We sat down with Jain to discuss her work and recent research into the ways the COVID-19 pandemic has affected the efficacy of India’s healthcare services for people living with chronic, non-communicable diseases. Listen to the full conversation above or via our Soundcloud channel.

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Jain’s research focuses on the role of the private sector in health systems, frictions in health care markets, the extent to which public health policies serve the needs of target populations, and health policy design in lower-income countries. In particular, she studies India's health care system, probing into data sets and administrative records to identify the factors that contribute to poor health outcomes and determine what interventions increase the effectiveness of public health insurance.

In the case of India, the private healthcare sector is highly fragmented and made up of a collage of small and independently-run hospitals and service providers with varying levels of oversight and administrative regulation. Gathering data on patient costs, insurance use, and benefit allocation for different cohorts of people using private healthcare in the world's second-most populous nation is a central pillar in Jain's efforts to better understand and document how health systems are used and how they can be improved to better serve vulnerable populations.

COVID-19 Lockdown Impacts on Non-COVID Health Care and Outcomes

For Jain, the ongoing effects of the COVID-19 pandemic have re-emphasized the crucial role that a well-functioning public, government-backed health system plays in providing care to citizens during times when the private sector experiences sudden and severe disruptions. Working in collaboration with Pascaline Dupas, the faculty director at the Stanford King Center on Global Development and a senior fellow at the Stanford Institute for Economic Policy Research, Jain has documented the adverse effects of COVID-19 on accessibility to health services for patients needing treatment for chronic, non-communicable diseases.("The Effects of India’s Covid-19 Lockdown on Critical Non-Covid Health Care and Outcomes: Evidence From a Retrospective Cohort Analysis of Dialysis Patients"

Jain's and Dupas' recent working paper (published in AHPP's Working Paper Series) shows that the abrupt, severe lockdown instituted by the Indian government as a preventive measure against the spread of the coronavirus had widespread impacts on individuals' ability to receive care for non-COVID-related healthcare needs such as dialysis. Their findings indicate that, among patients needing dialysis, the death rate between April and July 2020 was 25 percent higher than the death rate for a comparable cohort in the same months in 2019.

This increase in mortality is directly related to disruptions to critical health service delivery and accessibility caused by the lockdown measures. Sixty-three percent of those surveyed by Jain and Dupas reported experiencing disruptions to their care, with travel barriers and hospital closures or refusals cited as the most common causes. As a cohort, vulnerable populations were affected most by both the lockdown and ensuing disruptions to healthcare access.

Discrepancies like this between how a health system performs on paper and what happens in real-world practice is something Jain has a deeper appreciation for in light of the pandemic. “There were many policy prescriptions about how to respond to the lockdown, but what was done in India was a poorly conceived political response,” she cautions. “That’s something we who work on health policy need to keep in mind and contend with: What is the role of the political system, what is the role of the health system, and how does our research interact with all of that?”

Looking ahead, Radhika intends to continue researching and writing recommendations on how to make health systems viable and usable for all populations, including the most vulnerable. In particular, she is interested in investigating strategies to close engagement gaps and accessibility challenges women in India experience in utilizing healthcare services. She will continue working at APARC as a postdoctoral fellow with the Asia Health Policy Program through the end of the 2021-22 academic year.

Asia Health Policy Program Director Karen Eggleston and colleagues examine China’s progress in enhancing financial protection under its social health insurance to achieve universal health coverage.

In 2009, China launched comprehensive health system reforms to address challenges such as increasing rates of non-communicable diseases and population aging, problems with health financing and healthcare delivery, and overall growing health expectations of its people. Promoting universal health coverage by building a social health insurance system was a central pillar of the reforms.

After a decade of system reforms, has the Chinese government made good on its commitment to bolster universal health coverage? In a new article published in a BMJ collection, a team of four co-authors including Karen Eggleston, APARC’s deputy director and director of the Asia Health Policy Program, evaluates China’s progress towards enhancing financial protection of social health insurance and identifies the main gaps that need to be filled to achieve universal health coverage. Their article is part of a special BMJ collection with Peking University that marks the tenth anniversary of China’s health system reforms by analyzing their accomplishments and challenges ahead.

The 2009 reforms aimed to cover the entire Chinese population with one of three (since 2012 one of two) basic social health schemes. To provide added financial protection to patients with critical illnesses, catastrophic medical insurance was initially launched in 2012 and implemented nationally in 2015. Eggleston and her co-authors determine that the expansion of health insurance has had several major successes. First, it improved access to and use of healthcare. In 2011, China achieved near-universal health insurance coverage, with more than 95% of the Chinese population covered by health insurance. Moreover, the annual inpatient hospital admission rate increased from 3.6% in 2003 to 17.6% in 2017, and admission rates for outpatient services were much higher than the global average.

Second, the expansion of health insurance coverage reduced the share of out-of-pocket heath expenses in total health expenditure, thus raising the level of financial protection. Third, catastrophic medical insurance was also effective in supplementing the basic social health insurance schemes and provided extra financial protection to a range of vulnerable groups. By 2017, more than a billion people in China were covered by such insurance.

However, much remains to be done. Out-of-pocket health expenditures remain fairly high and are one of the main reasons for catastrophic health expenses and low financial protection in China, which disproportionately affect deprived populations. Catastrophic medical insurance currently does not target underprivileged people, while medical aid is relatively small in scale and covers only a minority of patients with catastrophic health expenses.

Eggleston and her colleagues conclude that the Chinese government should focus on underprivileged populations within the current insurance system and enhance their financial protection as an important element of targeted poverty alleviation. Such targeting, the researchers emphasize, requires a clear and integrated policy encompassing the basic social health insurance schemes, catastrophic medical insurance, medical aid, and improved healthcare efficiency.

People who are acquainted with the work of Shorenstein APARC’s Asia Health Policy Program (AHPP) may be aware of the Innovation for Healthy Aging collaborative research project led by APARC Deputy Director and AHPP Director Karen Eggleston. This project, which identifies and analyzes productive public-private partnerships advancing healthy aging solutions in East Asia and other regions, encompasses an upcoming volume, co-authored by Eggleston with Harvard University professors Richard Zeckhauser and John Donohue, about public and private roles in governance of multiple sectors in China and the United States, including health care and elderly care. This volume, however, is not the first collaboration between Eggleston and Zeckhauser.

Zeckhauser, the Frank P. Ramsey Professor of Political Economy at Harvard University’s Kennedy School, is known for his many policy investigations that explore ways to promote the health of human beings, to help markets work more effectively, and to foster informed and appropriate choices by individuals and government agencies. In 2006, Eggleston and Zeckhauser co-wrote a paper about antibiotic resistance as a global threat, an issue that has since received much attention as it has become a critical public health and public policy challenge. Zeckhauser was a pioneer in framing antibiotic resistance as a global threat.

On October 20, 2018, Eggleston was among some 150 colleagues, students, and friends who participated in a special symposium at the Kennedy School to celebrate Zeckhauser’s 50th anniversary of teaching and research, and to anticipate what the next 50 years might bring in the multiple fields he has influenced throughout his long career.

Eggleston joined the first of two panels in that symposium, where she spoke about Zeckhauser’s impact on health policy and about what academics and policymakers should be tackling next on the path to addressing the global threat of antibiotic resistance.

The panel was moderated by Harvard Professor Edward Glaeser. In addition to Eggleston, it included Jeffrey Liebman, Daniel Schrag, and Cass Sunstein.

A video recording of the panel is made available by the Kennedy School. Listen to Eggleston’s remarks (beginning at the 8:42 and 36:20 time marks):