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Radhika Jain and Pascaline Dupas with a screenshot of the cover of their Social Science & Medicine journal article

Highlights

  • India's nationwide COVID-19 lockdown severely disrupted critical chronic care.

  • Non-COVID-19 morbidity and mortality increased sharply in the subsequent months.

  • Socioeconomically disadvantaged patients were worst affected.

  • Indirect health effects increase the toll of pandemics and worsen health inequality.

  • Pandemic control policies must ensure critical health services continue.

Abstract

India's COVID-19 lockdown, one of the most severe in the world, is widely believed to have disrupted critical non-COVID health services. However, linking these disruptions to effects on health outcomes has been difficult due to the lack of reliable, up-to-date health outcomes data. The authors identified all dialysis patients under a statewide health insurance program in Rajasthan, India (N = 2110), and conducted surveys to examine the effects of the lockdown on non-COVID care access and health outcomes. Post-lockdown mortality was their primary outcome and morbidity and hospitalization were secondary outcomes.

63% of patients experienced a disruption to their care. Transport barriers, hospital service disruptions, and difficulty obtaining medicines were the most common causes. We compared monthly mortality in the four months after the lockdown with pre-lockdown mortality trends, as well as with mortality trends for a similar cohort in the previous year. Mortality in May 2020, after a month of exposure to the lockdown, was 1.70 percentage points (95% CI 0.01–0.03) or 64% higher than in March 2020 and total excess mortality between April and July was estimated to be 22%. A 1SD increase in an index of care disruptions was associated with a 0.17SD (95% CI 0.13–0.22) increase in a morbidity index, a 3.1 percentage point (95% CI 0.012–0.051) increase in hospitalization, and a 2.1 percentage point (95% CI 0.00–0.04) increase in probability of death between May and July. Females, socioeconomically disadvantaged groups, and patients living far from the health system faced worse outcomes. The results highlight the unintended consequences of the lockdown on critical, 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.

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Evidence from Dialysis Patients

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Social Science & Medicine
Authors
Radhika Jain
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Time:  7:30am-8:45am  California, USA 2 March 2022 
9:00pm-10:15pm New Delhi, India 2 March 2022
 

India’s international position has evolved sharply in the first two decades of the 21st century, and it is poised to become only more consequential in coming decades. Its strategic interests and influence have now stretched into the distant reaches of the Indo-Pacific, it has emerged as a central actor in managing global governance challenges like climate change, and it may have the capacity to take a commanding position in some key leading-edge technologies. In this webinar, veteran journalist Indrani Bagchi, who spent nearly two decades covering India’s foreign relations for the Times of India, will reflect on India’s recent trajectory and its prospects. Through the prism of some key episodes and issues of India in the 21st century, the webinar will examine India’s capacity and approach to manage international issues, as well as the constraints and challenges Indian policymakers must face. 

Speaker: 

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Headshot photo of Indrani Bagchi
Indrani Bagchi is CEO-designate at Ananta Aspen Centre, India. She was Associate Editor with the Times of India, where she reported and analyzed foreign policy issues for the newspaper from 2004 until 2022. As Diplomatic Editor, Indrani covered the Ministry of External Affairs (MEA) on her news beat, and interpreted and analyzed global trends with an Indian perspective. Earlier, Indrani worked with India Today, the Economic Times and The Statesman, and has held fellowships at Oxford University and the Brookings Institution. She is a Fellow of the Kamalnayan Bajaj Fellowship Class 3 of the Ananta Aspen Centre and a member of Aspen Global Leadership Network. She graduated from Loreto College, Calcutta University with English honors. 

Moderator:

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Photo Portrait of Arzan Tarapore
Arzan Tarapore is the South Asia research scholar at the Shorenstein Asia-Pacific Research Center at Stanford University, where he leads the newly-restarted South Asia research initiative. He is also a senior nonresident fellow at the National Bureau of Asian Research. His research focuses on Indian military strategy and contemporary Indo-Pacific security issues. Prior to his scholarly career, he served as an analyst in the Australian Defense Department. Arzan holds a PhD in war studies from King’s College London. 

 

This event is co-sponsored by Center for South Asia

Via Zoom  Register at:
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Indrani Bagchi, CEO-designate, Ananta Aspen Centre, India<br> Panelist
<br>Arzan Tarapore, South Asia Research Scholar, Shorenstein APARC Moderator South Asia Research Scholar, Shorenstein APARC
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Noa Ronkin
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As the COVID-19 pandemic remains a crucial global public health threat, pandemic control measures such as lockdowns and mobility restrictions continue to disrupt the provision of health services, leading to reduced healthcare use. Indeed, evidence shows the pandemic has emerged as a particular challenge for people with chronic conditions such as diabetes and hypertension. Yet there is limited data comparing the pandemic’s impact on access to care and the severity of chronic disease symptoms at the population level across Asia.

Now a new collaborative study, published by the Asia Pacific Journal of Public Health, addresses this limitation. The study co-authors, including APARC’s Asia Health Policy Program Director and FSI Senior Fellow Karen Eggleston, offer the first report comparing the impacts of the COVID-19 pandemic and its associated mobility restrictions on people with chronic conditions at different stages of socio-demographic and economic transitions in five Asian regions — India, China, Hong Kong, Korea, and Vietnam.

The findings show that the pandemic has disproportionately disrupted healthcare access and worsened diabetes symptoms among marginalized and rural populations in Asia. Moreover, the pandemic’s broad social and economic impact has adversely affected population health well beyond those directly suffering from COVID-19, with the resulting delayed and foregone care leading to uncertain longer-term effects.


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Unintended Adverse Consequences

Routine screening, risk factor control, and continuity of care for non-communicable diseases are a global challenge. The COVID-19 pandemic has exacerbated the challenge even further. Existing reports show the pandemic has particularly adverse impacts on essential prevention and treatment services for people with chronic conditions. These reductions in health services arose from pandemic-associated factors such as mobility restrictions, lack of public transport, and lack of health workforce.

Eggleston and a group of colleagues set out to provide evidence on how the pandemic has impacted chronic disease care in diverse settings across Asia during COVID-19-related lockdowns. Using standardized questionnaires, the researchers surveyed 5672 participants aged 55.9 to 69.3 years with chronic conditions in India, China, Hong Kong, Korea, and Vietnam. The researchers collected data on participants’ demographic and socio-economic status, comorbidities, access to healthcare, employment status, difficulty in accessing medicines due to financial and nonfinancial (COVID-19 related) reasons, treatment satisfaction, and severity of their chronic condition symptoms.

If no immediate actions are taken to mitigate pandemic impacts, the Asia-Pacific region will struggle to achieve the 2030 Sustainable Development Goal target 3.4 to reduce premature mortality from non-communicable diseases […] and to promote mental health and wellbeing.
Karen Eggleston et al.

The results show that the pandemic’s broad social and economic impact has adversely affected population health well beyond those directly suffering from COVID-19. Study participants with chronic conditions faced significant challenges in managing their symptoms during the pandemic. They experienced a loss of income and difficulties in accessing healthcare or medications, with the resulting delayed and foregone care leading to uncertain longer-term effects. For a nontrivial portion of participants, these factors are associated with the worsening of diabetes symptoms. The threat is twofold among people living in rural populations with limited access, availability, and affordability of healthcare services.

A Global Health Priority

The unintended adverse consequences of the COVID-19 pandemic on chronic disease care may also further aggravate inequality in health outcomes. “If the trend continues and no immediate actions are taken to mitigate pandemic impacts,” Eggleston and her colleagues caution, then “the Asia-Pacific region will struggle to achieve the 2030 Sustainable Development Goal (SDG) target 3.4 to reduce premature mortality from non-communicable diseases by a third relative to 2015 levels and to promote mental health and wellbeing.”

Addressing the pandemic’s unintended negative social and economic impacts on chronic disease care is a global health priority, determine the researchers. They propose several measures to help provide timely care for people with chronic conditions in resource-constrained settings. These include implementing innovations in healthcare delivery models to improve the adoption of healthy lifestyle changes and self-management of chronic disease and mild COVID-19 symptoms, increasing investment in interventions to provide social and economic support to disadvantaged populations, and strengthening primary healthcare infrastructure and support of healthcare providers.

The study was supported in part by funding from Shorenstein APARC’s faculty research award, Stanford King Center for Global Development, and a seed grant from the Stanford Center for Asian Health Research and Education.

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A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations

A research team including APARC's Karen Eggleston developed a new simulation model that supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes among Chinese and East Asian populations, for whom existing models may not be applicable.
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Bargaining Behind Closed Doors: Why China’s Local Government Debt Is Not a Local Problem

New research in 'The China Journal' by APARC’s Jean Oi and colleagues suggests that the roots of China’s massive local government debt problem lie in secretive financing institutions offered as quid pro quo to localities to sustain their incentive for local state-led growth after 1994
Bargaining Behind Closed Doors: Why China’s Local Government Debt Is Not a Local Problem
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In the first report of its kind comparing the impacts of the pandemic on people with chronic conditions in five Asian regions, researchers including APARC’s Karen Eggleston document how the pandemic’s broad social and economic consequences negatively affected population health well beyond those directly suffering from COVID-19.

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What is the relationship between internal development and integration into the global economy in developing countries? How and why do state–market relations differ? And do these differences matter in the post-Cold War era of global conflict and cooperation? Drawing on research in China, India, and Russia and examining sectors from textiles to telecommunications, Micro-Institutional Foundations of Capitalism introduces a new theory of sectoral pathways to globalization and development. Adopting a historical and comparative approach, Hsueh's Strategic Value Framework shows how state elites perceive the strategic value of sectors in response to internal and external pressures. Sectoral structures and organization of institutions further determine the role of the state in market coordination and property rights arrangements. The resultant dominant patterns of market governance vary by country and sector within country. These national configurations of sectoral models are the micro-institutional foundations of capitalism, which mediate globalization and development.



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Portrait of Roselyn Hsueh
Roselyn Hsueh is an associate professor of political science at Temple University, where she co-directs the Certificate in Political Economy. She is the author of Micro-Institutional Foundations of Capitalism: Sectoral Pathways to Globalization in China, India, and Russia (Cambridge University Press, forthcoming, 2022), China’s Regulatory State: A New Strategy for Globalization (Cornell University Press, 2011), and scholarly articles on states and markets, comparative regulation and governance, and political economy of development. She is a frequent commentator on politics, finance and trade, and economic development in China and beyond. BBC World News, The Economist, Foreign Affairs, National Public Radio, and The Washington Post, among other media outlets, have featured her research. Prestigious fellowships, such as the Fulbright Global Scholar Award, have funded international fieldwork and she has served as a Visiting Scholar at the Institute of World Economics and Politics, Chinese Academy of Social Sciences. She holds a B.A. and Ph.D. in Political Science from the University of California, Berkeley.

 

Via Zoom Webinar. Register at: https://bit.ly/3zoAafx

Roselyn Hsueh Associate Professor of Political Science, Temple University
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Cover of book "Drivers of Innovation"

Innovation and entrepreneurship rank highly on the strategic agenda of most countries today. As global economic competition intensifies, many national policymakers now recognize the central importance of entrepreneurship education and the building of financial institutions to promote long-term innovation, entrepreneurship, and economic growth. Drivers of Innovation brings together scholars from the United States and Asia to explore those education and finance policies that might be conducive to accelerating innovation and developing a more entrepreneurial workforce in East Asia. 

Some of the questions covered include: How do universities in China and Singapore experiment with new types of learning in their quest to promote innovation and entrepreneurship? Is there a need to transform the traditional university into an “entrepreneurial university”? What are the recent developments in and outstanding challenges to financing innovation in China and Japan? What is the government’s role in promoting innovative entrepreneurship under the shadow of big business in South Korea? What can we learn about the capacity of services to drive innovation-led growth in India? 

Drivers of Innovation will serve as a valuable reference for scholars and policymakers working to develop human capital for innovation in Asia.

Contents

  1. Educating Entrepreneurs and Financing Innovation in Asia 
    Fei Yan, Yong Suk Lee, Lin William Cong, Charles Eesley, and Charles Lee
  2. Fostering Entrepreneurship and Innovation: Education, Human Capital, and the Institutional Environment 
    Charles Eesley, Lijie Zhou, and You (Willow) Wu
  3. Entrepreneurial Scaling Strategy: Managerial and Policy Considerations 
    David H. Hsu
  4. Innovation Policy and Star Scientists in Japan 
    Tatsuo Sasaki, Hiromi S. Nagane, Yuta Fukudome, and Kanetaka Maki
  5. Financing Innovation in Japan: Challenges and Recent Progress 
    Takeo Hoshi and Kenji Kushida
  6. Promoting Entrepreneurship under the Shadow of Big Business in Korea: The Role of the Government 
    Hicheon Kim, Dohyeon Kim, and He Soung Ahn
  7. The Creativity and Labor Market Performance of Korean College Graduates: Implications for Human Capital Policy 
    Jin-Yeong Kim
  8. Financing Innovative Enterprises in China: A Public Policy Perspective 
    Lin William Cong, Charles M. C. Lee, Yuanyu Qu, and Tao She
  9. Forging Entrepreneurship in Asia: A Comparative Study of Tsinghua University and the National University of Singapore 
    Zhou Zhong, Fei Yan, and Chao Zhang
  10. Education and Human Capital for Innovation in India’s Service Sector 
    Rafiq Dossani
  11. In Need of a Big Bang: Toward a Merit-Based System for Government-Sponsored Research in India 
    Dinsha Mistree
  12. The Implications of AI for Business and Education, and Singapore’s Policy Response 
    Mohan Kankanhalli and Bernard Yeung

 

 

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Entrepreneurship, Education, and Finance in Asia

Authors
Yong Suk Lee
Fei Yan
Fei Yan
Book Publisher
Shorenstein APARC
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Portrait of Arzan Tarapore and cover of the volume 'Routledge Handbook on South Asian Foreign Policy'

Arzan Tarapore analyzes key factors in the India–Pakistan military dynamic to explore how internal and external factors account to balance the military dynamic between the volatile conflict and prevent any major escalations in disputes. Tarapore argues that geography, economic fragility, strategic implications, and a variety of other qualitative factors serve to deter the two nations from any major conflict escalation.

This chapter is part of the volume Routledge Handbook on South Asian Foreign Policy, edited by Aparna Pande.

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A chapter in the edited volume 'Routledge Handbook on South Asian Foreign Policy'
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Cover of issue 16 of the journal Asia Policy and the Nimitz Carrier sailing in the Indian Ocean

U.S. strategy, directed toward an escalating competition with China, now sees the Indian Ocean as inseparable from the Pacific—combined in an organic Indo-Pacific whole—and India as a linchpin partner in it. As the United States plans to redouble its military power in the western Pacific, it is relying on India to grow more powerful and help safeguard their shared interests in the Indian Ocean, easing demands on U.S. resources in that region.

But that will not be the end of the story. India remains the most consequential strategic actor in the Indian Ocean by virtue of its geographic centrality, economic and military power, and abiding networks of influence across the region. But its capabilities and intentions—and therefore the strategic trajectory of the Indian Ocean—will continue to evolve as they have since the uncertain days of 1989 and long before. What if in the coming years India fails to expand its military power as its champions expect and instead is outmatched by China in the Indian Ocean? Or what if, in the throes of competition with China, India exercises its power more nakedly than its regional partners would wish? Relatedly, what if the United States, which has for decades underwritten regional security, chooses to retrench its strategic presence to focus efforts in the western Pacific? Policymakers in Washington, Canberra, and regional capitals would be well-advised to accept that many trajectories—some sharply divergent—are possible.

This essay offers a preliminary attempt at illustrating some of those sharply divergent scenarios. It uses a novel alternative futures methodology known as major/minor trends to derive scenarios of Indian and U.S. strategic behavior and their resulting effects on the Indian Ocean region. The essay briefly introduces the methodology and then sketches three alternative futures designed around a relatively weaker India, an aggressive India, and a retrenching United States, respectively. Each scenario is designed to convey a key lesson for policymakers on the fragility of the assumptions that underpin current policy. 

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Re-examining assumptions of capability and intent
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Asia Policy
Authors
David Brewster
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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.
 

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Working Papers
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Asia Health Policy Program Working Paper Series working paper #60
Authors
Radhika Jain
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Introduction

Governments around the world suspended immunization outreach to control COVID-19 spread. Many have since resumed services with an emphasis on catch-up vaccinations. This paper evaluated immunization disruptions during India’s March-May 2020 lockdown and the extent to which subsequent catch-up efforts reversed them in Rajasthan, India.
 

Methods

In this retrospective observational study, we conducted phone surveys to collect immunization details for 2,144 children that turned one-year-old between January and October 2020. We used logistic regressions to compare differences in immunization timeliness and completed first-year immunization status among children that were due immunizations just before (unexposed), during (heavily exposed), and after (post-exposure) the lockdown.
 

Results

Relative to unexposed children, heavily exposed children were significantly less likely to be immunized at or before 9 months (OR 0.550; 95% CI 0.367–0.824; p = 0.004), but more likely to be immunized at 10–12 months (OR 1.761; 95% CI 1.196–2.591; p = 0.004). They were also less likely to have completed their key first-year immunizations (OR 0.624; 95% CI 0.478–0.816; p = 0.001) by the time of the survey. In contrast, post-exposure children showed no difference in timeliness or completed first-year immunizations relative to unexposed children, despite their younger age. First-year immunization coverage among heavily exposed children decreased by 6.9 pp to 10.4 pp (9.7% to 14.0%). Declines in immunization coverage were larger among children in households that were poorer, less educated, lower caste, and residing in COVID red zones, although subgroup comparisons were not statistically significant.
 

Conclusion

Disruptions to immunization services resulted in children missing immunization during the lockdown, but catch-up efforts after it was eased ensured many children were reached at later ages. Nevertheless, catch-up was incomplete and children due for their immunizations during the lockdown remained less likely to be fully immunized 4–5 months after it lifted, even as younger cohorts due for immunizations in June or later returned to pre-lockdown schedules.

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A retrospective observational study
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Vaccine
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Radhika Jain
Ambika Chopra
Camille Falézan
Mustufa Patel
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Issue 31
Authors
Shreya Khaitan
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This article was first published by the social and political economy portal IndiaSpend.


Women from poor households made about 235,000 fewer hospital visits compared to men for seven gender-neutral disease categories between January 2017 and October 2019, a new study analyzing a Rajasthan state health insurance scheme has estimated. The Bhamashah Swasthya Bima Yojana aims to provide health insurance to about 46 million persons living below the poverty line, as a step towards universal and equitable access to healthcare in the state, per the study.

Pascaline Dupas and Radhika Jain of Stanford University studied data of insurance claims from 4.2 million hospital visits under the Bhamashah scheme from its launch in December 2015 till October 2019, and the study was published as a National Bureau of Economic Research working paper. The study was conducted in partnership with the Rajasthan state government.

Women made up 45% of hospital visits under the Bhamashah scheme between January 2017 and October 2019, though their share in the population is 48%, per the study. The gender gap is starker for girls and older women. The share of girls in children aged under 10 years who visited the hospital under this insurance program was 33%, though their share of this age group's population is 47%; among those aged above 50 years, women are 51%, yet their share of hospital visits under this insurance program was 43%.

"We were struck by this discrepancy in the data. We were not expecting such a large [gender] difference," Dupas, an economist and professor at Stanford University, told IndiaSpend. In most other developed countries for which such data have been analyzed, subsidized healthcare usually caters to those who otherwise don't have access to it, added Jain, a postdoctoral fellow in Asia Health Policy at Stanford University, US.

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Asia Health Policy Postdoctoral Fellow Radhika Jain Wins Prestigious Health Economics Award

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Asia Health Policy Postdoctoral Fellow Radhika Jain Wins Prestigious Health Economics Award
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A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations

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A woman walks past a mural referring to the Covid-19 coronavirus painted on a wall on December 10, 2020 in New Delhi, India.
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How COVID-19 Disproportionately Impacts People with Chronic Conditions in India

A collaborative study by a group of researchers including APARC’s Karen Eggleston documents the adverse effects of COVID-19 on people with chronic conditions in India, particularly among poor, rural, and marginalized populations. The pandemic’s impacts extend beyond health disparities to encompass psychosocial and economic consequences, the study shows.
How COVID-19 Disproportionately Impacts People with Chronic Conditions in India
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A new study of the Rajasthan government's Bhamashah health insurance program for poor households has found that just providing health insurance cover doesn't reduce gender inequality in access to even subsidized health care.

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