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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In the June 2016 publication of the EYElliance and World Economic Forum report, "Eyeglasses for Global Development: Bridging the Visual Divide," a case study for REAP's Smart Focus social enterprise was published on page 21. Read the entire report here.

The Rural Education Action Program (REAP), an impact-evaluation organization, aims to inform sound education, health and nutrition policy in China. Since 2011, REAP’s five randomized controlled trials have shown that quality vision care is the most cost-effective intervention for improving child welfare, and leads to large and sustainable increases in learning and school performance, along with positive spillovers to children who don’t have poor vision.

REAP is now establishing a network of for-profit vision centres based at county hospitals through an initiative called Smart Focus. Those centres partner with schools to deliver high-quality vision care. Optometrists administer six hours of training for classroom teachers, enabling the latter to conduct initial vision screenings and refer students needing more advanced care through a highly structured referral system. The teachers are provided free mobile-phone time as an incentive, and the vision centres earn revenue from urban consumers in a cross-subsidization scheme that supports providing care for poorer rural consumers whose unmet need is greatest. To date, REAP has provided access to free or affordable glasses for over 30,000 primary school students and screened an additional 120,000 children.

In addition to screening children and supervising their wearing glasses, teachers play a vital role in communicating with parents. Once a teacher’s screening indicates a child needs glasses, the teacher often spends significant time convincing parents that (a) the child’s condition requires attention, (b) the problem is correctable, and (c) taking the child to the vision centre to get glasses is highly advisable. 

Vision centres dispense “first pair free” or very low-cost glasses to rural elementary- and middle-school students, while providing part of the urban market with refraction and eyewear on a fee-for-service basis. Giving away the first pair of glasses is not “just charity”; rather, it provides access to the huge untapped rural market. To build confidence, vision centres unconditionally guarantee the frames for three months and lenses for six months, something that no private optician does. (A noteworthy challenge arises, however, with parents who believe that low-cost or free services must also be of low quality; usage rates and eyeglass prices have been shown to rise in tandem.)

Smart Focus provides county hospitals with management, retail expertise, training and equipment. Critically, the programme assigns a Smart Focus staff member at 
each vision centre to coordinate construction and staff training, and to manage operations and logistics, including relationship-building with schools, hospitals and optical suppliers. To date, REAP has built four vision centres with full approval from the county education and health bureaus. As revenues rise, Smart Focus is committed to expanding the network of vision centres to new counties that lack appropriate care. 
 
In addition, and in collaboration with Zhongshan Ophthalmic Center, Smart Focus arranges training in optometry and vision-centre management for three staff members from each centre. Smart Focus also trains nurses as optometrists through classroom instruction and an in-the-field training and mentoring programme. By the end of their training, nurses are certified to refract patients and make glasses, as well as identify more complex but common eye disorders for referral to ophthalmology departments. Further, Smart Focus pays vision centre staff salaries for the first six months during training and mentoring, and facilitates the centres’ purchasing of frames and lenses. Across China, 2,000 county hospitals each serve 400,000 people annually. 
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Boy with glasses in rural China, provided by social enterprise Smart Vision and REAP.
Smart Focus has a goal of developing a nationally supported system that could reach 100% of the 18 million children in rural China who will suffer from poor vision during the early 2020s.
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The debate over whether boarding school is beneficial for students still exists in both developing and developed countries. In rural China, as a result of a national school merger program that began in 2001, the number of boarding students has increased dramatically. Little research has been done, however, to measure how boarding status may be correlated with nutrition, health and educational outcomes. In this paper, we compare the outcomes of boarding to those of non-boarding students using a large, aggregate dataset that includes 59 rural counties across five provinces in China. We fi nd that for all outcomes boarding students perform worse than non-boarding students. Despite these differences, the absolute levels of all outcomes are low for both boarding and non-boarding students, indicating a need for new policies that will target all rural students regardless of their boarding status.

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China & World Economy
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Alexis Medina
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Purpose

  • Many public health systems have struggled with the dual questions of: why the uptake rate of maternal health (MH) services is low among some subpopulations; and how to raise it. The purpose of this paper is to assess the uptake rate of a new set of MH services in poor rural areas of China.
 

Design/methodology/approach

  • The analysis is based on the survey responses of women’s representatives and village cadres from almost 1,000 villages in June 2012 as part of a wide-scale public health survey in Sichuan, Gansu and Yunnan provinces in the western part of China.
 

Findings

  • The authors find that the uptake rate of MH services (including in-hospital delivery, antenatal care visits and post-partum care visits) in poor rural areas of Western China are far below average in China, and that the rates vary across provinces and ethnic groups. The analyses demonstrate that distance, income, ethnicity and availability appear to be systematically correlated with low uptake rates of all MH services. Demand-side factors seem to be by far the most important sources of the differences between subpopulations. The authors also find that there is potential for creating a Conditional Cash Transfer program to improve the usage of MH services.
 

Originality/value

  • The authors believe that the results will contribute positively to the exploration of answers to the dual questions that many public health systems have struggled with: why the uptake rate of MH services is low among some subpopulations; and how to raise it.

 

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China Agricultural Economic Review
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Alexis Medina
Scott Rozelle
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BBC News reports on REAP's program to train family planning officials, who used to enforce the one child policy, to become experts in early childhood education. To read the original article, click here.

Two-year-old Liu Siqi is curled up on her grandmother's lap, complaining of a tummy ache. A man tries to divert her with a squeaky plastic duck.

Gradually the toddler's mood brightens. She giggles and is persuaded to join him singing a nursery rhyme.

The man she calls Uncle Li belongs to China's army of family planning officers. Stationed in every city, town and village in China, for the past 35 years their job has been to hunt down families suspected of violating the country's draconian rules on how many children couples can have.

But with the end of the one-child policy at the beginning of this year, some, like Li Bo, are being retrained for a different role. Now he could even be mistaken for a Chinese Father Christmas visiting remote villages in the mountains of Shaanxi province with a bag full of toys and picture books.

Along with 68 of his colleagues, Li is part of a pilot programme involving academics from Shaanxi Normal University and Stanford University's Rural Education Action Programme. His new job is to teach parents and grandparents how to develop toddlers' minds by talking, singing and reading to them.

He works in Danfeng County, 700 miles (1,125km) south-west of Beijing, an impoverished area where more than half the adults of working age have left for jobs in the cities.

We meet at a new parenting centre in two-year-old Liu Siqi's village. It's part of the pilot project here in Shaanxi province designed to stimulate deprived rural children and give them the best start in life.

He watches toddlers throwing balls into boxes and playing with wooden shapes.

"This is a golden time for them to develop skills," he says. "I like this new job and I think my work is important, because what I am doing right now will probably influence what sort of people these children will become one day."

 

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Li, who used to enforce China's one child policy, works with REAP to become an early childhood development expert. Here, he reads a book to a child in an impoverished area of Danfeng County.
Li, who used to enforce China's one child policy, works with REAP to become an early childhood development expert. Here, he reads a book to a child in an impoverished area of Danfeng County.
BBC News / Lucy Ash
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Objectives: To test whether text message reminders sent to caregivers will improve the effectiveness of a home micronutrient fortification program in western China.

Methods: A cluster-randomized controlled trial was carried out in 351 villages in Shaanxi province in 2013-14. We enrolled children aged 6-12 months in target villages. Each village/cluster was randomly assigned into one of three groups: Free Delivery Group (FDG; caregivers received free micronutrient packets); Text Messaging Group (TMG; FDG treatment plus daily text message); and Control Group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat (ITT) effects on compliance and child anemia using a logistic regression model, controlling for infant, caregiver and household characteristics.

Results: There were 1393 eligible children. We found that assignment to TMG led to an increase full compliance (marginal effect = 0.10, 95% CI = 0.03, 0.16) and decrease in the rate of anemia at endline (marginal effect=-0.07, 95% CI= -0.12, -0.01).

Conclusions: Text messages improved compliance of caregivers to a home fortification program and children’s nutrition.

 

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AJPH Research
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Sean Sylvia
Alexis Medina
Scott Rozelle
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106
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Abstract: The general goal of the present study is to analyze whether children with siblings lag behind their only-child counterparts in terms of health and nutrition, cognition and educational performance, and non-cognitive outcomes. We draw on a dataset containing 25 871 observations constructed from three school-level surveys spanning four provinces in China. The analysis compares children with siblings and only children aged 9 to 14 years old in terms of eight different health, cognitive and non-cognitive indicators. We find that with the exception of the anemia rate, health outcomes of children with siblings are statistically indistinguishable from those of only children. In terms of cognition, children with siblings performed better than only children. Moreover, outcomes of children with siblings are statistically indistinguishable from those of only children in terms of the non-cognitive outcomes provided by measures of anxiety. According to our results, the same general findings are true regardless of whether the difference between children with and without siblings is disaggregated by gender.

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China & World Economy
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Scott Rozelle
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"What do I do about the chickens?"

When assistant professor of medicine Eran Bendavid began a study on livestock in African households to determine impact on childhood health, he'd already anticipated common field problems like poorly captured or intentionally misreported data, difficulty getting to work sites, or problems with training local volunteers.

But he'd never gotten that particular question from a fieldworker before. It didn't occur to him that participating families, in reporting their livestock holdings, would completely omit the chickens running around at their feet, thereby skewing the data.

"They didn't consider chickens to be livestock," recalled Bendavid. Along with Scott Rozelle, the Helen F. Farnsworth Senior Fellow at FSI, and associate professor of political science and FSI senior fellow Beatriz Magaloni, Bendavid spoke to a full house last week on lessons learned from fieldwork gone awry. The return engagement of FSI's popular seminar, "Everything that can go wrong in a field experiment” was introduced by Jesper Sørensen, executive director of Stanford Seed, and moderated by Katherine Casey, assistant professor of political economy at the GSB. The seminar is a product of FSI and Seed’s joint Global Development and Poverty (GDP) Initiative, which to date has awarded nearly $7 million in faculty research funding to promote research on poverty alleviation and economic development worldwide.

Rozelle, co-director of the Rural Education Action Program, spoke of the obstacles to accurate data gathering, especially in rural areas where record-keeping is inaccurate and participants' trust is low. Arriving in a Chinese village to carry out child nutrition studies, said Rozelle, "we found Grandma running out the back door with the baby." The researchers had worked with the local family planning council to find the names of children to study, but the families thought the authorities were coming to penalize them for violation of the one-child policy.

Cultural differences make for entertaining and illuminating (if frustrating) lessons, but Beatriz Magaloni, director of FSI's Program on Poverty and Governance at the Center on Democracy, Development and the Rule of Law had a different story to tell. Over the course of three years, her GDP-funded work to investigate and reduce police violence in Brazil - a phenomenon resulting in more than 22,000 deaths since 2005 - has encountered obstacle after obstacle. Her work to pilot body-worn cameras on police in Rio has faced a change in police leadership, setting back cooperation; a yearlong struggle to decouple a study of TASER International’s body worn cameras from its electrical weapons in the same population; a work site initially lacking electricity to charge the cameras or Internet to view the feeds; and noncompliance among the officers. "It's discouraging at times," admitted Magaloni, who has finally gotten the cameras onto the officers' uniforms and must now experiment with ways to incentivize their use. "We are learning a lot about how institutional behavior becomes so entrenched and why it's so hard to change."

Experimentation is a powerful tool to understand cause and effect, said Casey, but a tool only works if it's implemented properly. Learning from failure makes for an interesting panel discussion. The speakers' hope is that it also makes for better research in the future.

The Global Development and Poverty Initiative is a University-wide initiative of the Stanford Institute for Innovation in Developing Economies (Seed) in partnership with the Freeman Spogli Institute (FSI). GDP was established in 2013 to stimulate transformative research ideas and new approaches to economic development and poverty alleviation worldwide. GDP supports groundbreaking research at the intersection of traditional academic disciplines and practical application. GDP uses a venture-funding model to pursue compelling interdisciplinary research on the causes and consequences of global poverty. Initial funding allows GDP awardees to conduct high-quality research in developing countries where there is a lack of data and infrastructure.

 

 

 

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Laurie Burkitt quotes REAP's director Scott Rozelle on the impact of China cancelling the one-child policy . To read the original article, click here.

Chinese leaders implemented the one-child policy in 1980 in an effort to rein in explosive population growth and help raise living standards. It was rooted in a Mao Zedong-era baby boom. China’s population rose by nearly half to about 807 million people in 1969 from when the Communist Party took over the country 20 years before. That led to fears among the leadership that China faced a population boom it couldn’t feed.

Demographers began to present a united front in 2000, arguing that China was dangerously close to falling below a replacement rate of 2.1 children for every woman. Activists stepped up opposition. Chen Guangcheng, the blind activist who famously escaped home confinement and made his way to the U.S. embassy in 2012, became well-known in China in the 2000s for opposing forced abortion.

China effectively hobbled the one-child policy in 2013, when it allowed couples to have two children if one parent came from a household without other siblings. It has also long allowed exceptions in some parts of the country.

Just like on Thursday, the 2013 move led to a frenzy of anticipation from baby-related businesses and a brief bump in shares of Chinese formula makers and other baby-related companies. It resulted in 1.45 million new birth applications as of the end of May, according to the most recent data from the China’s National Health and Family Planning Commission. But the figures have so far disappointed many demographers.

Even rural residents, many of whom have been exempt of the one-child policy, are reluctant to have bigger families, said Scott Rozelle, co-director of Stanford University’s Rural Education Action Program. “Fertility has collapsed in rural and poor areas,” said Mr. Rozelle. “Anyone there can have two or three babies, but no one wants that.”

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Sourovi De, an early child development specialist with the education team at Oxford Policy Management, reports on REAP's Perfecting Parenting project in the Guardian. She discusses how Perfecting Parenting fits within the global context of early child development (ECD) research, and how ECD is fundamental to achieving the fourth Sustainable Development Goal: ensuring inclusive, quality education for all and promoting lifelong learning. Read the original article here.

 

"It’s encouraging to see “access to quality early childhood development” as one of the SDG targets. Policymakers have recognised that investing in children’s development is a way of investing in future social and economic growth. It can also result in more immediate benefits, such as preparing children to get the most out of school. Despite this, ECD programmes still face a number of major barriers – both on the supply and demand side.
 
"Funding is a huge issue. Our research shows that in many developing countries, public spending on pre-primary education amounts to less than 0.1% of gross domestic product, leaving families to absorb the cost either through private providers or informally within households and the community. Even where government pilot programmes look promising, the cost of replicating them on a large scale might be prohibitive – it’s probably no coincidence that most cases of successfully scaled-up projects are in middle- or high-income countries.

 

"Overcoming these barriers often means tailoring programmes to specific contexts and drawing on existing resources. In China, officials previously responsible for enforcing the country’s one-child policy are being retrained as parenting educators as part of the Perfecting Parenting project run by the government’s national health and family planning commission and the rural education action programme.
 
"The trainers visit children and their families in rural pilot villages, helping them follow a specially designed curriculum, incorporating arts and crafts, games and singing. By making use of existing networks and skills, the pilot minimises costs and overcomes infrastructure constraints. But the trainers have struggled to earn the trust of parents who think of them only in their family planning role."
 
 
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Professor of Neonatal and Developmental Pediatrics
gary_darmstadt_headshot.jpg MD, MS

Gary L. Darmstadt, MD, MS, is Associate Dean for Maternal and Child Health, and Professor of Neonatal and Developmental Pediatrics in the Department of Pediatrics at the Stanford University School of Medicine. Previously Dr. Darmstadt was Senior Fellow in the Global Development Program at the Bill & Melinda Gates Foundation (BMGF), where he led a cross-foundation initiative on Women, Girls and Gender, assessing how addressing gender inequalities and empowering women and girls leads to improved gender equality as well as improved health and development outcomes. Prior to this role, he served as BMGF Director of Family Health, leading strategy development and implementation across nutrition, family planning and maternal, newborn and child health.

Darmstadt was formerly Associate Professor and Founding Director of the International Center for Advancing Neonatal Health in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. He has trained in Pediatrics at Johns Hopkins University, in Dermatology at Stanford University, and in Pediatric Infectious Disease as a fellow at the University of Washington, Seattle, where he was Assistant Professor in the Departments of Pediatrics and Medicine. Dr. Darmstadt left the University of Washington to serve as Senior Research Advisor for the Saving Newborn Lives program of Save the Children-US, where he led the development and implementation of the global research strategy for newborn health and survival, before joining Johns Hopkins.

Faculty Affiliate at the Stanford Center on China's Economy and Institutions
Faculty Fellow at the Stanford Center at Peking University, May 2016
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