Stanford researchers launch new approach to health policy in India
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Millions of women in India give birth at home, where they don’t have easy access to medical help if things go wrong. And things go wrong often. The country has one of the world’s highest rates of maternal and neonatal deaths.
To curb this problem, the government pays eligible pregnant women to deliver their babies in an accredited medical facility. With both a financial incentive and the promise of a safer childbirth, it would stand to reason that most Indian women should choose to deliver their babies in a hospital.
But that’s not the case.
Most babies are still born in homes. Early numbers from the financial incentive programs show less than half of eligible women are choosing to participate.
Stanford researchers Grant Miller and Nomita Divi think the answer to this quandary—and so many other well-intentioned policies that fall short—needs to first be considered from the perspective of patients, doctors and other health care providers. And that, they say, is a different approach than most health interventions take.
Miller and Divi are spearheading the Stanford India Health Policy Initiative, a program that seeks to rethink health interventions based on Indian health care users’ and providers’ motivations for seeking care. And to get there, the initiative’s focus comes from the people who confront these problems every day.
The program, which is connected to the International Policy Implementation Lab at Stanford’s Freeman Spogli Institute, first brings together community leaders for an in-depth discussion of where best to focus efforts. Next, teams (including students) take these recommendations and spend several months conducting fieldwork to understand health care decision-making, both from the side of patients and providers. From this foundation, the initiative produces reports detailing the behavioral motivations for why certain dimensions of health care are or are not working.
“To really understand why health policies succeed or fail, you have to see the world through the eyes of the providers and patients,” said Miller, an associate professor of medicine and a core faculty member of FSI’s Center for Health Policy and Primary Care Outcome Research. “A lot of programs are created because they seem logical from the outside. But if you don't understand a patient’s priorities or motives, your program may not work.”
Miller and Divi first applied this approach to the very issue of childbirth in India. Why weren’t more women giving birth in hospitals when there were seemingly logical reasons to do so?
Over the summer, Miller, Divi, their Indian partners, and Stanford graduate and medical students set out to answer this question. During seven weeks of field interviews and subsequent analysis, the students—with guidance from Miller and Divi —identified reasons for why Indian women weren’t accepting a stipend to have their babies in the hospital. Some of these reasons included hidden costs of delivering a baby (like the transportation cost to the hospital or unexpected medical expenses), pressure from mothers-in-law to follow tradition and deliver at home, and fear of unwanted medical procedures like Caesarean sections or sterilization.
This understanding of why patients and providers don’t always make seemingly logical health care decisions is exactly what the India Health Policy Initiative is after.
“So much academic research is driven by donors or journal articles that we read,” Miller said. “So it seemed like we were starting from the wrong place in identifying health policy challenges that we should work on.”
In January, Miller and Divi convened a group of Indian health policy leaders, health care workers, academics and entrepreneurs to understand the challenges they faced in their daily work, and what health care questions they would most like to know more about. From this two-day meeting, the group identified two focus areas for the India Health Policy Initiative over the coming year: understanding more deeply the motivations and activities of both formal and informal health care providers, and what Indians value about care from the informal sector. These informal providers are often doctors or nurses with little or no medical training that are used by many low-income Indians.
To help answer these questions and provide opportunities for students, the Stanford India Health Policy Initiative engages top students from across the university. “We want to provide our students with an experience that will hopefully shape the way they think in their future careers,” said Divi, the initiative's project manager. “And we try to achieve this by training our students to help make sense of urgent health delivery challenges, immersing them in an intensive field experience, and teaching them how to generate insights.”
To better understand providers’ motivations, as well as patients’ perspectives on both the informal and formal providers, Miller and Divi will work with this new team to carry out qualitative fieldwork this summer.
Miller explained that the approach is very anthropological.
”To be able to understand these issues, we all have to see the world through another person’s eyes, whether that be a formal or informal health provider or a patient,” he said. “This approach fundamentally relies on strong collaboration with Indian partners.”
The initiative’s teams will spend their weeks interviewing different health care providers and patients in a handful of Indian villages, taking copious notes and ultimately translating hundreds of interviews into findings.
Roshan Shankar, MS/MPP ’14, worked as part of the initiative’s team last summer, focusing on understanding pregnant women’s decisions about where to deliver their babies. After considering several summer internships with consulting firms and international organizations, Shankar declined these opportunities, instead opting to work with the Stanford India Health Policy Initiative.
Shankar is from New Delhi and has always planned to move back to his home country and work in government after school. He said the India Health Policy Initiative was a way to better understand his nation and the pressing challenges facing it.
“I’m used to sitting at a table and not venturing out,” Shankar said. “This experience showed me that things are much more different on the ground than on paper.”
After his work with the Stanford Health Policy Initiative, Shankar said he is now certain he wants to return to India and work in government.
“It was a humbling and enlightening experience. I think the way we did this entire analysis will affect the way I do any work there,” he said. “It will ensure that I do a more effective evaluation of the policies and programs that I work on, and start by going to see people who use them.”
The Stanford India Health Policy Initiative is supported by several organizations including the Center for Innovation in Global Health and the Office of International Affairs.
Teal Pennebaker is a freelance writer.
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Stanford medical student Bina Choi, center, interviews a woman about her pregnancy experience for the Stanford India Health Policy Initiative last summer. Choi is joined by colleagues from SIHPI partner organization the Institute of Socio-Economic Research on Development and Democracy.
Roshan Shankar
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Born in Paris in 1956, Christine Lagarde completed high school in Le Havre and attended Holton Arms School in Bethesda (Maryland, USA). She then graduated from law school at University Paris X, and obtained a Master’s degree from the Political Science Institute in Aix en Provence.
After being admitted as a lawyer to the Paris Bar, Christine Lagarde joined the international law firm of Baker & McKenzie as an associate, specializing in Labor, Anti-trust, and Mergers & Acquisitions. A member of the Executive Committee of the Firm in 1995, Christine Lagarde became the Chairman of the Global Executive Committee of Baker & McKenzie in 1999, and subsequently Chairman of the Global Strategic Committee in 2004.
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Christine Lagarde was named Officier in the Légion d'honneur in April 2012. A former member of the French national team for synchronized swimming, Christine Lagarde is the mother of two sons.
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International Monetary Fund
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Minerva Postdoctoral Fellow 2013-2014, CDDRL Pre-doctoral Fellow 2011-2013
Eric Kramon received his PhD in political science from UCLA in 2013 and is a 2013-14 Minerva Postdoctoral Fellow. He will be an assistant professor of political science and international affairs at George Washington University starting in Summer 2014. While at CDDRL, he is working on a book project on vote buying and clientelism in Africa, as well as additional projects on the impact of election observation on electoral fraud and electoral quality, ethnicity and the politics of public goods provision in Africa, and the political determinants of good governance reforms.
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University of California, Santa Cruz
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Marcel Fafchamps is a Senior Fellow Emeritus at the Freeman Spogli Institute for International Studies (FSI) and a member of the Center on Democracy, Development and the Rule of Law. Previously, he was the Satre Family Senior Fellow at FSI. Fafchamps is a professor (by courtesy) for the Department of Economics at Stanford University. His research interests include economic development, market institutions, social networks, and behavioral economics — with a special focus on Africa and South Asia.
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Fafchamps has degrees in Law and in Economics from the Université Catholique de Louvain. He holds a PhD in Agricultural and Resource Economics from the University of California, Berkeley.
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Former FBI director targets cybercrimes
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Calling cybercrimes “the threat of the future,” former FBI Director Robert Mueller said federal investigators and businesses need to share information collected online in order to find and thwart hackers trying to disrupt Web-based networks.
“The intelligence that can be and is being collected by the private sector has to be made available in some way, shape or form to the federal government,” Mueller said. “And that which we pick up has to be made available to the private sector. If we do not get that kind of collaboration, we will replicate what we had before 9/11 when we had stovepipes and inadequate ways of sharing information.”
Mueller – who took over the FBI a week before the Sept. 11 terrorist attacks and left the job two months ago – made his comments Friday while delivering the Payne lecture at Stanford.
“Terrorism remains today our primary threat,” Mueller said. “But tomorrow, it will probably be cyber and its various iterations.”
He said cybercrimes present a new challenge to law enforcement agencies because perpetrators are often anonymous and their motives are not always clear.
A hacker could be associated with a terrorist organization, an activist group or “an 18-year-old in his garage here in Silicon Valley who has the talent and capability and wants to make a point.”
And if the bad guy can’t be easily fingered, it’s difficult to know who should investigate the crime – the FBI, CIA, NSA or another agency. In order to pool federal resources, Mueller said a task force composed of 18 agencies works to examine cyber threats.
But their efforts to safeguard online financial, government, corporate and educational systems will go only so far without the expertise, knowledge and information gathered by Internet service providers.
“It is going to be the relationships with the private sector that are going to be absolutely critical to any success we can have in addressing cyber attacks,” he said.
Mueller’s lecture capped his weeklong visit at Stanford. He was invited by the Freeman Spogli Institute for International Studies and Stanford Law School to spend the academic year as a consulting professor and as the Payne Distinguished Lecturer.
The Payne Lectureship is named for Frank E. Payne and Arthur W. Payne, brothers who gained an appreciation for global problems through their international business operations. The position is given to someone with an international reputation as a leader, with an emphasis on visionary thinking; a broad, practical grasp of a given field; and the capacity to clearly articulate an important perspective on the global community and its challenges.
FSI Director Mariano-Florentino Cuéllar called Mueller a “perfect fit for Stanford.”
“His career embodies what I take to be the ethos of this university –practical yet principled; sensitive to complexity but also to the value of clarity and focus,” Cuéllar said.
Mueller will make several visits to Stanford during the year, spending his time working with FSI and law school scholars to develop research agendas on emerging issues in international security. He will hold graduate seminars and deliver a major lecture at the law school and work with students and fellows at the Haas Center, the law school and the Graduate School of Business. He will also mentor honors students at FSI’s Center for International Security and Cooperation and Center on Democracy, Development, and the Rule of Law.
As the FBI’s longest-serving director after J. Edgar Hoover, Mueller presided over some of the most drastic changes in the agency’s history.
The Sept. 11 attacks forced the FBI to change its priorities, placing the hunt for global terrorists at the top if its list. The counterterrorism and counterintelligence missions meant hiring more analysts and replacing the FBI’s more traditional targeting of mobsters, murderers and white-collar criminals.
Recalling his first briefing to George W. Bush after the terrorist attacks, Mueller said he began by telling the president what his agents were doing to investigate. He had been on the job for about a week, and started giving a rundown of command centers that were set up, evidence that was being collected and interviews being conducted.
“I’m about two or three minutes into it and President Bush stops me and says, `Bob, that’s all well and good,’” Mueller said. “That’s what the FBI has been doing for the hundred years of its existence. My question to you is: What is FBI doing to prevent the next terrorist attack?”
The question stumped the new director.
“I had not prepared for that question,” he said.
And it’s a question he answered continuously during the Bush and Obama administrations, and one that led to his reorganization of the FBI.
“Over those 12 years, the question has not changed,” Mueller said. “The question from both of the presidents to the FBI, to the CIA, to the community when it comes to counterterrorism is: What have you done to prevent the next terrorist attack?”
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