A quarter-century ago in a seminal paper, Hart, Shleifer, and Vishny (NBER1996, QJE1997) developed a theory of the ‘Proper Scope of Government.’ Oliver Hart, 2016 Nobel Laureate, reflects on that framework and its place in economics, as well as the inspiration for his more recent work on norms, guiding principles, and contracts as reference points. In discussion with Karen Eggleston, Hart answers questions posed by economists who have built upon Hart, Shleifer and Vishny (1997) and offers insights on how the theory applies to understanding public and private roles in healthcare, education, and other publicly-financed services.

Watch the webinar featuring Hart's keynote: https://youtu.be/sDp7ytudbsE

Oliver Hart is currently the Lewis P. and Linda L. Geyser University Professor at Harvard University, where he has taught since 1993. He is the 2016 co-recipient of the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel, a Fellow of the Econometric Society, the American Academy of Arts and Sciences, the British Academy, and the American Finance Association, a member of the National Academy of Sciences, a Distinguished Fellow of the American Economic Association, and has several honorary degrees. Hart works mainly on contract theory, the theory of the firm, corporate finance, and law and economics. His research centers on the roles that ownership structure and contractual arrangements play in the governance and boundaries of corporations. He has published a book (Firms, Contracts, and Financial Structure, Oxford University Press, 1995) and numerous journal articles. He has used his theoretical work on firms and contracts in several legal cases. He has been president of the American Law and Economics Association and a vice president of the American Economic Association.

This keynote is part of the Stanford Asia Health Policy Program colloquium series entitled Health, Medicine, and Longevity: Exploring Public and Private Roles

Oliver Hart, Andrei Shleifer, Robert W. Vishny, The Proper Scope of Government: Theory and an Application to Prisons, The Quarterly Journal of Economics, Volume 112, Issue 4, November 1997, Pages 1127–1161, https://doi.org/10.1162/003355300555448.

In one of the first studies of service sector robotics using establishment-level data, we study the relationship between robots and staffing in Japanese nursing homes. We utilize variation in robot subsidies across prefectures as an instrumental variable to explore the impact of robot adoption on nursing homes’ staffing decisions. We find that robot adoption appears to decrease difficulty in staff retention and to increase employment by augmenting the number of care workers and nurses on flexible employment contracts. Robot adoption is negatively correlated with the monthly wages of regular nurses, consistent with reduced burden of care such as fewer night shifts. Our findings suggest that robots may not be detrimental to labor and may help to remedy challenges posed by rapidly aging populations.

JEL Code: I11, J14, J23, O30,
Key words: Robots, jobs, nursing homes, automation, aging, healthcare

Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China’s efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% fewer inpatient admissions, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.

Background. People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India.
Methods. Between July 29, to September 12, 2020, we telephonically surveyed adults (n=2335) with chronic conditions across four sites in India. Data on participants’ demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the correlates of difficulty in accessing medicines and worsening of diabetes or
hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient’s experiences during the COVID-19 lockdowns and data analysed using thematic analysis.
Findings. 1,734 individuals completed the survey (response rate=74%). The mean (SD) age of respondents was 57·8 years (11·3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4·01,2·90-5·53), having diabetes (2·42, 1·81-3·25) and hypertension (1·70,1·27-2·27), and loss of income (2·30,1·62-3·26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3·67,2·52-5·35), and job loss (1·90,1·25-2·89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services.
Interpretation. People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.
Funding. None.