Health and Medicine

FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.

FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.

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According to hitherto available data, health expenditures in Pakistan are relatively low in international comparison. Data1F published by the World Health Organization (WHO) for the year 2005 shows a lack of Pakistani health expenditures in most indicators, compared to other low-income countries (LIC). To answer the question whether these results reflect the real situation in Pakistan or whether they exist due to statistical problems, Pakistan, for the first time, developed its National Health Accounts (NHA) in 2009. Only the availability of good estimates of health expenditures allows for evidence-based policymaking and therefore good governance.

The results clearly indicate that the situation in Pakistan is better than what was earlier estimated; however, the total health expenditure (THE) is still low compared to neighboring countries and other LIC. As a result, it is clear that the WHO health expenditure figures for Pakistan are understated, because they mainly comprise public and household out-of-pocket expenditures on health. Expenditures of many other entities, like military, cantonment boards, autonomous bodies, private hospitals, and so on, have not been taken into account in earlier estimations. Therefore, expenditure figures of NHA Pakistan are higher than those of WHO. Overall, the official NHA results show that THE is 27 percent higher than the WHO figure.

Furthermore, this paper cross-checks NHA results with other already available data sources on household expenditure. This comparison includes preliminary results of the Family Budget Survey (FBS), which also includes health items as well as National Accounts (NA) data. In line with this comparison, we calculate a raising factor that can be used for the adjustment of NHA results according to NA. The raised NHA result shows 102 percent higher out-of-pocket (OOP) spending on health; this would result in OOP health expenditures of $25.15 USD per capita (compared to only $12.45 USD per capita in the NHA estimation). This result, based on the NA figure with $33 USD THE per capita, leads to a different evaluation in international comparison, since it nearly reaches the level of India, with $37.5 USD and more than the average of all LIC with $27 USD.

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AHPP working paper #14
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Policy makers and academics have long debated the existence and extent of defensive medicine in the face of medical malpractice liability pressure. In this paper, I investigate how physicians’ test-ordering behavior and propensity to perform cesarean sections were affected first by a series of court rulings in Taiwan that increased physicians’ liability risks, and then by a subsequent amendment to the law that reversed the courts’ rulings. I find that physicians faced with higher malpractice pressure increased laboratory tests as expected but unexpectedly reduced cesarean sections. The reduction in cesarean deliveries may be due to the fact that liability risks were more closely aligned with physicians’ standard of care after the court rulings. After the law was amended to negate the court decisions, physicians reversed their previous behavior, reducing laboratory tests and increasing cesarean deliveries. This pattern of behavior strongly suggests that physicians in Taiwan practice defensive medicine.

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Asia Health Policy Program working paper #13
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Brian Chen
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China is transforming itself, and the world is adapting in response. Profound forces have reshaped the country's socioeconomic and political landscapes, but they have also brought challenges—growing pains—that China must face if it is to continue its upward trajectory.

Despite its successes, China is experiencing sharp growing pains. Rising levels of protest have accompanied the country's wrenching structural transformation. Corruption has prompted some observers to claim that the Chinese government is nothing short of a "predatory state." Legal reform continues to languish. Given that such challenges remain, can it be said that China's structural changes have succeeded? Or is the country trapped in transition?

"Growing Pains deserves the attention of every scholar interested in contemporary China." -Scott Kennedy, Indiana University

Growing Pains contains new analytical and empirical research from preeminent scholars working on contemporary China. These scholars identify which of the many problems thought to threaten China's reforms are not as serious as some interpreters claim, as well as those that have already been solved. Further, they point to other high-profile challenges, some of which truly are serious and loom on the horizon. With thoughtful, nuanced analysis, the contributors tackle thorny issues in China's ongoing reforms—employment, land policy, village elections, family planning, health care, social inequality, and environmental degradation—and use rich survey data and on-the-ground observation to assess the severity of the problems and the likelihood of near-term solutions.

Moving beyond the hype and hysteria that often characterize conversations about contemporary China, Growing Pains seeks to present not an optimistic or pessimistic perspective but rather an objective, empirically based view of the country's transition.

Examination copies: Desk, examination, or review copies can be requested through Stanford University Press.

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Tensions and Opportunity in China's Transformation

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Jean C. Oi
Scott Rozelle
Xueguang Zhou
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Shorenstein APARC
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Demographic changes are profoundly shaping the political, economic, and social landscape of the Asia-Pacific region. How have individuals, families, communities, and policymakers responded? How should they? For example, how will national and social identities transform as population ageing strains traditions of filial piety and immigration disrupts ethnic homogeneity? Will the economies of East Asia languish, or will a "second demographic dividend" spur renewed economic growth? Demographic change can have important psychological and political effects. For example, can one seriously imagine a resurgent, militaristic Japan with a declining and aging population? The responses to demographic change in Japan, South Korea, China, and their neighbors will have great potential long-term effects in the Asia-Pacific region.

This panel discussion, the opening and public portion of a 1-1/2 day workshop that will define a research agenda for the next three years, will bring together selected outside experts and faculty within the Shorenstein Asia-Pacific Research Center for an interdisciplinary and comparative discussion of the policy responses to rapid demographic change in East Asia.

  • 3:00p.m. – 3:10p.m.
    Gi-Wook Shin, Director, Shorenstein Asia-Pacific Research Center, Stanford University: Introduction and welcome
  • 3:10p.m. – 3:25p.m.
    Brian Nichiporuk, RAND Corporation: The Security Implications of Demographic Trends in East Asia
  • 3:25p.m. – 3:40p.m.
    Michael Sutton, East-West Center, Washington, DC: Political & Security Implications of Population Aging in Japan
  • 3:40p.m. – 3:55p.m.
    John Skrentny, Director, Center for Comparative Immigration Studies, Professor of Sociology, University of California, San Diego: An East Asian Model to Managing Immigration? Durability & Change in the 2000s.
  • 3:55p.m. – 4:10p.m.
    Chong-En Bai, Chair, Department of Economics, Freeman Chair Professor of Economics, Tsinghua University: Policy Responses to Demographic Change in China
  • 4:10p.m. – 4:25p.m.
    David Bloom, Clarence James Gamble Professor of Economics and Demography Chair, Department of Global Health and Population, Harvard University: Demographic Change in East Asia: Challenges, Options and Evidence
  • 4:25p.m. – 4:40p.m.
    Naohiro Ogawa, Director, Population Research Institute, Nihon University: Population Aging & Changing Human Capital in Japan & other East Asian Countries
  • 4:40p.m. – 4:55p.m.
    Andrew Mason, Professor of Economics, University of Hawaii, Manoa & Senior Fellow, East-West Center, Hawaii: Population Aging and the Generational Economy: Key Findings
  • 4:55p.m. – 5:10p.m.
    James Raymo, Professor of Sociology, University of Wisconsin, Madison The “Second Demographic Transition” and family change in Japan
  • 5:10p.m. – 5:30p.m.
    Discussion/Conclusion

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Shorenstein APARC
Encina Hall E301
616 Jane Stanford Way
Stanford, CA 94305-6055
(650) 724-8480 (650) 723-6530
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Senior Fellow at the Freeman Spogli Institute for International Studies
Professor of Sociology
William J. Perry Professor of Contemporary Korea
Professor, by Courtesy, of East Asian Languages & Cultures
Gi-Wook Shin_0.jpg PhD

Gi-Wook Shin is the William J. Perry Professor of Contemporary Korea in the Department of Sociology, senior fellow at the Freeman Spogli Institute for International Studies, and the founding director of the Korea Program at the Walter H. Shorenstein Asia-Pacific Research Center (APARC) since 2001, all at Stanford University. In May 2024, Shin also launched the Taiwan Program at APARC. He served as director of APARC for two decades (2005-2025). As a historical-comparative and political sociologist, his research has concentrated on social movements, nationalism, development, democracy, migration, and international relations.

In Summer 2023, Shin launched the Stanford Next Asia Policy Lab (SNAPL), which is a new research initiative committed to addressing emergent social, cultural, economic, and political challenges in Asia. Across four research themes– “Talent Flows and Development,” “Nationalism and Racism,” “U.S.-Asia Relations,” and “Democratic Crisis and Reform”–the lab brings scholars and students to produce interdisciplinary, problem-oriented, policy-relevant, and comparative studies and publications. Shin’s latest book, The Four Talent Giants, a comparative study of talent strategies of Japan, Australia, China, and India to be published by Stanford University Press in the summer of 2025, is an outcome of SNAPL.

Shin is also the author/editor of twenty-six books and numerous articles. His books include Korean Democracy in Crisis: The Threat of Illiberalism, Populism, and Polarization (2022); The North Korean Conundrum: Balancing Human Rights and Nuclear Security (2021); Superficial Korea (2017); Divergent Memories: Opinion Leaders and the Asia-Pacific War (2016); Global Talent: Skilled Labor as Social Capital in Korea (2015); Criminality, Collaboration, and Reconciliation: Europe and Asia Confronts the Memory of World War II (2014); New Challenges for Maturing Democracies in Korea and Taiwan (2014); History Textbooks and the Wars in Asia: Divided Memories (2011); South Korean Social Movements: From Democracy to Civil Society (2011); One Alliance, Two Lenses: U.S.-Korea Relations in a New Era (2010); Cross Currents: Regionalism and Nationalism in Northeast Asia (2007);  and Ethnic Nationalism in Korea: Genealogy, Politics, and Legacy (2006). Due to the wide popularity of his publications, many have been translated and distributed to Korean audiences. His articles have appeared in academic and policy journals, including American Journal of SociologyWorld DevelopmentComparative Studies in Society and HistoryPolitical Science QuarterlyJournal of Asian StudiesComparative EducationInternational SociologyNations and NationalismPacific AffairsAsian SurveyJournal of Democracy, and Foreign Affairs.

Shin is not only the recipient of numerous grants and fellowships, but also continues to actively raise funds for Korean/Asian studies at Stanford. He gives frequent lectures and seminars on topics ranging from Korean nationalism and politics to Korea's foreign relations, historical reconciliation in Northeast Asia, and talent strategies. He serves on councils and advisory boards in the United States and South Korea and promotes policy dialogue between the two allies. He regularly writes op-eds and gives interviews to the media in both Korean and English.

Before joining Stanford in 2001, Shin taught at the University of Iowa (1991-94) and the University of California, Los Angeles (1994-2001). After receiving his BA from Yonsei University in Korea, he was awarded his MA and PhD from the University of Washington in 1991.

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Director of the Korea Program and the Taiwan Program, Shorenstein Asia-Pacific Research Center
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Gi-Wook Shin Director Speaker Shorenstein Asia-Pacific Research Center, Stanford University
Andrew Mason Professor of Economics, University of Hawaii, Manoa & Senior Fellow Panelist East-West Center, Hawaii
Naohiro Ogawa Director, Population Research Institute Panelist Nihon University
David Bloom Clarence James Gamble Professor of Economics and Demography, Chair, Department of Global Health and Population Panelist Harvard University
Chong-En Bai Chair, Department of Economics, Freeman Chair Professor of Economics Panelist Tsinghua University
John Skrentny Director, Center for Comparative Immigration Studies, Professor of Sociology Panelist University of California, San Diego
Michael Sutton Panelist East-West Center, Washington, DC
Brian Nichiporuk Panelist RAND Corporation
James Raymo Professor of Sociology Panelist University of Wisconsin, Madison
Panel Discussions
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Kirk R. Smith will speak about his current research on health-damaging and climate-changing air pollution from household energy use in developing Asia, including field measurement and health-effects studies in India, China, and Nepal, compared to other countries such as Mexico and Guatemala. The work encompasses developing and deploying small, smart, and cheap microchip-based monitors as well as tools for international policy assessments.

Dr. Smith is Professor of Global Environmental Health and Director of the Global Health and Environment Program at the School of Public Health at the University of California, Berkeley.  Previously, he was founder and head of the Energy Program of the East-West Center in Honolulu, where he still holds appointment as Adjunct Senior Fellow in Environment and Health after moving to Berkeley in 1995. He serves on a number of national and international scientific advisory committees including the Global Energy Assessment, National Research Council's Board on Atmospheric Science and Climate, the Executive Committee for WHO Air Quality Guidelines, and the International Comparative Risk Assessment. He participated along with many other scientists in the IPCC's 3rd and 4th assessments and thus shared the 2007 Nobel Peace Prize. He holds visiting professorships in India and China and bachelors, masters, and doctoral degrees from UC Berkeley. In 1997, he was elected a member of the US National Academy of Sciences. In 2009, he received the Heinz Prize in Environment.

Daniel and Nancy Okimoto Conference Room

Kirk R. Smith Professor of Global Environmental Health and Director of the Global Health and Environment Program at the School of Public Health Speaker University of California, Berkeley
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Populous, economically dynamic, and rapidly urbanizing, the Asia Pacific both reflects and strongly shapes trends in global public health. A comparative assessment of chronic disease prevalence, risk factors, and policy responses in nine Pacific Rim cities shows that chronic diseases are rapidly becoming the leading cause of morbidity and mortality even in the lower income cities of the Pacific Rim. Policy responses are heterogeneous, with few sufficiently funded or adequately informed by evidence. Much could be learned from comparative research and rigorous evaluation of prevention and control initiatives in this region.

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Asia Health Policy Program working paper #21
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Over the past year, the Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) has engaged in leading-edge research on demographic change in East Asia. Karen Eggleston, director of the Asia Health Policy Program at Shorenstein APARC, discusses the recent book Aging Asia: The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea, and the workshop on the economic, social, and political/security implications of demographic change in East Asia, held January 20-21 at Shorenstein APARC.

Across Northeast Asia, countries are facing the issue of an aging population, which causes socio-economic challenges that have policy implications. You explore this phenomenon in your forthcoming book Aging Asia: The Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea. When did aging begin to become an issue and what are some of the greatest factors that you address in the book?

Aging started at different times in the countries of East Asia. The country with the oldest life expectancy in the world and the oldest age structure of its population is Japan. It had a very short baby boom after the war and has had a steep decline in fertility. Mortality has also been falling around the world, and so this creates a change in the population. Japan is already at the fourth stage of demographic transition. South Korea is rapidly moving towards that and already has one of the lowest fertility rates in the world. Of course, neither of them have policies to reduce fertility; in fact, they are trying to encourage it. China, on the other hand, has long been trying to control fertility and is not as extreme in terms of the population age structure, but it is rapidly changing. China will be older in median age than the United States soon—this is not a trivial factor when you think in terms of the absolute size of the Chinese population.

One of the things that we wanted to study in this project is the premise that the demographic transition is a "problem." It is true that you need to think about and have policy responses to it. But it can also be seen as a sign of success, and as an opportunity. We wanted to reframe the issue and think about evidence on both sides. There is some research highlighted in the book, for example, that looks at the impact of population aging on economic growth, which is one of the first things that comes to many people's minds. For example, if you have a lot of elderly people, they are not in the work force and they need to be supported. It is true that this can be bad for economic growth, but there also are policy and individual responses that may moderate the effects. Our research is trying to highlight several different aspects of aging, including the question of opportunity. For example, there is more investment in individual children now and elderly persons' savings have actually contributed to economic growth. In some aspects, this has been a sign of resiliency for Japan where there are a lot of transfers to the working-age population.

Ronald Lee at the University of California, Berkeley and Andrew Mason at the East-West Center at the University of Hawai'i, who is participating in the January workshop, have been working on the concept of a "second demographic dividend." They find that as countries have an older age structure, there are more people that are saving. In the widely accepted "first demographic dividend," there are more people in the working-age part of the population—more people employed and more people contributing to the GDP. You get a boom contributing to growth. We know that this contributed to Japan and South Korea's earlier growth, and to China's in the 80s and part of the 90s, but only one or two percent of GDP. The question then is whether it is a problem that with aging you are losing that first demographic dividend. A second demographic dividend might arise because people who are preparing for a longer retirement life are saving more, and those savings are then invested in the economy and the investment drives economic growth.

Is there any correlation to demographic issues faced by the United States?

Interestingly, the aging issue is more pronounced in East Asia than in the United States for several reasons. We have a higher fertility rate than in Japan and South Korea, and many other countries in Europe as well. We also historically are much more open to immigration than most other countries, and this has led to a certain vitality in the population mix that has slowed the impact of demographic change. That said, of course, there are issues with having a lot of baby boomers. Sometimes, depending on the specific question or the specific area of policy, you find other factors that are much more important than aging. For example, the growth of healthcare spending has been in the news a lot lately. Although obviously there is an impact from having more elderly people, there are much bigger issues, such as what we are spending per person per age group and the growth of that spending. Just aging per se is not as big of an issue as people might think.

In late January, you will be holding the workshop Comparative Policy Responses to Demographic Change in East Asia: Defining a Research Agenda. What are the major issues you will explore in the conference? Who will be involved? Finally, what is the publication or research project that you will launch from this?

We had an Aging Asia conference in February 2009, co-sponsored with the Global Aging Program at the Stanford Center on Longevity. The outcome of this is the forthcoming volume, co-edited with Shripad Tuljapurkar of the Department of Biology at Stanford University. We started with a basic survey of the region and thought about the basic trends-demographic, social, and economic-and built upon that to figure out where the gaps are in the literature and where the interesting research questions are. That is where the January 2011 workshop comes in as the next step. We are bringing in some of the same and some different people to focus on three specific themes: economics, society, and politics/security. The upcoming event again focuses on East Asia and there will be a public component, but it is a smaller event and its main goal is to dig deeper into these themes to figure out an interesting research agenda on the policy responses to demographic transition.

We decided to focus again on East Asia, which is the research focus of a lot of our Shorenstein APARC faculty. Masahiko Aoki and Michael Armacost are going to chair sessions, and Gi-Wook Shin is going to kick it all off and talk about the social aspects of demographic change. Andrew Walder will be participating in that session as well. Thomas Fingar will be covering the political and security implications. All Shorenstein APARC faculty have been invited to participate and think about how this issue of demographic change—and particularly policy responses—might be related to their own areas of research. 

An illustration that I like to give when people ask about how demographic change is related to other things is from Andrew Walder when he was talking about China's transition in the 1980s. He received a question about whether or not there had been an impact from the One Child policy. He said that obviously there are many different impacts, but the one thing that he noted was that students in China now, especially if they are only children, are under a lot of career pressure. This has changed the space or the freedom for self-exploration. Why does this have broader implications? Young people see access to political power as one key for their careers and this changes their views about joining the Communist Party, which has big implications for China's political future. This is just one illustration of how we are trying to explore the broader implications of demographic change.

Finally, what is the outcome that you would most hope to achieve through Aging Asia and the upcoming demographic change workshop?

I think that the biggest hope would be to develop a much better understanding of what is going on with demographic change: what are the processes and how is society changing? What are the individual challenges that families are facing and what are they are doing about it? What is the broader social or even global perspective on how this is going to shape our future world? For me, I think about the world that my children are going to grow up in.

Through our research, I hope that we will impact not only the understanding of what has driven past developments, but create policy recommendations for each of the societies that were are examining—including our own—on the opportunities and the challenges related to changes in population. That hopefully will be useful as these different societies think about how to respond.

Our research on the economic, the social, and political/security aspects of demographic change is intended to be tangible for individuals and families as well as for broader national policy.

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The Shorenstein Asia-Pacific Research Center and its Asia Health Policy Program have joined with other centers and programs across the university as collaborative partners for the new Stanford Center for Population Research (SCPR). Supporting population research among faculty and students throughout Stanford, the SCPR is led by Professor Shripad Tuljapurkar, co-editor with Karen Eggleston of the book Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and South Korea.

The Stanford Center for Population Research, based in the Institute for Research in Social Sciences, has leadership and involvement across campus including the Humanities, Natural Sciences, Environmental programs, and the Medical School. The goal is to promote, support and develop population studies through collaboration among researchers and training for undergraduate and graduate students, serving as both a resource and nexus for faculty at Stanford across disciplines with interests in population studies, broadly defined.  

The Asia Health Policy Program will work with the Stanford Center for Population Research in studying the implications of demographic change in the Asia-Pacific region. For example, Karen Eggleston is undertaking comparative study of population health trends in China and India with other Stanford faculty associated with SCRP.

AHPP will also support the mission of strengthening the teaching of population studies at the undergraduate, graduate and postdoctoral levels, by helping to make connections for students studying demographic change in Asia. The 2011 postdoctoral fellow in Asia health policy, Qiulin Chen, will be studying population aging in China in comparative perspective. Shorenstein APARC’s affiliation with the SCRP will also help to reinforce the new Shorenstein APARC initiative studying policy responses to population aging in East Asia, kicking off with a workshop in January 2011.

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The objective of this paper is to estimate the causal effect of coresidence with an adult child on depressive symptoms among older widowed women in South Korea. Data from the first and second waves of the Korea Longitudinal Study of Aging were used. Analysis was restricted to widowed women aged ≥ 65 years with at least one living child (N=2,449). We use an instrumental variable approach that exploits the cultural setting where number of sons predicts the probability of an elderly woman's coresidence with an adult child but is not directly correlated with the mother's depressive symptoms. Our models adjust for age, education, total assets, residence, functional limitations, self-rated health, and various illnesses. Our robust estimation results indicate that, among older widowed women, coresidence with an adult child has a significant protective effect on depressive symptoms, but that this effect does not necessarily benefit those with clinically relevant depressive symptoms. Future demographic and social transitions in South Korea portend that older women’s increasing vulnerability to poor mental health is an important though less visible public health challenge.
Keywords: living arrangements, coresidence, depressive symptomatology, elderly, KLoSA

Published: Do, Young Kyung, and Chetna Malhotra. "The effect of coresidence with an adult child on depressive symptoms among older widowed women in South Korea: an instrumental variables estimation." The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 67.3 (2012): 384-391.

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Asia Health Policy Program working paper #20
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Young Kyung Do
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Objective: To show the pattern of patient satisfaction with top-level delivery organizations (Level 2 and Level 3 hospitals), and using neo-institutionalism approach to explain the relatively low satisfaction and to explore the limitations with top providers, focusing on how to improve the competence of Level 2 and Level 3 hospitals at both the individual hospital level and the whole delivery system level.

Data Sources/Study Setting: The household survey by the National Bureau of Statistics in China in 2008; China Health Statistics Yearbooks.

Data Collection/Extraction Methods: The analysis uses a 2008 sample medical experiences of 5,036 residents from 17 provinces collected in a household survey by the National Bureau of Statistics in China. The linear regression model, the structural difference regression model, and the ordered probit model are used in our framework.

Principal Findings: The imbalance between the needs of patients and the limited competence of top-level providers, and the conflict between the business expansion and the limited competence of those providers are deeply and widely influenced by patterns of patient needs, the top providers’ expansion, and the institutional environment.

Conclusions: In order to effectively respond to patient needs, top and lower level providers need to set their own individual priorities. The government needs to improve institutional arrangements to respond to patient needs with the development of a fair and appropriate reimbursement and compensation pricing mechanism, and with further evaluation of top level providers’ advanced and limited health services.

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Asia Health Policy Program working paper #19
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Qunhong Shen
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