constructed and calibrated a set of 21 microsimulation models of weight and height of Indian adults. The models separately represented current urban and rural populations of India's major states and were further stratified by sex.

-

A tremendous amount of radioactive products were discharged as a result of the accident at the Fukushima nuclear power plant in March 2011, which resulted in radioactive contamination of the plant and surrounding areas. While geographical distribution of radioactive iodine, tellurium, and cesium in the surface soils was smoothly (but not always systematically) widespread all over the region, health risk information by the government, media, and other organizations is most likely to be given in terms of administrative boundaries (cf. prefectures, municipalities, etc.) and/or distance from the radiation source.

This paper estimates the effect of such health risk information rather than the actual health risks of radiation on land and other prices in different locations. We find that the prefecture and municipality border effects – but not the distance effect from the nuclear power plant – are significantly related to a reduction in land and other prices after the accident. This shows that people responded to health risk information based on administrative boundaries rather than the actual health risk of radiation after the disaster. Although health risk information based on prefecture and municipality boundaries has an obvious advantage of distilling large and complex risk information into a simple one, the government, media, and other organizations need to recognize and carefully examine the potential of misclassifying non-contaminated areas into contaminated prefectures. Doing so will avoid unintentional consequences to the region’s economy.

Hiroaki Matsuura is currently Departmental Lecturer in the Economy of Japan in the School of Interdisciplinary Area Studies, University of Oxford and a Junior Research Fellow of St. Antony’s College. His main interests are health economics and demography, with a special interest in the relation between laws and population health. Hiroaki received his B.A. in Economics from Keio University, M.A. in Social Science from the University of Chicago, M.S. in Project Management from Northwestern University’s McCormick School of Engineering and Applied Science, and Sc.D. in Global Health and Population (Economics track) from Harvard University’s School of Public Health. In the past, he was affiliated with Institute of Quantitative Social Sciences, Human Rights in Development, and Takemi Program in International Health at Harvard University. He also worked as a research assistant at the National Bureau of Economic Research. His doctoral dissertation research explores a right to health or to health care in national constitutions of 157 countries and state constitutions of the 50 U.S. states and estimates the impact of introducing (or removing) a right to health or to health care into national and state constitutions on health system and population health outcomes. His most recent article, “The Right to Health in Japan: Challenges of a Super Aging Society and Implication from Its 2011 Public Health Emergency” (with Eriko Sase) will be appeared on “Advancing the Human Right to Health”, edited by José M. Zuniga, Stephen P. Marks, and Lawrence O. Gostin, Oxford University Press, 2013. 

Daniel and Nancy Okimoto Conference Room

Hiroaki Matsuura Departmental Lecturer in the Economy of Japan in the School of Interdisciplinary Area Studies Speaker University of Oxford
Seminars
Paragraphs

Controversy surrounds the role of the private sector in health service delivery, including primary care and population health services. China’s recent health reforms call for non-discrimination against private providers and emphasize strengthening primary care, but formal contracting-out initiatives remain few, and the associated empirical evidence is very limited. This paper presents a case study of contracting with private providers for urban primary and preventive health services in Shandong Province, China. The case study draws on three primary sources of data: administrative records; a household survey of over 1600 community residents in Weifang and City Y; and a provider survey of over 1000 staff at community health stations (CHS) in both Weifang and City Y. We supplement the quantitative data with one-on-one, in-depth interviews with key informants, including local officials in charge of public health and government finance.

We find significant differences in patient mix: Residents in the communities served by private community health stations are of lower socioeconomic status (more likely to be uninsured and to report poor health), compared to residents in communities served by a government-owned CHS. Analysis of a household survey of 1013 residents shows that they are more willing to do a routine health exam at their neighborhood CHS if they are of low socioeconomic status (as measured either by education or income). Government and private community health stations in Weifang did not statistically differ in their performance on contracted dimensions, after controlling for size and other CHS characteristics. In contrast, the comparison City Y had lower performance and a large gap between public and private providers. We discuss why these patterns arose and what policymakers and residents considered to be the main issues and concerns regarding primary care services.

Keywords:

Private providers; Contracting; Ownership; Primary care; Prevention; China

All Publications button
1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Health Economics Review
Authors
Yan Wang (former)
Yan Wang
Karen Eggleston
Karen Eggleston
Zhenjie Yu
Qiong Zhang
Paragraphs

Context  The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown.

Objective  To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively.

Design, Setting, and Participants  Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics.

Main Outcome Measure  Adult all-cause mortality.

Results  We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively.

Conclusions  Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.

All Publications button
1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Journal of the American Medical Association
Authors
Eran Bendavid
Eran Bendavid
Charles Holmes
Jay Bhattacharya
Jay Bhattacharya
Grant Miller
Grant Miller
Authors
Sarah L. Bhatia
News Type
Q&As
Date
Paragraphs

China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.

All News button
1
Subscribe to Population health