We study two interventions in Beijing, China, that provide patients with information on antibiotic resistance via text message to discourage the overuse of antibiotics. The messages were sent once a month for five months. One intervention emphasizes the threat to the recipient’s own health and is found to have negligible effects. The other intervention, which highlights the overall threat to society, reduces antibiotics purchases by 17% in dosage without discouraging healthcare visits and other medicine purchases. The results demonstrate that prosocial messaging can have the potential to address public health issues that require collective action.

Keywords: Social-regarding message; Antibiotics; Field experiment

JEL codes: C93, D83, I12

Published: https://doi.org/10.1016/j.jdeveco.2023.103056

India’s COVID-19 lockdown is widely believed to have disrupted critical health services, but its effect on non-COVID health outcomes is largely unknown. Comparing mortality trends among dialysis patients in the eight months around the lockdown with the previous year, we document a 64% increase in mortality between March and May 2020 and an estimated 22-25% total excess mortality through July 2020. The mortality increase is greater among females and disadvantaged groups. Barriers to transportation and disruptions in hospital services appear to be the main drivers of increased morbidity and mortality. The results highlight the unintended consequences of the lockdown on critical and life-saving non-COVID health services that must be taken into account in the implementation of future policy efforts to control the spread of pandemics.
 

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.

Effective as of July 1, 2018, South Korea set a new cap on employees’ weekly working hours, decreasing the maximum number from 68 to 52. In this study, we comprehensively analyze the effectiveness of the law’s implementation by observing changes in work time, health status, health care utilization, health behavior, monthly expenses, and satisfaction between pre- and post-implementation periods (2014–2017 vs. 2019). We find evidence of both intended and unintended consequences—and, in this last category, some are beneficial and some not. As intended, employees eligible for the 52-hour work week saw their average working hours decrease, while their monthly spending on leisure increased substantially. A beneficial unintended consequence was that work time also decreased in firms with less than 300 employees that had not yet implemented the 52-hour work schedule (they have done so since, in January 2020). Among adverse unintended consequences, the most notable were heterogeneous effects across employment types (full-time vs. precarious employment) and, in particular, negative impacts on precarious employees (that is, those facing relatively high levels of job insecurity). Despite almost no change in their work time, precarious employees saw substantial increases in outpatient visits and monthly expenses for health care, indicating suggestive evidence of adverse health consequences. Another adverse unintended consequence was that overall job satisfaction decreased among several groups of employees. This may reflect a heavy workload among employees still expected to work overtime, especially experienced employees or those working in large firms. While employment rates increased after the new schedule’s implementation, the majority were in precarious jobs. This has negative implications because of the adverse health impacts of being in precarious employment; also, the workload of experienced employees in this field might have intensified amid all the new hiring. Our findings suggest key policy recommendations for how to leverage the benefits of the 52-hour cap on weekly working hours while addressing its negative unintended consequences.

COVID-19 presents humanity with not just a health crisis but also a governance crisis as leaders around the globe confront the challenges of stemming the spread of the virus. Various governments have responded in various ways to slow the transmission of the virus. Ideally, the leaders of a country should approach the crisis with a two-pronged attack. The first is to flatten the epidemic curve (epi curve), which is simply a graphical representation of the number of cases and date of onset of the illness, and the second is to raise or strengthen the capacity of the health system. 

Flattening the epi curve includes mass testing for COVID-19, which has been done in South Korea, for example. Decreasing the incidence also includes quarantine, isolation, and other social distancing strategies, which have been done by various countries in varying degrees. For example, in China, total lockdown (cordon sanitaire) was implemented in Wuhan, of the Hubei province, while in the Philippines, the entire Luzon, which consists of eight administrative regions, including the national capital region (NCR), was in total lockdown (enhanced community quarantine, or ECQ) since March 16 (World Health Organization [WHO] 2020a). Other parts of the Philippines were under different degrees of quarantine at different periods since the appearance of local transmission.

Raising the health care system capacity of a country may include, but is not limited to, training of health care workers, increasing facilities or hospitals that receive COVID patients, and providing adequate personal protective equipment (PPE).

This paper offers a brief epidemiological review of COVID-19 since its first case in China and how the hotspots for this disease evolved and changed over a relatively short period. This paper also aims to provide a short descriptive review of the existing data on COVID-19 in the Association of Southeast Asian Nations (ASEAN) region and the government response of its ten member countries, so that we can somehow draw lessons and learn from these myriad experiences as we continue to combat the spread of this dangerous pathogen. The findings in this paper are preliminary, and more rigorous analysis is expected to be performed as the data becomes more extensive and available.

The intention to pay for human papillomavirus (HPV) vaccination among women of childbearing age in Vietnam, where cervical cancer remains a significant public health concern, has been mostly lacking. To examine this issue, we conducted a cross-sectional study of 807 pregnant women in an urban and a rural district (Dong Da and Ba Vi) of Hanoi, Vietnam. The vast percentage of our respondents expressed a firm intention to vaccinate, especially women in rural areas (over 90.0%). However, on being informed of the current price of the HPV vaccine, their intention to vaccinate dropped to about one-fifth of overall respondents, i.e., only 4.4% of women in rural areas. It was also observed that the initial intention to get the HPV vaccination among women in the rural district was
about ten times higher than that of women living in the metropolitan district. Those participants who had greater knowledge of cervical cancer andHPV vaccinations also had a significantly higher intention to vaccinate. Our findings underscore the need to develop a well-designed vaccination program in Vietnam and other countries in a similar situation to increase the adoption of HPV vaccination.

Keywords: HPV vaccination; cervical cancer; intention; women; Vietnam

Published: Intention to Pay for HPV Vaccination among Women of Childbearing Age in Vietnam

China’s national health reforms over the past two decades have brought the system closer to the modern, safe, reliable and accessible health system that is commensurate with China’s dramatic economic growth, improvement in living standards, and high hopes for the next generation. Celebrating a decade this year, China’s national health reforms of 2009 consolidated a system of social health insurance covering the entire population for basic health services, contributing to a surge in healthcare utilization while reducing out-of-pocket costs to patients – which declined from 56% to 28% of total health expenditures between 2003 and 2017. An expanded basic public health service package, funded by per capita government budget allocations that include a higher central government subsidy for lower income provinces, provides basic population health services to all Chinese. A higher percentage of Chinese accessed hospital admissions in 2017 than in the average high-income (OECD) country – a large increase from the turn of the 21st century.i A recent re-shuffle of the governance structure consolidates the purchaser role for social health insurance schemes under the newly created National Healthcare Security Administration, with most other health sector functions under the re-christened National Health Commission, among other changes. China’s world-leading technological prowess in multiple fields spanning digital commerce to artificial intelligence—and accompanying innovative business models such as WeDoctor that have not yet been fully integrated into the health system—hold promise for supporting higher quality and more convenient healthcare for China’s 1.4 billion.

Keywords: China; Health System

Published:   Healing-one-fifth-of-humanity