Does the new wave of digital technologies portend a future in which robots and automation increasingly replace workers and destroy livelihoods? In one of the first studies of service sector robots, APARC experts find evidence to offset dystopian predictions of robot job replacement.

The researchers — Asia Health Policy Program Director Karen Eggleston, SK Center Fellow Yong Suk Lee, and University of Tokyo health economist Toshiaki Iizuka, our former visiting scholar — set out to examine how robots affect labor, productivity, and quality of care in Japan’s nursing homes. Their findings indicate that robot adoption may not be detrimental to labor and may help address the challenges of rapidly aging societies.

Eggleston recently joined the Future Health podcast, an initiative of the New South Wales Ministry of Health, to discuss the study and its implications. The program is available both as a video and audio podcast. Watch and listen below:

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Published by the National Bureau of Economic Research, the study suggests that robot adoption has increased employment opportunities for non-regular care workers, helped mitigate the turnover problem that plagues nursing homes, and provided greater flexibility for workers. It is also published in AHPP's working paper series and is part of a broader research project by Eggleston, Lee, and Iizuka, that explores the impact of robots on nursing home care in Japan and the implications of robotic technologies adoption in aging societies.

The study has attracted media attention. The Financial Times Magazine, in a feature story and podcast, called it “groundbreaking in several ways but perhaps most clearly for setting its sights not on manufacturing but on the services sector, where robots are only just beginning to make their mark.” The Freakonomics Radio podcast also hosted Eggleston and Lee for a conversation about their research as part of an episode on collaborative robots and the future of work.

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Introducing the new book, Lawrence H. Summers, president emeritus of Harvard University and the Charles W. Eliot University Professor at the Kennedy School, called the co-authors’ analysis of collaborative governance “micro microeconomics” that shows how particular tasks and particular commitments of resources, once decided on, are going to be best accomplished. This work, Summers noted, sheds light on situations involving both cooperation and competition — aspects that affect almost any complex problem yet are rarely considered by economists.

A key element of collaborative governance, noted Zeckhauser, is the sharing of discretion. Rather than contracting at one pole and complete laissez-faire at the opposite pole, in a collaborative governance process, the two parties involved play a role in determining what is produced and how it is produced. It is a process that calls on the best capabilities of both the private and public sectors and that grants each of them an element of control. Sometimes that process results in triumphs, sometimes in tragedies, and other times in outcomes that are “in-between.” The book analyses cases of this entire gamut. “We hope that this volume provides guidance on how the triumphs can become more common, the tragedies more scarce, and the in-between outcomes improved,” said Zeckhauser.

Collaborative Governance in the Time of COVID-19

The unfolding of the COVID-19 pandemic provides dramatic current illustrations of collaborative governance. The urgent need for an effective vaccine created the conditions for a successful partnership between the U.S. government and the pharmaceutical sector, with the former offering both regulatory processes and significant financing, the latter its innovation. Consider the Moderna vaccine, which, based on evidence from clinical trials, is over 90% effective at preventing laboratory-confirmed COVID-19 illness. The vaccine was created within less than a year using a new approach, based on Messenger RNA technology, by a company that had never before produced a commercial product. “This is a triumph of collaborative governance,” said Zeckhauser.

The vaccine distribution process in the United States, however, has proved to be challenging and chaotic. Zeckhauser contrasted this experience with China’s activation of technology giant Tencent, which is using its ubiquitous WeChat application to allow individuals to easily find where the vaccine is distributed and sign up for vaccination appointments. “There is probably a lesson here in the way these two outcomes came about. We hope that individuals in both China and the United States will examine the lessons in this volume to see how they can achieve outcomes for their citizens that produce public benefits more effectively.”

A Spectrum of Policy Domains

The book details how China and the United States grapple with the complexity of producing the goods and services they need to meet a broad array of public goals. Eggleston surveyed the five broad policy domains she and her co-authors examine in the book through detailed historical legacies and case studies of the application of collaborative governance in both countries.

These domains include the railroads that build the nation historically in both countries and China’s high-speed rail network; real estate's intricate tangle of public and private partnerships; hosting the Olympic Games and the experience of the public and private sectors in that endeavor in both countries; education provision; and state and market in population health and health care in both countries. The book spotlights the different ways in which both countries produce public goods and services in these broad policy domains.

East and West

Professor Yijia Jing of Fudan University, an expert on privatization, governance, and collaborative service delivery, participated in the discussion with the book co-authors and shared insights on public-private relationships in China. Collaborative governance in the country, he said, has undergone a gradual process of institutionalization. He observed that Chinese local governments apply different strategies in collaborating with private companies. For example, local governments like Guangdong and Shanghai partner in different ways with digital giants Tencent and Alibaba to build up their digital capacities — collaborations through which they have been learning how to balance their multiple roles as partners, policymakers, and market regulators.

Jing noted that China uses collaborative governance not only in domestic arenas but also in areas of international development, through entities such as the BRICS Development Bank and the Asian Infrastructure Investment Bank. China is also promoting collaborative governance as part of its Belt and Road initiative.

A Call for Transparency

The Dragon, the Eagle, and the Private Sector helps decision-makers apply the principles of collaborative governance to effectively serve the public. The book's overarching conclusion is that transparency is the key to the legitimate growth of collaborative governance. In the United States, said Donahue, the principle of governmental transparency is widely accepted as a broad-spectrum accountability device. He recognized that he and his co-authors do not expect China to adopt the U.S. approach to transparency, but expressed their hope to see more transparency “with Chinese characteristics.” “It is crucial for China to embrace the transparency imperative because the evil twin of collaborative governance is cronyism or corruption,” Donahue argued.

In many countries and policy arenas, collaborative governance could effectively increase innovation but is not available because the populace is convinced that any interaction between the public and private sectors amounts to corruption on the part of elites against the public interest. The potential in China to create public value through interaction between its public and private sectors is enormous, concluded Donahue. ”It would be a shame to squander that.”

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Oliver Hart and the ‘Proper Scope of Government’

Hart’s seminal economic theory, ‘The Proper Scope of Government,” underpins much of the research into public-private partnerships in healthcare. Hart developed this touchstone framework jointly with Andrei Shleifer and Robert W. Vishny to better evaluate when a government should provide a service itself and when it should contract with a private provider for support and execution of services.

The model outlined in Hart, Shleifer, and Vishny’s original 1996 working paper is designed to help providers and contractors consider the costs and benefits of a proposed contractual service agreement. While this model was originally applied to the case of prison privatization, the framework has served as an invaluable tool for researchers in multiple sectors including health policy and provision.

Reflections and Updates to the Theory

In reflecting on ‘The Proper Scope of Government,’ there are things Hart would like to see more fully incorporated into the theory to enrich its real-world applicability. Chiefly among these is better accounting for contractual incompleteness or the reality that a contract cannot anticipate and outline every possible unforeseen event or area of ambiguity. However, modeling contractual incompleteness is notoriously difficult given the almost-limitless factors of variability.

Some of Hart’s recent work on guiding principles responds to this challenge. Rather than trying to predict every aspect of a contractual relationship within the framing and language of a standard contract model, Hart argues that mutually agreed-upon guiding principles —such as equity, loyalty, and honesty — can serve as a foundation for navigating inevitable areas of ambiguity and potential conflict that a contract does not specifically state or that the original theory does not fully account for.

These guiding principles also help preserve space for renegotiation and innovation, which are necessary in an era of rapid technological advances and explosion of measurable data. In this context, Hart cautions against the mentality of ‘more is more:’

“If you put more and more things into the contract and then something happens that wasn’t in the contract, the fact that you put so much more in may make it more difficult to negotiate about the thing that you didn’t put in.”

 Applying ‘The Proper Scope of Government’

Hart shared a prime example of his theory at work in health systems in a case study of the Vancouver Island Health Authority. Traditionally, family physicians would continue as the primary care provider for their patients even if a patient needed hospitalization. But a change of law in 2006 required all specialized in-hospital care be contracted to hospitalists with little to no crossover with care provided by family practice physicians.

The result was a rise in caseload and stress levels amongst hospital specialists and repeated failed negotiations of the standard contract. The addition of guiding principles to the contract, however, provided avenues where reasonable solutions and additional communications could happen beyond the limits of the formal contract.

This is just one case of innumerable where Hart’s work has helped inform and contextualize how policymakers consider relationships between the public and private spheres of healthcare. Responding to the praise and input from fellow economists presented in a tribute documentary to the impact of his framework, Hart remarked:

“I hadn't realized how many people have been influenced by this paper and how they've been using it in different contexts. I knew some of the applications, but there were others I didn't, and it’s been truly amazing to see that.”

Looking Toward the Future

The tradeoffs between public and private partnerships in healthcare systems across the world will continue to be a dynamic and evolving area of research that will rely on theories such as ‘The Proper Scope of Government’ for framing and application. Looking towards the future, Hart was hopeful but cautious about the vitality of the kind of theoretical tradition which allowed for the development of his original theory. He recognizes that specialties such as contract theory and contractual incompleteness are inherently “messy” and somewhat out of vogue with current trends in economics which tend to favor theories that are “impressive, clever, and non-obvious,” regardless of whether they address important questions.

As he iterated in his Nobel Prize lecture, the incomplete world of contracts nonetheless “underlies numerous significant phenomena, some of which have great policy relevance,” and therefore fully deserving of upcoming economists’ time and efforts.

Further Research into Public-Private Partnerships

The Asia Health Policy Program’s 2020-21 colloquium series focuses on the roles and impacts of public-private partnerships in healthcare and the tradeoffs in equity, accessibility, and cost that come with contracted agreements in health systems. All of the events from the colloquium series are available on our YouTube channel. Click the thumbnails below to start exploring.

Collaborative governance — that is, relationships involving both the private and public sectors in the pursuit of public value — is part of ongoing research by Karen Eggleston. Her forthcoming book, The Dragon, the Eagle, and the Private Sector (Cambridge University Press), co-authored with Harvard’s John D. Donahue and Richard J. Zeckhauser, examines the ways in which collaborative governance works across a wide range of policy arenas in China and the United States, with the goal of empowering public decisionmakers to more wisely engage the private sector. Join us for the book launch event, which will be held jointly with the Harvard Kennedy School on March 5 

 

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The Walter H. Shorenstein Asia-Pacific Research Center (APARC) has broadened its fellowship and funding opportunities to support Stanford students working in the area of contemporary Asia. The Center introduced these expanded offerings in response to the harsh impacts of the COVID-19 pandemic on student’s academic careers and their access to future jobs and valuable work experience, and in recognition of the critical need to make the field of Asian Studies more diverse and inclusive.

APARC’s diversity grant aims to encourage Stanford students from underrepresented minorities (URM) to engage in the study and research of topics related to contemporary Asia and U.S.-Asia relations, including economic, health, foreign policy, social, political, and security issues. The grant, which was first announced in June 2020, is now an ongoing offering. APARC will award a maximum of $10,000 per grant. Current  Stanford undergraduate and graduate students in the URM category from any major or discipline are eligible and encourage to apply.

APARC also invites Stanford Ph.D. candidates specializing in topics related to contemporary Asia to apply for its 2021-22 predoctoral fellowship. Up to three fellowships are available and the application deadline is May 1, 2021.

In addition, APARC continues to offer an expanded array of research assistant internships. The Center is currently seeking highly motivated Stanford undergraduate- and graduate-level students to join our team as paid research assistant interns for the spring and summer quarters of 2021. Applications for spring 2021 research assistant assignments are due on February 22, for summer 2021 assignments on March 8.