Jin Xu

Interviewers: Angela Esi Micah and James Buchanan

The Early Career Researcher Interview Series is a new initiative led by the IHEA Early Career Researcher Special Interest Group (ECR-SIG). The aim of this interview series is to showcase the diversity of people in the ECR subgroup in IHEA. By interviewing a variety of ECRs, we hope to describe the many interesting and emerging career paths available to ECRs in health economics, highlight the choices that individuals have made to help them to reach this point in their career, and reveal how ECRs are navigating the various challenges that they face.

The fifth interview of this series is with Jin Xu. Jin is a Lecturer at the China Center for Health Development Studies, Peking University. He completed his PhD in Health Economics at the London School of Hygiene and Tropical Medicine in 2017. His research interests are in the use of cross-disciplinary approaches to study the transition of health systems and evaluation of complex interventions. Angela Esi Micah and James Buchanan, two of the conveners of the ECR-SIG, spoke to Jin in February 2019 to discuss his career to date.

Hi Jin, we are delighted to be able to learn more about your experience as an ECR today. Can you start by telling us about your PhD journey? As in where you did your PhD, why you chose that particular institution and how you funded your studies?

Yes. I did my PhD at the London School of Hygiene and Tropical Medicine (LSHTM). I chose LSHTM because of the amazing professors that taught at the school. I was admitted to Peking University in Beijing in 2002, and this was the same year that the SARS outbreak occurred and a series of health reforms were initiated in Beijing, so I became very interested in health policy studies. The head of the department at Peking University therefore encouraged me to pursue a PhD at the LSHTM. They recommended it as a very good institution with training on my subject of interest. Subsequently, I got some very good references that helped me to secure a grant from the China Scholarship Council to fully fund my PhD.

Fantastic! And when did you start your PhD?

I started in 2013 and finished in 2017.

Could you tell us more about the topic of your PhD?

My PhD focused on the balance between primary health care providers and hospitals in China. I was very interested in health reform in general and observed that while there were a lot of studies on hospitals there were very few studies that looked at the relationship between hospitals and primary care facilities. The dynamic relationship between the two sectors within the health sector was quite interesting to me. I had personally observed that in Beijing there was a lot of growth in hospitals and patients were bypassing primary care.

My PhD started as a small project evaluating a gatekeeping pilot. For this project, I carried out a mixed method evaluation of the gatekeeping pilot, looking at patient’s utilization of primary health care services. I found that although patients were coming to the primary health care center, they were not coming for treatment but for referrals to hospitals or for drugs. Through a qualitative study, I was able to explore the factors limiting utilization. This study revealed that the hospitals were actually siphoning human resources away from the primary health care facilities because they were growing so fast and needed a supply of good doctors, so while a new batch of students had been trained for primary care they were being absorbed by the hospitals because these institutions were growing and paying doctors at a much higher level.

I became more interested in how this structure is shaped as I read and thought more about capacity theories and systems thinking. Initially, I used systems thinking to frame my analysis of the qualitative interviews but I later realized that it was more complex than that, so I switched to a historical approach. This required me to review the evolution of primary and secondary health systems in China over the past 200 years. I found that there was a co-evolution of these two sub-sectors and that this was important in determining the structure of the health system. My main conclusion was that we have to study both sectors together.

It sounds like a very interesting project. Did you face any specific challenges during this process?

Very good question. I thought it would take me only three years but it took me four years to complete my PhD. I think the main challenge for such multidisciplinary studies is the difficulty in doing well in each aspect of the study. This is because you are evaluated very rigorously not only for each component but also for the coherence of the thesis.

Before we continue, could you tell us about your background? Obviously you used a mixed methods approach in your PhD, but is your background in economics or another field?

I have an undergraduate degree in Biomedical English from Peking University. It is actually quite a unique programme in China. We were trained not only in foundational medical sciences such as anatomy, physiology, and pathology, but also in English language, literature, and medical humanities. I also did a double major in Economics so that was the entry point of my interest in economic analysis and economic theories. In addition, I finished Master’s taught courses in Sociology before I started my PhD. This is because I was interested in how economic behavior is shaped by social institutions. I think this paved the way for my mixed methods thesis.

Great, now we better understand how you came to do the thesis that you chose!

Yes, I was very lucky to study at LSHTM because there are so many great professors from very different fields, and the faculty are very collaborative with each other and their students. The faculty actually treat students as colleagues; collegiality is very important there. They respect each other even though they are working in very different fields. The first lecture that I attended at the LSHTM was in the John Snow theatre, and I observed how people from all different disciplines were interacting with each other in a frictionless way. This was really something I hadn’t seen before. I had seen sociologists talking with other sociologists, and economists talking with economists, for example, but this was really eye opening for me. I think this also emboldened me to become risk preferring and not risk averse. So I was very bold in my choice of thesis. Fortunately, I got some very good encouragement and guidance from my supervisor – Professor Anne Mills. She is well-known as a health economist and health systems researcher, but few people know that she also had a major in history from her undergraduate degree. Originally, I was only planning to discuss the history of China’s health system in the background chapter of my thesis. Professor Mills saw that I was interested in history and introduced me to Professor Martin Gorsky, who is an expert in the history of health systems. I also had the support of other advisors. These included Professor Andy Haines, who is a leading primary care expert, Dr Tim Powell-Jackson, who helped enormously with econometrics, and Dr Karl Blanchet, who supported me in a qualitative systems dynamic analysis, as well as several other well-known professors who shared their comments generously with me. That kind of intellectual support was crucial for my PhD.

In terms of challenges during your PhD, where were you based? Were you in London the whole time or you were based in Beijing for part of your studies?

I was in London for three of the four years. I spent one year in Beijing and some other areas of China doing field work and data collection.

Ok so it was a defined block of time so you weren’t going back and forth between places.

No. My scholarship required that I spent most of the time in the UK. It was quite a challenge. Because the policy context back in China was very complex. There were a lot of different things going on and so I tried to keep in touch with policy makers in China in order to get their perspectives on policy issues and to keep my work relevant to ongoing policy in China.

Another challenge was family life. My son was born six months before I started my PhD. So my wife and my mother-in-law spent a lot of time taking care of my son while I was away. I think this is a standard challenge for many people who do their PhD away from home. Although there were challenges for myself and my family, there were also benefits. As a result of my experience at LSHTM, where there were more female professors than male, my wife decided to do a second Master’s degree at LSHTM in the third year of my PhD studies, and she eventually started her own PhD after I finished.

Another challenge related to the difficulty in getting data for studies on China. A similar challenge arises in many other developing countries because of the limited availability of established open data sources. So for many PhD students that study China, you have to collect your own data and that makes the process more challenging. You have to get more resources and maybe collaborate with a team in China that has already collected data. But then the issue of collaboration can be even more challenging than the PhD itself. Fortunately, I was able to work with some policymakers who were sympathetic towards rigorous research, which helped me to navigate this challenge.

So what are you doing now, and how did you make the transition to this role following the completion of your PhD? Were there any specific challenges? It sounds like you went back to an institution that you worked with previously. Was this a role that was developed specifically for you, or did the timing just work out perfectly?

I am currently a lecturer at the China Center for Health Development Studies at Peking University, which is a multi-disciplinary research centre, which mainly conducts high-quality policy-relevant studies about China’s health development reform and associated issues. Currently, I am focusing on the role of technology in strengthening primary care in China.

I think there are several steps in the transition that follows when one completes a PhD. The first transition is from being a student to becoming an independent individual researcher. This requires you to think carefully about what you really want to be studying, what you are really interested in. This is an intellectual challenge; you have to develop your own research agenda. I tried to continue from my PhD as I think my PhD intellectually was not a finished journey; it was only a starting point for me to engage with different disciplines and address the big challenge of primary care strengthening.

The second part of the transition is establishing a track record as a junior researcher. This is about getting grants and publishing papers. In the UK system, it isn’t compulsory to publish papers during your PhD, so this often becomes part of your transition after completing your PhD. Getting grants is particularly difficult in my area of research. Most of the available funding actually goes to technology oriented biomedical research. Health policy research is becoming more and more recognised, but it doesn’t really receive funding proportional to the potential impact of this work.

Related to this, the performance evaluation system for health policy research isn’t yet well established. When you work in a medical school, you are valued against other medical scientists, but a “one size fits all” policy isn’t necessarily appropriate. I think this will take time to change. When health policy and health economics research is more developed as a field it will have its own performance evaluation criteria separate from other medical sciences.

A further challenge is accessing good quality data for research. Data access is a particular problem for ECRs who often don’t have enough resources or sufficiently well-established relationships to access the data that they need. This is less of a challenge for more established researchers. Public health data has also traditionally not been easy to access in our setting. One problem is that funders don’t see the value in funding the generation of data and making data accessible. Also, some of the data that I need is generated by private companies, which presents a further access challenge.

The ultimate challenge is how to make your work impactful in terms of policymaking, so to transition from knowledge to impact and health improvement.

What one thing would you do differently if you were beginning your career now?

I don’t think I would change anything!

That is a perfectly acceptable answer! What are you excited about for the next 5-10 years in terms of your career?

I think there are four things that I am most excited about. First, I haven’t done that much teaching so far in my career – I’ve been a student for a long time. In the next 5-10 years I will have the opportunity to teach students. I have already been interacting with PhD students and also Masters students, in both London and Beijing, and I think I will learn a lot from teaching whilst sharing what I have learned with these students.

Second, I’m looking forward to developing collaborations and partnerships with researchers who share my interest in multidisciplinary health policy research.

Third, I’m looking forward to putting my research into practice and studying policy relevant topics. Health system reform in China has been quite dramatic over the past 10-20 years and I’ve seen some big changes; now almost everybody in China has health coverage. China will finalise the current round of health system reforms by 2020, and there are big plans for the coming years to improve population health by putting people at the center of the health system. So there will be many opportunities to do policy relevant research.

Finally, I am looking forward to my work being more future-oriented. I have been awarded a grant from the National Science Foundation of China to evaluate a telemedicine programme, and I’m particularly interested in studying the role of new technologies and how they can be integrated into health systems effectively to improve health worldwide.

Many thanks to Jin for talking to us today. Interested readers can learn more about Jin’s work by visiting his profile page. The next interview in the Early Career Researcher Interview Series will be published in May 2019.