Health and Medicine

FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.

FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.

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Pharmaceutical policies are interlinked globally, yet deeply rooted in local culture. The newly published book Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, edited by Karen Eggleston, examines how pharmaceuticals and their regulation play an important and often contentious role in the health systems of the Asia-Pacific.

In this colloquium, contributors to Prescribing Cultures discuss how the book analyzes pharmaceutical policy in China, Korea, Japan, Thailand, Taiwan, Australia, and India, focusing on two cross-cutting themes: differences in “prescribing cultures” and physician dispensing; and the challenge of balancing access to drugs with incentives for innovation.

As Michael Reich of Harvard University says in his Forward to Prescribing Cultures,

“The pharmaceutical sector…promises great benefits and also poses enormous risks.… Conflicts abound over public policies, industry strategies, payment mechanisms, professional associations, and dispensing practices—to name just a few of the regional controversies covered in this excellent book.

The tension between emphasizing innovation versus access -- a topic of hot debate on today’s global health policy agenda -- is examined in several chapters…

This book makes a special contribution to our understanding of the pharmaceutical sector in China… Globalization is galloping forward, with Chinese producers pushing the pace at breakneck speed. More and more, our safety depends on China’s ability to get its regulatory act together…”

The colloquium features presentations by Naoko Tomita (Keio University), Anita Wagner (Harvard University), and Karen Eggleston (Stanford FSI Shorenstein Asia-Pacific Research Center). They will give specific examples of how pharmaceutical policy serves as a window into the economic tradeoffs, political compromises, and historical trajectories that shape health systems, as well as how cultural legacies shape and are shaped by the forces of globalization.

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Anita Wagner Speaker Harvard University
Naoko Tomita Speaker Keio University

Shorenstein APARC
Stanford University
Encina Hall E301
Stanford, CA 94305-6055

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Senior Fellow at the Freeman Spogli Institute for International Studies
Center Fellow at the Center for Health Policy and the Center for Primary Care and Outcomes Research
Faculty Research Fellow of the National Bureau of Economic Research
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
karen-0320_cropprd.jpg PhD

Karen Eggleston is a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford University and Director of the Stanford Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center at FSI. She is also a Fellow with the Center for Innovation in Global Health at Stanford University School of Medicine, and a Faculty Research Fellow of the National Bureau of Economic Research (NBER). Her research focuses on government and market roles in the health sector and Asia health policy, especially in China, India, Japan, and Korea; healthcare productivity; and the economics of the demographic transition.

Eggleston earned her PhD in public policy from Harvard University and has MA degrees in economics and Asian studies from the University of Hawaii and a BA in Asian studies summa cum laude (valedictorian) from Dartmouth College. Eggleston studied in China for two years and was a Fulbright scholar in Korea. She served on the Strategic Technical Advisory Committee for the Asia Pacific Observatory on Health Systems and Policies and has been a consultant to the World Bank, the Asian Development Bank, and the WHO regarding health system reforms in the PRC.

Director of the Asia Health Policy Program, Shorenstein Asia-Pacific Research Center
Stanford Health Policy Associate
Faculty Fellow at the Stanford Center at Peking University, June and August of 2016
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Karen Eggleston Speaker Stanford University
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Sarah Catanzaro is a senior undergraduate student at Stanford University majoring in international relations and minoring in Art History. Her interest in international security studies was provoked by the September 11, 2001 terrorist attack on the Twin Towers. Living on Long Island in a community that was impacted by this tragedy, she experienced firsthand the acute anxiety and sense of vulnerability induced by terrorism and sought to understand this phenomenon through academic research. As a result, she, like Ms. Esberg worked as a research assistant for Jacob Shapiro, a former postgraduate fellow at CISAC, examining the inefficiencies and vulnerabilities of terrorist groups. Since her junior year, she has served as a research assistant for Professor Martha Crenshaw. Moreover, Sarah interned at the Center on Law and Security at New York University School of Law, where she created a database of released Guantanamo Bay detainees that now serves as a crucial research tool for the executive director of the Center, Karen Greenberg. She is also active in the Stanford community as the President of the Public Health Initiative and former Events Director of Stanford Women in Business. She looks forward to expand her knowledge and professional experiences in the field of international security in the near future.

Jane Esberg is a CISAC Undergraduate Honors Student graduating this June with a B.A. in International Relations. She currently works as a research assistant for acting co-director of CISAC, Professor Lynn Eden, investigating US nuclear war planning. Previously, she has researched for Professor Kenneth A. Schultz, CISAC Homeland Security Fellow Jacob Shapiro, and PhD Candidate Luke Condra. In Summer 2008 Jane received a Stanford in Government Fellowship to work with the International Institute for Strategic Studies (IISS) in London, in the Transnational Threats and Political Risks division. She studied abroad at Oxford University, where she completed a tutorial on "the Politics of Terrorism," and in Santiago, Chile, where she was awarded a Stanford Quarterly Research Grant to conduct independent research for use in her thesis. After graduation, she will be traveling as a Haas Center Fellow to the Tambopata region of the Peruvian Amazon to conduct a research and service project on the impact of national policy, urbanization, and immigration on agricultural sustainability.

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Sarah Catanzaro CISAC Honors Student and winner of the William J. Perry Prize Speaker
Jane Esberg CISAC Honors Student and winner of the Firestone Medal Speaker
Michael M. May CISAC Co-Director Moderator
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As part of health reforms announced in April 2009, China plans to expand and strengthen primary care (i.e., provision of first contact, person-focused, ongoing care over time, and coordinating care when people receive services from other providers). Other nations of Asia continue to grapple with how to promote population health and constrain healthcare spending. What is the evidence about the effectiveness of primary care in improving population health and making healthcare accessible and affordable?

In this talk, Dr. Starfield will speak about the robust evidence of the association between primary care and better health outcomes at lower cost; ways of measuring the effectiveness of primary care; how selected Asian countries compare in such rankings; and the broader implications of primary care research for health policy in Asia.

Dr. Starfield, a physician and health services researcher, is internationally known for her work in primary care; her books, Primary Care:  Concept, Evaluation, and Policy and Primary Care: Balancing Health Needs, Services, and Technology, are widely recognized as the seminal works in the field.  She has been instrumental in leading projects to develop important methodological tools, including the Primary Care Assessment Tool, the CHIP tools (to assess adolescent and child health status), and the Johns Hopkins Adjusted Clinical Groups (ACGs) for assessment of diagnosed morbidity burdens reflecting degrees of  co-morbidity.   She was the co-founder and first president of the International Society for Equity in Health, a scientific organization devoted to furthering knowledge about the determinants of inequity in health and ways to eliminate them.  Her work thus focuses on quality of care, health status assessment, primary care evaluation, and equity in health. She is a member of the Institute of Medicine and has been on its governing council, and has been a member ofthe National Committee on Vital and Health Statistics and many other government and professional committees and groups. She has a BA from Swarthmore College, an MD from the State University of New York, Downstate Medical Center, and an MPH from Johns Hopkins University School of Public Health.

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Barbara Starfield University distinguished professor and professor of health policy and pediatrics Speaker Johns Hopkins University
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East and Southeast Asia are aging rapidly. South Korea, for example, has become one of the fastest aging societies in the world. In France, 115 years (1865–1980) were required for the proportion of population aged 65 and over to rise from 7 percent to 14 percent, but in South Korea, it is expected that a comparable change will occur in only eighteen years (2000–2018). More strikingly, it will take only eight years (2018–2026) for the proportion of South Korea’s elderly to increase from 14 percent to 20 percent. The nation’s old-age dependency ratio grew from 5.7 percent in 1970 to 12.6 percent in 2005, and is projected to further increase to 72.0 percent by 2050. At the macroeconomic level, these figures suggest an increasing burden on the working-age population to support the elderly population.

Such figures, however, do not tell the whole story about the burden shouldered by the working-age population. The lives of elderly and working-age individuals are not separate but rather, are linked by the institution of the family. Working-age adult children often take on the role of caring for elderly parents, who may have functional limitations and cognitive impairments. Such informal family caregiving is embedded in traditional Korean culture, as it is in many Asian societies that uphold traditional norms of filial piety.

As the elderly population grows, the demand for elderly long-term care will increase sharply. The supply of informal care, however, is decreasing for a number of reasons. Declining fertility rates have already diminished the potential pool of family caregivers. Further reducing the availability of family caregivers is an array of socioeconomic changes, such as increased migration, decreasing rates of intergenerational co-residence, and increasing labor force participation rates among women, who have historically served as the main family caregivers. Adult children, therefore, will increasingly experience a conflict between parental care responsibilities and their own work. Anecdotal evidence suggests that many daughters or daughters-in-law give up their professional employment to care for their disabled parent(s) or parent(s)-in-law. The work-family conflict also has important implications for the economy—informal caregiving may have additional negative effects on the labor force participation of the already shrinking working-age population.

I recently conducted a study using data from the Korean Longitudinal Study of Aging. My study indicated that providing at least ten hours of care per week reduces the probability of female labor force participation by 15.2 percentage points. I concluded that informal care is already an important economic issue in South Korea even though its population aging is still at an early stage. If the current trend continues, the labor market costs of informal caregiving will increase as the country experiences the full force of the demographic transition. One of the expected benefits of the public long-term care insurance implemented in July 2008 is to help family caregivers participate more easily in the labor force. In Japan, there is some evidence that long-term care insurance positively affects female labor force participation, but such beneficial effects have not yet materialized clearly in Korea. In both countries, there is much to learn from early experience with long-term care insurance.

In most parts of Asia, informal caregivers remain invisible on the policy agenda, not only because of cultural norms that perpetuate family-centered care but also because informal care incurs no public cost. However, the demographic transition, coupled with socioeconomic changes in the region, underscores the need to examine whether informal care is really without costs, at both individual and societal levels. Throughout Asia, the challenge for public policy will be finding the optimal mix of informal, family-based and formal, socially supported elder care.

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AHPP sponsors special journal issue on health service provider incentives

The Director of the Asia Health Policy Program, Karen Eggleston, served as guest editor of the International Journal of Healthcare Finance and Economics for the June 2009 issue. The eight papers of that issue evaluate different provider payment methods in comparative international perspective, with authors from Hungary, China, Thailand, the US, Switzerland, and Canada. These contributions illustrate how the array of incentives facing providers shapes their interpersonal, clinical, administrative, and investment decisions in ways that profoundly impact the performance of health care systems.

The collection leads off with a study by János Kornai, one of the most prominent scholars of socialism and post-socialist transition, and the originator of the concept of the soft budget constraint. Kornai’s paper examines the political economy of why soft budget constraints appear to be especially prevalent among health care providers, compared to other sectors of the economy.

Two other papers in the issue take up the challenge of empirically identifying the extent of soft budget constraints among hospitals and their impact on safety net services, quality of care, and efficiency, in the United States (Shen and Eggleston) and – even more preliminarily – in China (Eggleston and colleagues, AHPP working paper #8).

The impact of adopting National Health Insurance (NHI) and policies separating prescribing from dispensing are the subject of Kang-Hung Chang’s article entitled “The healer or the druggist: Effects of two health care policies in Taiwan on elderly patients’ choice between physician and pharmacist services” (AHPP working paper #5).

In “Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand” (AHPP working paper #4), Sanita Hirunrassamee of Chulalongkorn University and Sauwakon Ratanawijitrasin of Mahidol University study the impact of multiple provider payment methods in Thailand, providing striking evidence consistent with standard predictions of how payment incentives shape provider behavior. For example, patients whose insurers paid on a capitated or case basis (the 30 Baht and social security schemes) were less likely to receive new drugs than those for whom the insurer paid on a fee-for-service basis (civil servants). Patients with lung cancer were less likely to receive an MRI or a CT scan if payment involved supply-side cost sharing, compared to otherwise similar patients under fee-for-service. (This article is open access.)

The fourth paper in this special issue is entitled “Allocation of control rights and cooperation efficiency in public-private partnerships: Theory and evidence from the Chinese pharmaceutical industry” (AHPP working paper #6). Zhe Zhang and her colleagues use a survey of 140 pharmaceutical firms in China to explore the relationships between firms’ control rights within public-private partnerships and the firms’ investments.

Hai Fang, Hong Liu, and John A. Rizzo delve into another question of health service delivery design and accompanying supply-side incentives: requiring primary physician gatekeepers to monitor patient access to specialty care (AHPP working paper #2).

Direct comparisons of payment incentives in two or more countries are rare. In “An economic analysis of payment for health care services: The United States and Switzerland compared,” Peter Zweifel and Ming Tai-Seale compare the nationwide uniform fee schedule for ambulatory medical services in Switzerland with the resource-based relative value scale in the United States.

Several of the papers featured in this special issue were presented at the conference “Provider Payment Incentives in the Asia-Pacific” convened November 7-8, 2008 at the China Center for Economic Research (CCER) at Peking University in Beijing. That conference was sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center at Stanford University and CCER, with organizing team members from Stanford University, Peking University, and Seoul National University.

As Eggleston notes in the guest editorial to the special issue, AHPP and the other scholars associated with the issue “hope that these papers will contribute to more intellectual effort on how provider payment reforms, carefully designed and rigorously evaluated, can improve ‘value for money’ in health care.”

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Thailand introduced a universal coverage program in 2001. This program is commonly known as a "30 Baht Health Reform," adding coverage for nearly 14 million more people. This presentation will give an overview of the 30 Baht Health Reform including its main features and evolution, as well as a preliminary evaluation of its success. The talk will mostly be based on a paper entitled "Early Results from Thailand's 30 Baht Universal Health Reform - Something to Smile About," published in Health Affairs.

Kannika Damrongplasit is currently the Agency for Healthcare Research and Quality (AHRQ) Postdoctoral Research Fellow at the University of California at Los Angeles and RAND Corporation. She received her Ph.D. in Economics from the University of Southern California. Her fields of interest are in program evaluation, applied econometrics, health economics and applied microeconomics. She has published in Journal of Business and Economic Statistics, Health Affairs, and Singapore Economic Review. In January 2010, she will assume an assistant professor position at the Department of Economics, Nanyang Technological University in Singapore.

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Kannika Damrongplasit Postdoctoral Research Fellow Speaker University of California at Los Angeles and RAND Corporation
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With what now seem like almost weekly product scandals, recalls, and supply chain exposes, the public increasingly wants to know more about the products they are putting in, on, and around their families. Until recently, consumers had no way to find out the full impacts of the products they consumed. However, with advances in information technologies, product assessment methodologies, and web and mobile platforms, there is now a real potential to radically increase transparency in consumer markets and global supply chains. Dara O'Rourke, Associate Professor at UC Berkeley, will discuss an experiment in providing information to the public about the environmental, social, and health impacts of products and companies: GoodGuide. GoodGuide's award-winning web and iPhone apps have been featured recently in the New York Times, Newsweek, Time, and even Oprah's Magazine! Dara will discuss GoodGuide's long-term vision, current strategies, and the information technologies they are applying to this challenge.

Dara O’Rourke is an Associate Professor at the University of California, Berkeley, and the co-founder of GoodGuide. Dara’s research focuses on systems for monitoring the environmental, labor, and health impacts of global production systems. His research has been featured in The New York Times, The International Herald Tribune, The Boston Globe, The Los Angeles Times, The Economist, Business Week, Newsweek, Time, and TechCrunch. Dara has served as a consultant to international organizations such as the World Bank, the United Nations Development Programme, the Organization for Economic Cooperation and Development, and a wide range of domestic and international non-governmental organizations. He has degrees in Mechanical Engineering, Political Science, and Energy and Resources, and he previously taught at MIT.

GoodGuide seeks to revolutionize how consumers see and interact with products and companies. GoodGuide provides a suite of tools that offer information about the environmental, social, and health performance of products and companies to consumers at the point of purchase (through web and mobile apps), and that empower people to screen and compare products based on their personal values and concerns. GoodGuide's tools seek to empower millions of consumers to buy products that better match their values, to avoid products that are detrimental to their health, the environment, or issues they care about, and to participate in a more transparent marketplace.

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Dara O'Rourke Good Guide and Associate Professor of Environmental and Labor Policy Speaker UC Berkeley
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