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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Fast Forward: Uncertainties, Risks and Opportunities of Rapid Aging in China, Japan, and Korea will be an innovative, invitation-only scenario planning exercise. Our goal is to develop a broader understanding of how population aging could affect the social, cultural, economic, and security futures of Asia over the next ten to twenty years. We’ve invited a select group of leaders from business, government, and academia with an interest in various aspects of Asia’s growth to identify key uncertainties and assess possible outcomes. This highly interactive session will be moderated by the Global Business Network, the world’s leading scenario consultancy.

This scenario planning workshop is part of a two-day conference at Stanford, Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and Korea. The first day, Aging in Asia Today: What the Experts Know, will feature keynote presentations and academic panels on the impacts of rapid aging in these countries, focused on four topics: economic growth, social insurance programs, long-term care, and health care.

Bechtel Conference Center

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This conference, sponsored by the Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center and the Global Aging Program of Stanford Center on Longevity, explored the impact of rapid aging on economic growth, labor markets, social insurance financing, long term care, and health care in China, Japan, and Korea.

Bechtel Conference Center

Michael H. Armacost Speaker
David Bloom Speaker Harvard University
Judith Banister Speaker The Conference Board
Naoki Ikegami Speaker Keio University
Soonman Kwon Speaker Seoul National University
Shripad Tuljapurkar Speaker Stanford University
Marcus W. Feldman Speaker Stanford University
Naohiro Ogawa Speaker Nihon University
Andrew Mason Speaker University of Hawaii
Shanlian Hu Speaker Fudan University
Edward Norton Speaker University of Michigan
Shuzhuo Li Speaker Xi'an Jiaotong University
Maria Porter Speaker University of Chicago
Meng Kin Lim Speaker National University of Singapore National University of Singapore
Kai Hong Phua Kai Hong Phua Speaker National University of Singapore National University of Singapore
John C. Campbell Speaker University of Michigan Emeritus
Byongho Tchoe Speaker Korea Institute for Health and Social Affairs
Young Kyung Do Speaker Asia Health Policy Program
Jian Wang Speaker Shandong University
Dolores Gallagher-Thompson Speaker Stanford School of Medicine
Conferences

This study aimed to better understand the dramatic health improvements in Maoist China and the age-related health disparities that it may have generated. The investigators validated official Chinese health statistics to establish the magnitude of China’s mortality decline between 1950 and 1980; and identified the proximate determinants correlated with China’s mortality decline, using data on regional variation in such factors as primary healthcare infrastructure, drinking water quality, sanitation, nutrition, and childhood vaccination rates.

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On October 2, 2008, Dr. Marcus Feldman of Stanford's Biology department delivered the first colloquium in the series on "The Implications of Demographic Change in China," co-sponsored by the Asia Health Policy Program and the Stanford China Program. Dr. Feldman discussed the sex-ratio imbalance and gender studies in China.

As Dr. Feldman noted, the total fertility rate in China has dropped dramatically in recent years, due in large part to the Chinese government's One Child Policy, which was introduced in 1979. In the early 1970s, the fertility rate averaged almost 6 births per woman, dropping to about 1.6 after the year 2000. China's sex ratio of males to females at birth (SRB), meanwhile, has risen. In 1975, the SRB was about 106 male births per 100 female births, and in 2005 had climbed to over 120 male births per 100 female births. When parity (birth order) is taken into account, the ratio becomes even more startling; for the first birth, the ratio is close to even (about 108 in the year 2005), but exceeded 145 in 2005 for the second birth and even higher for the third birth (almost163 in 2005). Research indicates that the imbalanced SRB is largely concentrated in the lower coastal regions of mainland China, where the population is predominantly Han. Shaanxi, Anhui and Jiangxi Province have the highest ratio of male to female births.

Evidence of gender imbalance is not merely limited to the ratio at birth; high ratios of male to female children are seen through ages 0-4, indicating that son preference affects not only which children survive birth, but also the survival rate of females in early childhood. In fact, research indicates that while excess girl child mortality (EGCM) has decreased for infants less than a year old in the period between 1973 and 2000, it has become increasingly pronounced for children between the ages of 0-4 and 5-9, with EGCM rates increasing every year.

Two Studies

Two studies were carried out in 1997 and 2000 by the Institute for Population and Development Studies of Xi'an Jiaotong University to investigate the causes of gender imbalance. The 1997 study focused on the cultural transmission of son preference, and the 2000 study on marriage form and old age support.

Three counties were chosen as sites, and the studies were a combination of surveys, in-depth interviews and focus group discussions. The first county, Sanyuan () in Shaanxi province, is a medium-developed region whose principal agricultural product is wheat. Fertility is high in Sanyuan, which is characterized by the dominance of virilocal marriage (in which the bride joins the family of her husband) and strict patrilineal family systems. The second county, Lueyang () in Shaanxi province is an underdeveloped mountainous region in which the patrilineal family system is more relaxed, fertility is lower than in Sanyuan, and there are diversified forms of marriage. The third site, Songzi () in Hubei province, is a well-developed rice- and cotton-producing plains region, with low fertility, relaxed family systems and diversified marriage. The results of household surveys showed a strong preference among parents in both Sanyuan and Lueyang to live with their sons in old age, which was not surprising, but a surprising result was found when parents were asked about the primary benefits of having a son. The most-reported reason was for carrying on the family name, which shows that traditional (Confucian) values played a bigger role in son preference than practical considerations such as labor or old age support. Overall, Lueyang was shown to have a much higher rate for transmitting no son-preference than Sanyuan, with older women slightly more likely to transmit no son-preference.

The marriage study found that rates of uxorilocal marriage (in which the groom joins the family of his wife) have, for the most part, been dropping in both Lueyang and Songzi since the 1970's. In Sanyuan, where uxorilocal marriage has been traditionally uncommon, the rates have remained steady at around 5 percent since the 1950's. The researchers calculated children's odds ratios of providing financial help to parents based on marriage form, and found the net ratios highest for women in virilocal marriages and sons in uxorilocal marriages.

Mechanisms of gender imbalance

There are several likely factors for the imbalanced sex ratio at birth in China. Underreporting of female births, infanticide, and sex-selective abortion (post-pre-natal gender testing) all contribute to this syndrome. Furthermore, poor nutritional and medical care for girls in their younger years can further skew the gender balance by exacerbating excess female child mortality. At the basic source of this issue, however, remains a fundamental gender bias that dates back historically and philosophically through Confucian culture and traditional patriarchal structures.

If the SRB, EFCM, TFR (total fertility rate) were all to remain at their early 2000s levels, then by 2030 the total population of China would be 84.2% of what would normally be expected at the current fertility rate (potentially causing economic welfare issues for the elderly, along with a work force deficiency). Moreover, there would be an excess in the male population of 20-21% (relative to females), essentially making it mathematically impossible for this proportion of the male population to marry. Needless to say, the possibility of such a severe "marriage squeeze", and the general top-heavy ratio of aging population to young working population are very problematic prospects for China's population and for the government's endeavors to promote both economic growth and social stability.

Examples of government efforts

The government is considering several policy options to try to avert this potential crisis. Stronger punishments were suggested at the 2008 National People's Congress (NPC) and Chinese People's Political Consultative Conference (CPPCC) for non-medical sex identification and sex-selection abortions (both of which can be obtained for relatively cheap rates within the country, despite being illegal). More proactively, an experimental program called "Care For Girls" was implemented in 2000 in Chaohu (a city in Anhui province). This program includes: financial help for 1- and 2-daughter families; sponsoring of girls' educational fees and increased pensions to families with daughters; and the promotion of uxorilocal marital structures. Since the introduction of the program, the local SRB went from 125 in 1999 to 114 in 2002. In response to this apparent success, the government expanded the "Care For Girls" program to 24 counties with high SRB rates in 2003-2004, and saw the average SRB in those counties drop from 133.8 in 2000 to 119.6 in 2005. Stipulation and initiation of a national "Care For Girls" campaign occurred in January 2006 - July 2006, with the goal of bringing the national SRB average to normal levels within 15 years. In January 2008, the government expanded on this effort by launching the "Care For Girls Youth Volunteer Action", beginning with more than 1000 students (mostly at the university level) directed at engaging in promotional activities and data collection (under the Chinese Communist Youth League). These policies are part of a comprehensive aspiration on the part of the PRC government towards the "construction of a new reproductive culture."

Son preference among migrant workers in Shenzhen

With the Chinese economic reform of the early 1980s, millions of laborers have been migrating from rural to urban areas. After migration, rural-urban laborers have to familiarize themselves with the rules and customs of their new locations, rebuilding their social networks in the process of adapting to their new occupations and habitation. But how do individual characteristics (i.e. gender, education level and the time of residency), restructured social networks, and the experiences of migration influence migrants' attitudes and behaviors regarding son preference? These questions were examined in a 2005 study conducted in Shenzhen.

Shenzhen is the first Special Economic Zone in China to implement economic reform and has since developed from a small fishing village into a modern coastal city. According to the 2000 Population Census, the total population of Shenzhen is 7,008,800, and the ratio of migrants to permanent urban residents is 4.77:1.

The Shenzhen study seemed to indicate initially that only a small minority of migrants (7% of total respondents) expressed a strong attitude towards son preference. However, the actual childbearing behavior of rural-urban migrants was remarkably different compared to their reported attitudes. The sex ratio of migrant children is as high as 163 male births per 100 female births, and the later in the birth order, the higher the sex ratio for the child, i.e., the sex ratio is 1.52 for the first birth and rises steeply to 1.80 for the second birth, peaking at 1.94 for the third and above birth. Thus the results suggest that migrants' childbearing behaviors actually suggest a strong son preference.

The Shenzhen study also found that three major determinants, namely social networks, migration history, and individual factors, all have significant effects on son preference among rural-urban migrants.

First, weak ties (formed by friends, bosses, and fellow workers) in social networks affect the attitude of son preference among rural-urban migrants. That is, the risk of having son-preference tends to decrease when the overall influence of network members is positive (without son preference). Moreover, increasing social contacts with network members will reduce the dependence upon strong ties (formed by family members and kin) and thus decrease the traditional culture of "rearing a son to support parents in their old age" and familial pressures to have more children.

Second, the duraction of residency in an urban area has a significant effect on the attitude of son preference among rural-urban migrations. The longer the migrants live in an urban area, the more likely that their attitudes of son-preference will adapt to urban reproductive norms. For example, the data indicated that ratio of male and female birth is more balanced among those living in urban areas for 8 years or longer. However, rural-urban migrants still exhibit a strong overall behavior of son preference. In other words, the change in childbearing behavior in terms of birth patterns still lags far behind the apparent change of attitudes.

Age and education are identified as factors affecting son preference among rural-urban migrants. For instance, an increase in age relative to initial migration will often decrease the imbalance in the sex ratio.

An additional study on rural-urban migrants examined the relationship between the gender of married migrants and their provision of financial support to parents and parents-in-law post-migration. The results showed, in fact, that female migrants are more likely to give financial support to their parents-in-law after migration.

Even today, the patrilineal conception of support for elderly family members is still very prevalent in rural China. Sons are expected to provide fundamental support to their parents, while daughters tend to provide supplementary and emotional support. This traditional old-age support pattern of reliance on sons can often intensify the syndrome of son bias among rural or traditional Chinese. However, the results here proved that if aging parents are more likely to receive sustenance from married daughters compared to married sons, the dominant son-preference in rural China could be logically undercut and eventually the traditional patrilineal conception of old-age support, and resulting gender bias, could be ameliorated and even eliminated.

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Dr. Forsberg will present findings from studies in China and Vietnam and put those findings into a broader comparative perspective regarding the future role of the private sector in improving health service delivery and population health.

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Birger Carl Forsberg is a public health specialist and lecturer in International Health at the Karolinska Institute in Stockholm, Sweden from where he holds an MD and a PhD. He is also trained in economics and has health economics as one of his areas of work. Dr Forsberg has more than 20 years experience from international health from around 25 low- and middle-income countries as an adviser to bilateral donors and international organisations. Since 2002 he has been a consultant to the World Bank on public private sector collaboration in health. He is also coordinator since 2002 of a joint Harvard-Karolinska research programme called Private Sector Programme in Health (PSP). The programme has coordinated studies of the private health sector in five countries in Asia and Africa. In his talk Dr Forsberg will present findings from PSP studies in China and Vietnam and put those findings into a broader perspective on the future role of the private sector in health service delivery for increased access to health services and improved health.

Philippines Conference Room

Birger Carl Forsberg, MD Private Sector Program in Health Coordinator Speaker Karolinska Institutet, Sweden
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Dr. Shea will talk with us about her research on menopause and aging among Chinese women and issues surrounding romance, sex, and marriage in later life in mainland China, as part three of the colloquium series on "The Implications of Demographic Change in China," co-sponsored by the Stanford China Program and the Asia Health Policy Program. 

A sociocultural anthropologist who specializes in medical and psychological anthropology and Chinese culture, Dr. Shea's research interests include gender issues, health and healing, aging and the lifecycle, and intergenerational issues. She has spent three cumulative years living, studying, and doing research in the People's Republic of China.

Dr. Shea earned a B.A. in Asian Studies from Dartmouth College in 1989, followed by an M.A. and Ph.D. in Anthropology from Harvard University in 1994 and 1998.

Philippines Conference Room

Jeanne Shea Associate Professor, Department of Anthropology Speaker University of Vermont
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The July/August issue of Health Affairs, the leading U.S.-based health policy journal, focuses on China and India. The special issue includes an article on China’s pharmaceutical policy by five contributors to Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, a book forthcoming in 2009 from the Shorenstein Asia-Pacific Research Center series with Brookings Institution Press. Chapters on Korea and Japan by Soonman Kwon (Seoul National University) and Toshiaki Iizuka (Aoyama Gakuin University) also appear in Chinese translation in the journal Bijiao (Comparative Studies), along with an overview paper (“Pharmaceutical policy reforms to separate prescribing from dispensing in Japan and South Korea: Possible implications for China”) by Karen Eggleston, Asian Health Policy Program Director.

As Eggleston writes in the introduction to Prescribing Cultures, pharmaceuticals and their regulation play an increasingly important and often contentious role in the health care systems of the Asia Pacific.  For example, some economies such as China have extraordinarily high drug spending as a percentage of total health spending; India and a few others host thriving domestic pharmaceutical industries of global importance, while controversy surrounds patents, trade-related aspects of intellectual property (TRIPS), and pharmaceutical pricing within bilateral trade agreements (Australia-US, Republic of Korea-US); nations throughout the region struggle with appropriate regulation of drugs, from patents to evidence-based purchasing (e.g., Australia’s Pharmaceuticals Benefit Scheme) and direct-to-consumer advertising; deeply-rooted traditions of indigenous medicine are modernizing and integrating into broader health care systems; and policies to separate prescribing and dispensing re-write the professional roles of physicians and pharmacists, with modifications to accommodate cultural norms and strong economic interests. Effective prescribing and pharmaceutical use will be central to controlling infectious diseases, both old and emerging; protecting the global public good of antimicrobial effectiveness; and treating the growing burden of chronic disease in the Asia Pacific.

The forthcoming book will explore these issues in detail, through a multi-disciplinary lens. The first section of the book features chapters on pharmaceutical policy within seven selected health care systems of the Asia Pacific: South Korea, Japan, Thailand, Taiwan, Australia, India, and China. The second section focuses on the cross-cutting themes of prescribing cultures and access versus innovation. Taken as a whole, the contributions aim to provide an evidence base for policy while acknowledging the historical and cultural context that makes policies distinctive.

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Health Affairs 072008
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Clear evidence suggests the importance of health service provider payment incentives for achieving efficiency, equal access, and quality, including attention to primary, secondary, and tertiary prevention. “Pay for performance” may be on the cusp of significant expansion in Asia, and reform away from fee-for-service has been underway for several years in several economies. Yet despite the policy relevance, the evidence base for evaluating payment reforms in Asia is still very limited.

China in particular has been undertaking significant reforms to its health care system in both rural and urban areas. With the expansion of insurance coverage and need to resolve incentive problems like “supporting medical care through drug sales,” there is an urgent need for evaluating alternative ways of paying health service providers. Evidence from policy reforms in specific regions of China, as well as other economies of the Asia-Pacific, can provide valuable evidence to help inform policy decisions about how to align provider incentives with policy goals of quality care at reasonable cost.

To illuminate these questions, the Asia Health Policy Program and several collaborating institutions are planning to convene a conference on health care provider payment incentives on November 7-8, 2008 in Beijing. The conference will highlight and seek to distill “best-practice” lessons from rigorous and policy-relevant evaluations of recent reforms in China and elsewhere in the Asia Pacific.

The organizing committee – including health economists from Shorenstein APARC, Peking University, Tsinghua University, and Seoul National University – reviewed submissions in June 2008 and accepted sixteen. The conference papers cover payment issues in Korea, Japan, China, Taiwan, Thailand, Tajikistan, the Philippines, and the US, and the disciplines of economics, health services research/health policy, public health, medicine, and ethics. Topics include institutionalized informal payments; the impact of global budget policies on high-cost patients; public-private partnerships; public-sector physicians owning private pharmacies; evidence-informed case payment rates; payment and hospital quality; bonuses and physician satisfaction; physician prescription choice between brand-name and generic drugs; and differences in pharmaceutical utilization across insurance plans that pay providers differently (fee-for-service versus capitation).

Policymakers from China’s National Development and Reform Commission and Ministry of Health will also speak at the conference. Selected research papers will be published through the Shorenstein Asia-Pacific Research Center either in a special volume or in a special issue of an English-language health policy journal.

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Contradictory goals plague China’s pharmaceutical policy. The government wants to develop the domestic pharmaceutical industry and has used drug pricing to cross-subsidize public hospitals. Yet the government also aims to control pharmaceutical spending through price caps and profit-margin regulations to guarantee access even for poor patients. The resulting system has distorted market incentives, increased consumer cost, and financially rewarded inappropriate prescribing, thus undermining public health. Though pharmaceuticals account for about half of total healthcare expenditures in China, representing 43% of expenditure per inpatient episode and 51% of expenditure per outpatient visit, some essential medicines are unavailable or of questionable quality.

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