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.

India-China border tensions along the disputed Line of Actual Control show no signs of letting up and the prospects of peace in the conflict between the nuclear-armed rivals are daunting. How do the Indian and Chinese militaries compare against each other?

FSI Center Fellow at APARC Oriana Skylar Mastro and our South Asia Research Scholar Arzan Tarapore join the Observer Research Foundation’s ‘Armchair Strategist’ podcast to discuss the Indian and Chinese strategic power postures, military modernization and reform by the two Asian neighbors, the ways they can marshal both military and non-military forces, and the possible outcomes of a confrontation along their Himalayan border. Listen here:

Based in Delhi, the Observer Research Foundation (ORF) is a leading South Asian nonprofit policy research institution whose work spans a wide range of topics, including national security, economic development, cyber issues and media, and climate and energy.

This article by Oriana Skylar Mastro originally appeared in The Interpreter, a daily publication of the Lowy Institute.

There is no end in sight for the ongoing China-India border crisis. In June, China and India’s border dispute along the LAC (Line of Actual Control) resumed after a decades-long halt to the fighting, with the deaths of 20 Indian soldiers and an unspecified number of casualties on the Chinese side. After a few months of relative calm, tensions erupted in late August with “provocative military movements” near Pangong Tso Lake and a Tibetan soldier’s death in India’s Special Frontier Forces. Only a few weeks ago, both sides accused each other of firing warning shots, the first use of live fire in 45 years.

Although China and India’s foreign ministers recently agreed to disengage at talks in Moscow during the Shanghai Cooperation Organisation meeting, troops remain massed at the border. China is reportedly building military infrastructure. Many worry that increased tensions could lead to war, especially given India’s limited options.

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As the second- and fourth-largest militaries in the world – and two nuclear powers at that – soon enter the fifth month of a standoff, the world has been relatively silent. All countries, especially the United States, should help China and India avoid an armed confrontation. Wars happen, especially over territory. And it wouldn’t be the first time the two countries have fought over this issue. Fifty-eight years ago, the two countries found themselves at war when massed Chinese artillery opened fire on a weak Indian garrison in Namka Chu Valley, in an eastern area China considers Southern Tibet and India calls Arunachal Pradesh. China launched a simultaneous assault against the western sector, clearing Indian posts north of Ladakh. After 30 days of sporadic fighting, the war came to an end with a unilateral Chinese withdrawal from much of the territory it had seized.

But such a unilateral ceasefire is extremely rare. Most contemporary conflicts end through a negotiated settlement. This means getting the two countries to talk to each other face-to-face during a war can be necessary for war termination. But my research shows this does not come easily – states are often concerned that a willingness to talk will communicate weakness to their adversary, who, in turn, will be encouraged to continue the fighting. Only when states are confident their diplomatic moves will not convey weakness, and their adversary does not have the will or capabilities to escalate is a belligerent willing to come to the negotiating table.

Continue reading Mastro's comments in The Interpreter >>

This analysis by Arzan Tarapore was originally published at The Monkey Cage by The Washington Post.

Last week, the India-China border standoff came the closest it has yet to war. As Taylor Fravel explained, the long-standing border dispute dates from the 1962 Sino-Indian War. The dispute came to a boil in May when a large force of Chinese soldiers crossed the Line of Actual Control (LAC), the disputed border between the two countries since 1962. A deadly skirmish in June temporarily raised tensions, but it was the result of tragic happenstance rather than large and risky military maneuvers.

Tensions have escalated more seriously since late August because both sides have jostled for tactical advantage, creating incentives for each side to outflank or even fight the other.

Here’s where things stand in this crisis.

Aggressive tactical maneuvers led to rising tensions

A new phase of the four-month-long border crisis opened when Indian special forces quietly occupied several peaks in the mountainous Chushul sector of Ladakh during the night of Aug. 29-30. These peaks sit on India’s side of the LAC, just south of a divided lake — Pangong Tso — but had been left unoccupied in accordance with confidence-building agreements. They were the site of tenacious fighting in the 1962 border war and hold particular tactical significance because they overlook an important pathway through the mountains between India and China.

Occupying the high ground in Chushul was designed to prevent Chinese forces from establishing an even stronger position. India also may have calculated that it could negotiate a withdrawal from those tactically valuable peaks in return for a Chinese withdrawal from areas seized after May.

Tensions rose. Indian and Chinese troops also scrambled to secure high ground overlooking new Chinese fortifications on the north bank of Pangong Tso. They reinforced their positions with additional aircraft and armor and accused each other of firing the first gunshots on the LAC since 1975. Some Indian analysts warned that China might risk war to reverse India’s occupation of the Chushul peaks.

Continue reading Arzan's full analysis on Monkey Cage at The Washington Post >>

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This op-ed by Arzan Tarapore originally appeared in The Hindu.

Over four months ago, the Chinese army entered territory that India has long considered its own, and never left. In effect, the multiple incursions have changed the Line of Actual Control (LAC) and India has lost territory, at least for the time being. How could this happen?

In part, it was a failure of the warning-intelligence system. Either Indian intelligence services did not collect sufficient data of Chinese intentions and early moves, or they did not interpret it correctly, or their policy and military customers failed to take the warning seriously. Wherever the fault lay, the system apparently failed.

In part, however, the problem also lay in the Army’s concepts for defending the country’s borders. It is, as the current crisis shows, simply not postured or prepared for the type of security threat China presents. (Continue reading the full article in The Hindu.)

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U.S. policymakers are counting on India as a natural strategic partner. They focus on India’s increasing national power and its enticing potential as a counterbalance to China. But what happens if India’s strategic preferences shift? Will it fulfill its potential so that the U.S. strategic bet pays off?

In a special report, Exploring India's Strategic Futures, published by the National Bureau of Asian Research (NBR), APARC South Asia Research Scholar and NBR Nonresident Fellow Arzan Tarapore identifies a set of challenges for American strategists, illustrating alternative futures of India as a strategic actor and focusing on futures that may pose challenges to U.S. security interests.

Tarapore uses a novel method of major/minor trends to demonstrate that India’s strategic preferences are not fixed but could vary discontinuously under different environmental conditions. Based on detailed historical analysis, this method offers a powerful tool to sensitize decision makers to a range of possible futures. He analyzes three plausible scenarios:

First, a revisionist India driven by Hindu-nationalist ideology to settle the score with Pakistan, which will require it to keep the China front quiet and accommodate China’s Belt and Road Initiative in Eurasia. This scenario may severely complicate U.S. strategy in the Indo-Pacific and its efforts to counterbalance China.

Second, a risk-acceptant Indian military that engages in brinkmanship, which may endanger strategic stability with both Pakistan and China. In this scenario, rather than keeping the Chinese military in check, India may paradoxically have the opposite effect.

Third, an India that expands its competition with China into continental Eurasia, making common cause with U.S. rivals such as Russia and Iran. This scenario illustrates the tensions in a U.S. global strategy that lacks prioritization and prompts Washington to more carefully consider its preferences in Central Asia.

Tarapore by no means suggests that such futures are likely — they are decidedly unlikely — but rather that U.S. strategists should consider them plausible. Indeed, the three scenarios are all grounded in political processes that have long existed in India, from communalism to military adaptation, to the balancing of external threats. Therefore, argues Tarapore, U.S. policymakers should not assume Indian strategic preferences are stable. They must consider scenarios in which India might challenge U.S. security interests.

The Stanford Center at Peking University (SCPKU), the Center on Democracy, Development and the Rule of Law (CDDRL), and the APARC China Program jointly hosted a workshop on China’s Belt and Road Initiative (BRI) in early March. The workshop, held on March 2 and 3, welcomed researchers from around the world with expertise in the Initiative. Unfortunately, because of the rapidly developing health emergency related to the coronavirus, participants from not only China, but also Japan, were prevented from attending. As described by Professor Jean Oi, founding director of SCPKU and the China Program, and Professor Francis Fukuyama, director of CDDRL and the Ford Dorsey Master's in International Policy, who co-chaired the workshop, the meeting aimed to provide a global perspective on the BRI, consolidate knowledge on this opaque topic, and determine the best method and resources for future research.  

The workshop began with presentations from several of the invited guests. Dr. Atif Ansar from the University of Oxford’s Saïd Business School kicked off the first day by describing not only the tremendous opportunity that the BRI presents to developing economies, but also the serious pitfalls that often accompany colossal infrastructure projects. Pointing out the poor returns on investment of mega infrastructure projects, Ansar examined the frequest cost and schedule overruns, random disasters, and environmental degradation that outweigh the minimal benefits that they generally yield. China’s own track record from domestic infrastructure projects does little to mitigate fear of these risks, Ansar claimed. In response, he urged professional management of BRI investments, institutional reforms, and intensified deployment of technology in BRI projects. Dr. Ansar was followed by Dr. Xue Gong of the S. Rajaratnam School of International Studies, Nanyang Technological University, Singapore. Dr. Gong’s analysis centered on the extent to which China’s geopolitical motivations influenced its outward foreign direct investments (OFDI). Although her research was still in the early stages, her empirical analysis of China’s OFDI inflows into fifty BRI recipient countries from 2007-2018 nevertheless revealed that geopolitical factors often outweigh economic factors when it comes to China’s OFDI destinations.

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Professor Curtis J. Milhaupt and Scholar-in-Residence Jeffrey Ball, both at Stanford Law School, followed with individual presentations on the role of State-Owned Enterprises (SOEs) in the BRI and the emissions impact of the BRI on climate change, respectively. Professor Milhaupt  characterized Chinese SOEs as both geopolitical and commercial actors, simultaneously charged with implementing Party policies and attaining corporate profits. Chinese SOEs are major undertakers of significant overseas BRI projects, acting not only as builders but also as investors, partners, and operators. This situation, Milhaupt asserted, carries significant risks for SOEs because these megaprojects often provide dismal returns, have high default rates, and can trigger political backlash in their localities. Milhaupt highlighted the importance of gathering firm-level data on businesses actually engaged in BRI projects to better infer geostrategic, financial, or other motivations. Jeffrey Ball turned the discussion to carbon emissions from BRI projects and presented preliminary findings from his four-country case studies. He concluded that, on aggregate, the emissions impact of the BRI is still “more brown than green.” Twenty-eight percent of global carbon emissions may be accounted for by BRI projects, Ball asserted, underscoring the importance of the BRI to the future of global climate change.

The day concluded with presentations by  Michael Bennon, Managing Director at the Stanford Global Projects Center, and Professor David M. Lampton, Oksenberg-Rohlen Fellow at the Freeman Spogli Institute for International Studies. Bennon first presented findings from two empirical case studies of BRI projects and then went on to describe how the BRI is now practically the “only game in town” for infrastructure funding for developing countries. Lengthy environmental review processes at Western multilateral banks have turned the World Bank, for example, from a lending bank into a “knowledge bank,” he argued. He also highlighted that, in general, economic returns on BRI projects for China are very poor, even though recipient countries may accrue macroeconomic benefits from these projects. Finally, Professor Lampton turned the discussion back to Southeast Asia, where China is currently undertaking massive cross-border high-speed rail projects through eight ASEAN countries. He described how each host country had varying capacity to negotiate against its giant neighbor, and how the sequential implementation of these cross-border rail projects also had varying impacts on the negotiating positions of these host countries. BRI played out differently in each country, in other words, eliciting different reactions, push-backs and negotiated terms.

The second day of the workshop was dedicated to working toward a collaborative approach to future BRI research. The group discussed the key gaps in the existing research, including how to know what China’s true intentions are, how to measure those intentions, who the main players and their interests in both China and the host countries are, and even what the BRI is, exactly. Some cautioned that high-profile projects may not be representative of the whole. Participants brainstormed about existing and future sources of data, and stressed the importance of diversifying studies and seeking empirical evidence.

When economists, policymakers, and media commentators discuss growth or compare living standards across countries, they typically turn to a single measure: Gross Domestic Product (GDP). In layman’s terms, GDP is the monetary value of all goods and services made or exchanged in a country during a specific period of time. The calculation of a nation’s GDP is complex and takes in a multitude of country-specific caveats, but the final figure per capita is supposedly a proxy for a nation’s economic health.

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Using GDP as a measure of welfare, however, has multiple problems. Just ask Dr. Amit Kapoor, an expert in economic development and business strategy, who rebuts the focus often placed on the importance of GDP. As the chair of the Shared Value Institute of India, president and CEO of the India Council on Competitiveness, and as an affiliate faulty member with the Institute of Strategy and Competitiveness of the Harvard Business School, Kapoor has spent a great deal of time and effort working with the governments of India and other countries on measuring social progress and developing living standards, performance, and progress indices. In a recent lecture as part of APARC’s South Asia Colloquia, Kapoor made his case for looking past GDP when considering the overall well-being of nations.

GDP, says Kapoor, originated in the 1940s as a wartime estimate to provide a window into a region’s economic situation and is based on the paradigm that economic objectives equal social objectives. Yet economic development doesn’t always lead to advancements in social progress and human prosperity. To gain a complete understanding of a nation’s growth, he argued, it is important directly to measure social progress, which includes indicators of human well-being such as access to education, equal opportunity, health services, sanitation and clean water, social inclusion, and even tolerance.

 Our world as we know it is facing multiple threats, Kapoor reminds us, from environmental extinction to the rise of populism and to the crisis of capitalism. We can only address these issues “by creating alternate measures of how we assess human well-being.”

Kapoor points to the apparent growing gap between economic gains and social parity as evidence that GDP-centricity gives a very pixelated, partial picture of national development. In the past 80 years, economies as a whole have gained exponentially, as indeed reflected in GDP measurements, but progress on issues such as basic human needs, personal well-being, and opportunities for individual fulfillment have seemed to lag.

Kapoor’s issue with GDP is that it fails to account for these other kinds of social, environmental, and cultural factors. To this end, he advocates considering other means of measuring success and development, such as the Human Development Index, or his research to gauge and codify “ease of living” measurements in his home country of India.

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That research, says Kapoor, shows there exists a non-linear relationship between ease of living and per capita GDP. Therefore, the impact of economic development on a population’s ease of living will depend on where the region is placed. Moreover, if one is at a lower level of economic development, then investing in economic well-being will translate into social well-being, but after the cutoff is reached, higher economic development will lead to a fall in the ease of living.    

“In an economy with well-being at its heart, economic growth will simply be another tool to guide it in the direction that the society chooses. In such an economy, the percentage points of GDP, which are rarely connected with the lives of average citizens, will cease to take the center stage. The focus would instead shift towards more desirable and actual determinants of welfare.”

You can read more of Amit Kapoor’s perspectives and learn more about his work to redefine development in India in his Harvard Business Review article, “GDP Is Not a Measure of Human Well-Being.”