THE WORLD BANK GROUP ARCHIVES PUBLIC DISCLOSURE AUTHORIZED Folder Title: National Health Project - The Gambia - Credit 1760 - P000812 - Research Folder ID: 30159541 Project ID: P000812 Dates: 03/1/1985 - 11/31/1986 Fonds: Records of the Africa Regional Vice Presidency ISAD Reference Code: WB IBRD/IDA AFR Digitized: 10/9/2018 To cite materials from this archival folder, please follow the following format: [Descriptive name of item], [Folder Title], Folder ID [Folder ID], World Bank Group Archives, Washington, D.C., United States. The records in this folder were created or received by The World Bank in the course of its business. The records that were created by the staff of The World Bank are subject to the Bank's copyright. Please refer to http://www.worldbank.org/terms-of-use-earchives for full copyright terms of use and disclaimers. M THE WORLD BANK Washington, D.C. @ International Bank for Reconstruction and Development / International Development Association or The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org
Transcript
THE WORLD BANK GROUP ARCHIVES
PUBLIC DISCLOSURE AUTHORIZED
Folder Title: National Health Project - The Gambia - Credit 1760 - P000812 - Research
Folder ID: 30159541
Project ID: P000812
Dates: 03/1/1985 - 11/31/1986
Fonds: Records of the Africa Regional Vice Presidency
ISAD Reference Code: WB IBRD/IDA AFR
Digitized: 10/9/2018
To cite materials from this archival folder, please follow the following format:[Descriptive name of item], [Folder Title], Folder ID [Folder ID], World Bank Group Archives, Washington, D.C., UnitedStates.
The records in this folder were created or received by The World Bank in the course of its business.
The records that were created by the staff of The World Bank are subject to the Bank's copyright.
Please refer to http://www.worldbank.org/terms-of-use-earchives for full copyright terms of use and disclaimers.
MTHE WORLD BANKWashington, D.C.
@ International Bank for Reconstruction and Development / International Development Association orThe World Bank1818 H Street NWWashington DC 20433Telephone: 202-473-1000Internet: www.worldbank.org
Ar~ II4S30159641 221
R1992161 Other#: 1 121
Ntoal Health project - The Gambiae. Credft 1 70- P000812 - Research
* Record Removal Notice ____
File Title Barcode No.
National Health Project - The Gambia - Credit 1760 - P000812 - Research
30159541
Document Date Document TypeAug 19, 1985 Routing slip with attachment
Correspondents / ParticipantsTo: J. D. EvansFrom: Mely
Subject I TitleResearch Proposal - Health Care and Family Planning in The Gambia: Determinants and Consequences of Service Utilization
Exception No(s).
Z 1 [:] 2 L 3 L 4 [ 5 [ 6 E 7 E 8 I 9 E 10 A-C D 10 D E Prerogative to Restrict
Reason for RemovalPersonal Information
Additional Comments The item(s) identified above has/have been removedin accordance with The World Bank Policy on Accessto Information. This Policy can be found on the WorldBank Access to Information website.
Withdrawn by DateSherrine M. Thompson Feb 22, 2013
Archives 1 (May 2012)
1"1
.S
FORM NO. 75(6-83) THE WORLD BANK/IFC
DATE:
ROU N SLIP Nove r 3, 1986
AME X ROOM NO.
Messrs. rh, B , Sai sf
Dphing, Sch eck, Ranganathan
Mme-,r-t=dWmA, Husain
APPROPRIATE DISPOSITION NOTE AND RETURN
INITIAL SIGNATURE
NOTE AND FILE URGENT
REMARKS:
You may find of interest and wish to- circulate the attached correspondence
between CDC and the British MedicalResearch Council in the Gambia, regardingthe May 31 Economist article critical ofPHC (also attached).
FROM: ROOM NO.: EXTESION:
AR~easham N440 61573
PRIORITYFROM: IHPO DR STEVE JONES CDC ATLANTA, GATO: AMEMBASSY BANJUL, GAMBIA USAID PLEASE PASS TO CDC DRS.MICHAEL DEMING AND MAC OTTENINFO: AMEMBASSY ABIDJAN, IVORY COAST FOR REDSO
IHPO 6148 ;
SUBJECT: FOLLOW-UP ON ECONOMIST ARTICLE ON PUBLIC HEALTH CAREIN AFRICA (698-0421)
1. AN ARTICLE PUBLISHED IN MAY 1986 IN THE QUOTE ECONOMISTUNQUOTE RAISES SUBSTANTIAL QUESTIONS ON THE SUCCESS OF PUBLICHEALTH CARE IN AFRICA. WE RECENTLY SENT THE FOLLOWING TELEX TODR. BRIAN GREENWOOD AT MRC, THE GAMBIA:
BEGIN TEXT OF TELEX
FROM: IRPO DR. STEVE JONES, CDC ATLANTA GATO: DR. BRIAN GREENWOODMRC LABORATORIES P.O. BOX 273SERRE KUNDA, GAMBIA, -WEST AFRICATELEX 9962211 UKREPGV
IHPO: 6101
1. AS MENTIONED IN PREVIOUS TELEX DATED 7-31-86, HAVEATTEMPTED TO TELEPHONE YOU SEVERAL TIMES WITHOUT SUCCESS,BECAUSE TASK FORCE FOR CHILD SURVIVAL AND CENTERS FOR DISEASECONTROL STAFF ARE INTERESTED IN FURTHER DETAILS ON MRC STUDIESCITED IN ECONOMIST MAY 31 ARTICLE ENTITLED QUOTE PRIMARY HEALTHCARE IS NOT CURING AFRICA'S ILLS UNQUOTE. THAT ARTICLEREFERRED TO A STUDY IN 40 VILLAGES NEAR THE TOWN OF FARAFENNI.THE ARTICLE STATED THAT 14 VILLAGES HAD A PRIMARY HEALTH CARESCHEME IN PLACE AND THAT THE REMAINDER HAD ACCESS ONLY TOVACCINATIONS. THE ARTICLE STATES QUOTE THERE WAS NO CHANGE INOVERALL INFANT MORTALITY RATE UNQUOTE PRESUMABLY COMPARING THEPRIMARY HEALTH CARE INTERVENTION AREA WITH THE VACCINATIONSONLY AREA.
2. AS REPORTED IN THE ECONOMIST, THESE FINDINGS IMPLY THATPRIMARY HEALTH CARE INTERVENTIONS, INCLUDING IMMUNIZATIONS,HAVE LITTLE IMPACT ON INFANT MORTALITY RATES.
3. GIVEN THE CURRENT WIDE SPREAD DONOR SUPPORT FOR CHILDSURVIVAL ACTIVITIES BASED ON PRIMARY HEALTH CARE INTERVENTIONS,THE REPORTED FINDINGS OF THIS STUDY ARE EXTREMELY IMPORTANT.IF AVAILABLE, WE REQUEST THAT INFORMATION ON THIS STUDY(INCLUDING DETAILS ON THE PRIMARY HEALTH CARE INTERVENTIONSINCLUDED, THE COVERAGE LEVELS ACHIEVED, AND THE MORTALITY RATESFOUND) BE SENT TO DR. STEPHEN JONES, CENTERS FOR DISEASECONTROL, ATLANTA GA 30333, UNITED STATES. IN ADDITION, WEWOULD LIKE TO KNOW IF YOU FEEL THAT THE ECONOMIST ARTICLECORRECTLY REPORTED THE FINDINGS AND CONCLUSIONS OF THEFARAFENNI STUDY.
END TEXT OF TELEX
2. IHPO/CDC REQUESTS THAT DRS. DEMING AND OTTEN MEET WITH DR.
BRIAN GREENWOOD AND/OR STAFF FROM MRC GAMBIA TO DISCUSS SUBJECTSTUDY. FYI - THESE MEETINGS HAVE LOWER PRIORITY THAN THE
ONGOING POLIO EPIDEMIC INVESTIGATION. END FYI. REQUEST THATDEMING AND OTTEN OBTAIN AS MUCH BACKGROUND INFORMATION AS
POSSIBLE ON SUBJECT STUDY.
3. APPRECIATE ASSISTANCE OF USAID AND DRS. DEMING AND OTTEN.
END TEXT
CLEAREDAGLEWENDY
CC:GIORDANOFOSTERDOSOIH
CDC/IHPO:TSJones:jwg Doc. 3370Y 8/26/86
Medical Research Council LaboratoriesFajara. near BanjulThe Gambia. West Africa
Medical Research Council telephone Serrekunda 2442/6cables TROPMEDRES, Banjul. The Gambia
Your reference
Our reference
18th August, 1986
Dr T Stephen JonesDirectorEvaluation and Research Division
International Health Program OfficeCDC
Atlanta, GA 30333USA
Dear Dr Jones,
Thank you for your telegram about the Economist article whicharrived yesterday. I am afraid that telephone connections withThe Gambia are difficult and I never received your telex.
It is not easy for me to summarise the results of 5 yearsobservations at Farafenni in a letter but I will try. In 1982-3we conducted a base-line study on a population of 12,000 in 41villages and hamlets. Throughout 1 year we followed the outcomeof all pregnant women, identified by urine testing, and
investigated all maternal and neonatal deaths. The maternal
death rate was extremely high - 20 per 1,000. We also investi-gated all deaths in children under the age of 7 years. The IMRwas 140; ARI and malaria were the most frequent cause of
- childhood deaths. Although few curative services were available
the population was very well vaccinated; The Gambia has the bestcoverage levels in Africa, comparable to those in the UK. Tofind a high IMR was, therefore, disappointing. The results ofmost of the preintervention analyses have now been completed and
3 papers will be submitted for publication in the next few weeks.
In 1983 a PHC programme was introduced into the 14 villages in
the area with a population of 400 or greater. Each village chose
a VHW and a TBA who received a short period of training - about 2
months - from the Government. The village is responsible for
their upkeep. VHW's are authorised to keep about 10 drugs which
they must sell to replace their stocks. Thus, it is a fairly low
key PHC system but one that is independent of outside resources.
There have been some failures but in general the system (which
now operates in most of the country) has worked well we have
been impressed by the sense of responsibility of the TBA's.
In 1984-5 we undertook another complete survey of maternal and
child health allowing us to compare findings in PHC and non - PHC
villages. These analyses are not complete and I don't want to be
misquoted until I am sure of our facts. There have been some
changes for the better in PHC villages but these have been onlymodest. These analyses should be finished by the end of this
year. In April 1986 we started another 1 year survey to see what
has happened now that initial enthusiasm for the PHC programme
had warned.
Thus, The Economist article, which I was not given a chance tosee before publication, is a mixture of truths and half-truthsabout Farafenni. Incidentally it is quite untrue that there are6 physicians at the Dunn Nutrition Unit Field Station at Keneba;there is only 1 involved in clinical care, assisted part-time bvhis wife and 1 mid-wife.
I have some sympathies with the general tenor of the Economistarticle although I think it goes too far. I think that we mustbe careful not to exuect too much of simple PHC programmes on TheGambia model. I can cive a number of examples why I feel thatthis is the case. We have found that haemorrfrage, suddencollapse and overwhelming infections are the main causes ofmaternal death. How can we expect TBA's to make an impact onmaternal deaths when local referal centres are poor and when thenearest place that a blood transfusion can be obtained im 200 kmaway? Because of their limited training there was a debate as towhether VHW's should be allowed to dispense antibiotics. As acompromise they have been allowed to dispose only oralpenicillin, an antibiotic which is unlikely to be effectiveagainst the severe ARis which kill many young Gambian children.There is no doubt that PHC workers contribute to the welfare oftheir villages in less dramatic ways, for example by makingaspirin readily available, but I don't think that they will beable to make a major impact on indicators such as maternal andinfant mortality rates unless their curative skills are enhanced(as has happened in China) and the effectiveness of referalcentres improved. If expectations of village based PHC schemesare set too high an unfortunate counter reaction is likely tooccur and the Economist article may be the leader of a trend.
I hope this helps.
Yours sincerely,
B M GREENWOOD
SCIENCE AND TECHNOLOGYPart of the landscape
um be d eelh ui ierA N A ( chi llre 11 now il me
on e per F gI n I. Yeare w ite Stuneed Ae ee Pubirtls owtM aees,908
developing countries. Up to 10% of wo -Primary health care is not nM.*"ra*Prim ry hualh ca e is noten die from complications during preg-nancy or botched abortions. wHo is pro-CUring r -a'S ills moting contraceptives and advice on birthcontrol.c MotAersood and child care. These arematters of education. Up to a quarter of
In 1978, the World Health Organisation set Itself a goal: "health for all" maternal deaths during childbirth couldby the year 2000. The means was to be primary health care: a package of be avoided by simple improvements inlowtechnology measures to prevent disease In poor countries. Our hygiene, such as using sterile equipmentspecial correspondent reports from Africa, where it Is not working to cut the umbilical cord. Breast feeding,
in the absence of clean water, protectsDisease is part of the landscape of the scientists to think again. children from disease (even when thethird world. In 1978, at the outset of the In 1978, WHo turned its back on high- mother herself is sick), postpones anotherWHO campaign, nearly one in five of the technology cures and turned to preven- pregnancy, and saves the mother the highchildren born alive in developing coun- tion instead. That year, at a conference in cost of bottle-feeding her baby.tries died before the age of five. One in Alma-Ata in the Soviet Union, it came up Education can also help against diar-ten of the survivors would grow up crip- with the "primary health care" pro- rhoea. Diarrhoea kills through dehydra-pled. One in ten women died during gramme. Primary health care is aimed tion, but mothers often withhold fluidpregnancy. The main killers were (and particularly at children and child-bearing from children during diarrhoeal attacks,are) the infectious diseases now largely women, because they are the most vul- thinking it will make the disease worse.eliminated from rich countries. Six dis- nerable. It has six main elements: Many such deaths could be averted witheases-polio, measles, diphtheria, teta- e Clean water. In the third world, around oral rehydration: a simple mixture ofnus, whooping cough and tuberculosis- 80% of infections are spread by water. sugar, salt and clean water. The cost ofkill 5m of the 15m children who die each WHo's aim is that by 1990, all the people such treatment is negligible comparedyear in the third world (excluding China). of developing countnes be provided with with that of the anti-diarrhoeal drugs onMany also die from pneumonia and ma- an adequate supply of clean water and which some families spend up to 10% oflaria. The biggest single killer is diar- with sanitation. This is the most expen- their income-and which are useless, ac-rhoea, which claims the lives of more than sive part of the programme. cording to UNICEF.5m children a year. e Vaccination. Both wHo and the United e Medical training. To support these ini-
In Europe and the United States, dis- Nations children's fund (UNICEF) main- tiatives and ensure that even rural popu-ease was vanquished mainly by prosperity tain that one of the quickest and least lations have access to some sort of quali-and what it could buy--better nutrition, expensive ways to break the cycle of fied medical assistance, wHo wants morehygiene, education, housing, roads and malnutrition and infection is through im- training to be given to local health work-railways. To wait for prosperity in Africa munisation against the six common child- ers chosen by the villagers.would be to wait too long. In the 1970s, hood infections. The expanded pro- e Essential drugs. Most third-worldAfrican governments tried to improve gramme of immunisation (EPI) aims to countries have no choice but to buy theirhealth with drugs, pesticides and centra- make immunisation available to every drugs from western companies whichlised hospitals catering predominantly for new-born baby by 1990. This is rather dominate the international medicineurban people. By the end of the decade, cheap, costing about $5 a child. trade. Some drugs are, at best, a waste ofthese measures were not working. Vac- 0 Contraception. Population growth lies money; at worst, dangerous if misused.cines had eradicated smallpox. But the at the root of many third-world problems; At the same time, many poor countries gopersistence of many diseases and the any reduction in the birth rate can help. short of the drugs that they do need toresurgence of others, like malaria, forced Childbirth is a dangerous business in treat the most common diseases and inju- 91THE EcONoMWST MAY 31 198
SCIENCE AND TECHNOLOGY
nes. WHO has drawn up a list of the 220 (painkillers, anti-malarials, antibioticsdrugs it considers essential. In the early and eye drops), and managed to ensure a1980s, wio began to buy many of these constant supply of these to health centresdrugs in bulk, often at half price, on for several years. Kenya's most promisingbehalf of developing countries. innovation has been to stop pretending
that government clinics and centres canAmbliJ~mitdo the job. Instead, village shops arewHo believed that if one-tenth of a devel- encouraged to market simple remedies.opng nation's budget were devoted to Senegal made its commitment to pr-heath, then "health for all" would be mary health care in the late 1970s. Pre-achievable. The target was ambitious, but ventive measures have been taken againstthe methods seemed practical, and have the main endemic diseases, notably tu-been widely adopted. Between 35 and 40 berculosis, malaria and leprosy. Externalcountries have built primary health care aid has helped improve the level of nutn-into their policies, depending on the defi- tion. Mobile teams have pursued massnition used. The number of rural people vaccination campaigns, reaching aboutin the developing world served with water 20% of the population. And UNICEF hassupplies increased by 15m between 1980 just launched a new campaign to improveand 1983. Around 80 developing coun- the immunisation coverage.tries have adopted an essential drugs list; Though poor and tiny, Gambia has oneand the worldwide demand for vaccines of the most extensive primary health-carenow runs at three times its 1983 levels. campaigns in Africa. Since 1980, pump ?Take Kenya, where nine-tenths of the wells have been installed in 700 of itspopulation live in rural areas and where 2,000 villages. Nearly all villages withhuge hospitals in the cities scoop most of populations of more than 400 will have Lucky survivorsuch money as the government can afford access to trained health workers by theto spnd on health. Since the late 1970s, end of this year. Gambia has immunised there are still more than 150 deatlthe number of modest health centres and about 70% of children. And all this has among infants younger than one year fidispensaries has more than doubled, to been achieved by spending no more than every 1,000 live births-among the wor1,600. Kenya's ruling party was recently $1.50 on health per person a year, much mortality figures in Africa. Some loc
converted to birth control. So the number of that paid for by aid agencies. areas have seen significant reductionsof women attending family-planning clin- infant-mortalty rates. But they are eics rose by 30%, to 80,000, between 1983 Flawed ceptions. The town of Kaneba has maiand 1984, and in 1984 more than 800,000 Despite the enthusiasm with which pri- aged to reduce deaths among its infantspeople, a quarter of the target popula- mary health care has been adopted, there 24 per 1000 live births-thanb to ttdon, visited child-welfare clinics. is little evidence that health standards continuous attention of six qualified dotMeanwhile, UNICEF has implemented have been raised. Some experts suggest tors and four midwives, seconded frororal-rehydration and EPI schemes in Ke- that the programme is flawed not just in the University of Newcastle in Britairnya, though it has immunised only 10% of its execution-a common cticism-but The doctors at Kaneba argue that it mathe target population so far. There are in conception as well, be better to send fully trained health-caralso several thousand aid agencies in The British government's Medical Re- workers to rural areas rather than to traiiKenya, promoting preventive measures search Council, in collaboration with the local village workers, who may be eithesuch as clean water and sanitation. With Gambian government, has just complet- unable or reluctant to take on the workthe help of a Dutch agency, Kenya has ed the first five-year phase of a study load. Village health workers are normallput together a pilfer-proof kit of drugs comparing villages that have been x- not paid, and all over Africa (most notaposed to primary health care with those bly in Tanzania) they have tended tcG that have not. About 40 villages were leave their villages and try to set up asGetn th sa selected for the study, all at least seven dispensers on their own account forneedle 4. -(Tubol"o, miles from the nearest town, Farafenni. profit.%of chftrn undr . In 14 of the villages, primary health-care Senegal has experienced a more gener-I or immmiswd in 20 -schemes were in place; the remainder had al improvement in infant and child mor-devoping colntries access only to vaccines. In the whole area. tality. But it is ascribed by scientists fromc*v om) out of every 1,000 children born alive, 140 France's Office de la Recherche Scientifi-
die as infants. The big killers are pneumo- que et Technique Outre-Mer (ORSTOM)Poli h nia, malaria and diarrhoea. Malnutrition to the West African drought of the 197 0s.%coh I is widespread. which ruined farmers even as it savedJ40 Field workers visited villages every their children's lives by providing fewerf /month for four years, looking at chil- puddles for malaria-carrying anophelinq26 dren's weight, doing blood tests and so mosquitoes to breed in.on. The good news, according to the Richer Kenya has also seen a reductioni0 study's preliminary findings, is that pri- in infant mortality, frorp 140 deaths perTMemsn mary health care has resulted in fewer 1,000 live births in the 1960s to 100 in thedeaths among very small babies and fewer 1970s. These changes are probablymalarial deaths. The bad news is that direct result of Kenya's growing prospethere has been no change in the overall ty. Between 1960 and 1980, GDP grew by1070 75 * ' infant-mortality rate. an average 5.8% a year. The amount
The same story applies throughout GDP spent on health over the same peri92 S N Gambia where, according to UNICEF, almost doubled. but mostly went int
THE ECONOMIST MAY 31 ?
SCIENCE AND TECHNOLOGY
urban hospitals, not r. ral health. third world are just as eager as rho!Yet, since Kenya introduced primary The growing failure rich countries to believe that there ishealth care in the late 1970s. it has seen Fodroductiosperwsr ,2 for every ill.
little change in infant mortality, which AwVsp 1961-65. 100 .... ~ Advice on breast feeding is ignow stands at 92 deaths per 1.000 live - 121 s y ebirhsnealy ivetims a hih a in . . simply because mothers cannot sparebirths, nearly five times as high as in LogoAMnMa ee 0 11 time to feed their babies that way
Europe or America. Over the same peri- ie parts of West Africa women do 70_od, annuai growth rates in GDP have - pr of Wt workca, oe d 0-
.a0e toaonI-%wil h oua s of agricultural work and produce 40-,fallen to around 2-3% while the popula- % I As of the staple crop. That is partlytion grew faster, so the average person breast feeding has declined, and the sgrew poorer. of breast-milk substitutes have riser
Failure many developing countries.HoAe sr But perhaps the most disastrous faiHope cannot wish away a depressing Ai=- has been that of family-planningconclusion: that primary health care is gras n Aa. Th aerag :failing. Why? The main reason is that rainmes i Africa. The average tprimary health care is above all an inte- te in s population.0nowopou,grated package: its measures reinforce 1 s 14 the region's population, now rou;one another, and in isolation each may 530m. is growing at an annual rate of'
faster than in any other area of the wchave little effect. hospitals they built in the 1960s and The efforts of governments and aid aiThe programmes that have been imple- 1970s. Senegal still spends over half of its cies to publicise the virtues and meanmented have concentrated on specific health budget (which, at 6% of total birth control are effectively counteretargets or specific villages, partly because public expenditure is still lower than Muslim and Roman Catholic teachmany are run by independent, and occa- WHO's recommended 10%) supporting 11 High infant mortality and the factsionally competitive. aid agencies. In hospitals. Just one-fifth of Kenya's yearly children are seen as the only prospectHoma, a Kenyan village on the shore of expenditure on health goes on preventive comfortable old age do not help. AcctLake Victoria, several different aid agen- medicine. Despite the help Gambia gets ing to one Gambian health official. mcies market their own variety of primary from aid agencies, its health programme people attend family-planning clinicshealth care, while other villages nearby is failing to meet half its recurring costs, few take away contraceptives.have no form of aid. (There are even according to the government, which The huge growth in population w<reports of aid agencies setting up pro- hopes to raise more money by introducing against the success of primary health cgrammes to combat diseases not found in a partial-payment scheme for health. by intensifying the problems of maImthe area.) WHO also underestimated the force of tion and by promoting the rush iThe lack of co-ordination undermines habit or tradition. In 1984, USAID already overcrowded cities. Studies skthe efforts. If one village gets a tap and launched a one-year health-education that the urban poor are generally wctoilet and the one next door does not. the programme in Gambia to publicise oral fed than their rural counterparts becainhabitants of the first will be little health- rehydration. Hardly any mothers used the food they eat depends entirely onier unless they shun their neighbours. the cocktail before the programme; after- money they earn. Providing health carSometimes a remedy for one problem can wards, about half did. USAID could claim the country is more expensive. Inmagnify another. New water supplies can a resounding success. But, once the cam- sprawling slums of Nairobi, a sinprovide new breeding grounds for malar- paign stopped, mothers reverted to old health centre can serve more than 50.ial mosquitoes. habits and the useless drugs. People in the people.Even with good vaccination coverage.infant mortality has not declined, True, ' Remediesdeaths from measles and whooping cough The failure of primary health care shodecline sharply after immunisation pro- not be a cause for despair but for furtigrammes, but (as has happened in Gam- action. The researchers at ORSTOMbia) the children die of pneumonia. diar- liee that the lesson is to assess which trhoea or malana instead. If clean water ot the programme work best and to speand sanitation are not introduced simulta- on them what little money there is,neously, vaccination simply changes the example. what are the relative mert
paternof isese.- ~ l' j, feeding supplements and housingMoreover, even primary health care is study of the 1979 measles ouibreakproving too expensive for poor countries Guinea-Bissau suggests that over-cro%wHO's estimates of the money available , ing. not malnutrition. determined wheto carry out these projects (and of the er people died from the infection. Liwillingness of governments to spend it) research of this kind has been donenow seem absurdly optimistic. The World $ Another approach is to examine othBank has calculated that providing water richer countries and see what they hiand sanitation for most third-world vil- done. The lesson of rospertvisthat edlages and towns would cost $30 billion a Waterandcntroiof population rowthyear. Even in the first year of the pro- ter two s Tpequsites of heat~-tdessentii T-rerequittso egramme, in 1981, the total spent on water imp m . barand sanitation was only $10 billion. to birth coittolfare fixed. clean wateiAfrican governments have been unable everywhere welcome. That. above allto concentrate their health budget on w atW HO sould be spending its monprimary care because of the huge recur- onRerhember. Jo tdiseasethethi
94 rent costs of maintaining the expensive Breast feeding is safe-and cheap w0rd is spread by waer.
THE ECONOMIST MAY 31
Qduesti onn~ai re for Nanc y/key issues
(Will Eliza be invoLved in research project?
Shouid we try to do anthropomel ry?
DIS has worked out tqe hniues for large-scale surveys.
LSMS apears to use ins as heir units of observanes. Mybe e o i d
also, What do Gambian Census and MUC do
Roles of MVU and UNI"l
Has MRC project begun in Passe?
IncreP sampr size'? bo hth mS (now 1000) and for nomtiei Vs now 50)
Add expert on healAth status in Alrica?
e~.Bob I aek
how t 0 den I wit h r'V ri comumenl s re def/ann lylic i ssues? en. endogeneity
of male wr and neome, mult iperiod models
Many reservations K revJewS about WTP
Will cover health
helth care of all compound (or HH) mebes. hight?
RandWASHINGTON OFFICE
March 3, 1986
Dr. Andrew J. Hall
MRC Environmental Epidemiology Unit
University of Southampton
Southampton General HospitalSouthampton S09 4XYUNITED KINGDOM
Dear Dr. Hall:
I apologize for the delay of several months in replying to your letterconcerning our proposed research in the Gambia. Your letter went originallyto Cornell's medical school, then to my old office in the Nutrition Division,and finally to my new address here in Washington. (I have re-joined the RandCorporation.) Now I hope this reply catches up with you in the Gambia!
Our proposal for a survey research on determinants and consequences ofhealth care and family planning utilization in the Gambia was not funded bythe World Bank. Nancy Birdsall of the Bank and Julie DaVanzo of the RandCorporation are considering revising the proposal and seeking funds anew. Iwill send them copies of your project description, and I think they will agreethat there are some useful ways for the two efforts to reinforce each other.
I had learned of the hepatitis vaccination program at a demography con-ference at the London School of Hygiene and Tropical Medicine last summer.It sounds exciting. I am especially interested in what your project willshow about how well anthropometric indicators serve as predictors of mortalityin different age gropus. As you probably know, there are very few prospectivestudies from sub-Saharan Africa, and those that exist give equivocal results.Will the field trial include serological measures? If so, it would also beinteresting to know if there were associations between vitamin A status andinfectious disease incidence and severity. Prof. Somers at Johns Hopkinsis now in the process of trying to replicate and extend his findings fromIndonesia, and I know that there is a great deal of interest in whether vitaminA supplementation would be so useful in West and Central Africa as it apparentlyis in Indonesia, Malawi, and a few other countries.
I enclose a copy of the Rand publication dealing with the accuracy ofretrospective data from Malaysia. Malaysia has a very advanced system ofvital events registration -- obviously a similar study in the Gambia would relymore on indicators of internal consistency and re-test reliability and less oncomparison with external sources.
I
I remain very interested in your project and would appreciate being kept
on your mailing list for reports and articles as they appear.
With best wishes for success,
John Haaga
JH:bet
Enclosure -- N-2157-AID "The Accuracy of Retrospective Data from the
Malaysian Family Life Survey"
MRC Environmental Epidemiology UnitD University of Southampton
Please reply to: Southampton General HospitalSouthampton
Medical Research Council S09 4XY
Your reference Telephone Soutihampton 777624 E x
()II whloence
J kI 'r
K
G c WA
C La L-- 7
1)J (- /J1clIv.L~jL~mPA~ 'I
i6I Liu"
I. SUMMARY
A long-term intervention study in The Gambia, The Gambia Hepatitis
Intervention Study (GHIS), has been designed to evalu Le the effectiveness of
hepatitis B (HBV) vaccination for the prevention of chronic liver disease &nd
hepatocellular carcinan9 in a population at high risk. In addition, the study
will assist The Gxnbian Government in maintaining a strong immunization
programe.
71e Gambian Government, The International Agency for Research on Cancer
(IARO) and the Melical Research Council (tjC) Laboratories in The Gambia will
be jointly responsible for the conduct of the study.
The stury canprises three overlapping phases:
Pnase I : Vaccination programme - 5 years
Phase II : Lorgitudinal and cross-se: tional studies of selectel aroups -
at least 10 years
Phase III: Lona-term follow-up - 40 years
rKhase I: Ks Vaccinaticn Prcxra-rie
Followirng a peri& of pLYrsonnEl recruit!it, traininr D n, pllotn of -1"
,ccine delivery, IBV vaccination will be procressively incrporatei inLo the
regular vaccination schedule administere Ly the 17 ExprneK Proora27:- f <
ILnuiT cation (EPI) tecis current2y operatina in Tne Gambia (the nr.e: Of
tems s currentl beirn reviewx5). An -3< vaccine (approved by the Vld
lEalth Organization) will t, introduced on a tea.r-by-team basis at
approximately 3-monthIy intervals such tiat complere nationbl coveraE- Wil" b
ach.ieved withir atbut 4 years. Nationw-de3< vaccination is e>:pet t
continu- ::ftcr th&.t date.
-2-
At the end of the 4 years over wiich HV vaccination has been introuc-c,
twD groups of subjects will have been identified. Each will consist of abcut
60,000 children. One group will have received BV vacci;ation, the other will
not. Long-term follow up of these groups for the sequelae of MV infection,
especially hepatocellular carcinma (HC) ano chronic liver disease, will
enable the protectiva effect of vaccination against these conditions to te
clearly and unambiguously assessed.
Phase II: Studies of Selected Groups
Lonmitudinal studies:
Group I
1000 children will be randomly selected from those who attend the EPT and
receive HBV vaccine. They will be followed from the time they receive BV
vaccine for 10 years.
Cross-sectional studies:
Group 2
Group 2 will consist of cross-sectional s-amples of children rDt
vaccinated aiainst FEV. Ea:h year for the first five years after thc
start of the study, a sample of 1000 children will be rcn mly seleotef
frmn thsor attendir the EPF at the samr time as Group 1 bit '-, hal rt
receives EhV vaccine. Frther samples will be taken in wars 5 to 10
aftcr the start of the stuly.
GroU 3
Group 3 ;,1- consi-t of ULaec crc. ps, one to be formed fron oPildrnc er n
in ca,:h ycer b n n the second year of the oroject. Each qroup will
consist c4i 50 inf,-nts randromly selected, who have received WV vaccirn.
-3-
The clinical and laboratory data derived from groups I and 2 durirm the
first ten years following vaccination will provide information %,hich mal be
considered as short and medium term end points of the study. Those in grou' 3
will be examined only once for H3V markers following vaccination to assess the
continuing inunogen 4clty of the vaccine throughout the study perio3.
Phase IIT: Long Term Follow-up
Training programmes will be developed for hospital, clinic and other
staff of the national health care system directed to the identification,
characterization and recording of all cases of chronic liver disease and HCC.
A cancer registry will be established in The Gambia to coordinate ard
facilitate this task.
Tis study has been designed to provide new information on the na-tural
histoy of KBV infection in a West African population, to determine the
duration of E1V vaccine induced immunity and to yield conclusive data on thv
efficacy of vaccination for the prevention of HCC and other chronic sequjca.i
of !-HV infection. -bst of the previous wcrk on YEV in West Africa has b-en
Derforme in Senegal. Close ties have been created with the group in,
an future collaboration is anticipate-.
t
FORM NO 80(5-84)
THE WORLD BANK IFC DATEMESSAGES TIME
TO
FROM
DEPT./OFFICE
PHONE EXTENSION
L CALLED CALL BACKL CAME TO SEE YOU l WNILL CALL AGAIN
L RETURNED YOUR CALL L REQUESTS APPIN(TMENT
LURGENTREMARKS
RECEIVED BY
AVAILABILITY OF SERVICES
A. HeaLth
1. How far away is the nearest
distance place where number of hours travel usual modein km located (to and from) of transport
dry season main season
a. village health postb. sub dispensaryc. dispensaryd. MCH clinice. health centref. drug storeg. traditional healer
2. How often is there someone there to provide a service?
no. of hours a day no. of days a week no. of days a montha. village health postb. sub dispensaryc. dispensaryd. MCH clinice. health centref. drug storeg. traditional heater
3. How long do you have to wait to see someone? __--- minuteshours
4. What treatment do you normally receive for malaria?
5. What is your opinion of the service you receive?
Poor Good Reasonable Very Good
6a. Have there been times when clinics have been cancelled in?
Yes NoRainy SeasonDry Season
Page 2
6b. Does this happen often?Yes No
Rainy SeasonDry Season
7. Is this due mainly to:
shortage of fuel.................1shortage of supplies.............2staff problem....................3roads affected by bad weather....4other............................5don't know.......................6
8. when do you go to:
(a) VHP(b) sub dispensary(c) dispensary(d) MCH clinic/TBA(e) health store(f) drug store(g) traditional healer
9. Which one do you go to the most? And why?
10. Are there any illnesses for which you do not go to any of these?
Yes No
If yes, what do you do instead?
home treatment...........1
Pge 3
11. Are you in favour of family planning?
Yes No
If yes, where is the nearest source of contraceptives?
If no, for what reasons:
Pag~e 4
B. Education
1. How far away is the nearest primary school?
kms.
2. What are the costs involved in attendance?
Item Cost Unit
uniformexercise booktext bookpencilchairtable
3. Do all children of school going age attend the primary school?
Yes No
If no, most of them ___ some of them _-_ only a few of them
4. Is this equally true of the girls as well as of the boys?
Yes No
If no, why not?
5. What would you say are the major educational problems in this area?
(i)(ii)MC- -- - -- - -- - -- - -
Page 5
C. WATER AND ENVIRONMENTAL CONDITIONS
1. How far is the nearest permanent public water source?
kms.
2. How long does it take on average to go to this source, collect water and return?
minutes hours
3. How often on average does water need to be collected daily during:
rainy season ..... times/day dry season _____ times/day
4. What is the principal water supply source during the dry season used for?
USES -- drinking bathing laundry livestockPrincipal water supply
modern covered well with pumpsmodern open welltraditional wellstreampublic standpipeprivate piped water
5. What is the principal water supply source during the rainy season used for?
USES -- drinking bathing laundry livestockPrincipal water supply
modern covered well with pumpsmodern open welltraditional wellstreampublic standpipeprivate piped water
6. How many public wells are there in this village?
wells
Page 6
7. How many private wells are there in this vilLage?
.....- private wells
8.
9. Are the wells sufficient to cover entire village needs in both rainy and dry seasons for:
rainy season dry seasondrinkingwashinglaundrylivestock
10a. Are the following common?
rainy season dry season both seasonsYes No Yes No Yes No
mosquitoesother (specify)
10b. Do you use pesticides against them? Yes ---- _ No _
10c. If no, why not? (1) too expensive...........1(2) not available...........2(3) don't know about them...3(4) other (specify).........4
11. What type of sanitation services is used most frequently by adults and by children?
AduLt Childbucketpitriverbush
12. What public health campaigns have taken place in this area? (Do not prompt)
Yes No(a) diarrhoeaL control(b) water sanitation(c) meningitis(d) other
14. What preventative health measures do you undertake regularly as a community?
15a. Does your village health worker/public health inspector/community health --- conduct healtheducation activities? Yes No
15b. If yes, specify
Eae8
D. LABOUR MARKET
1. What are the main activities carried by residents in this village?
this year last year
2. Are all able bodied residents engaged in these activities? Yes No
If no, why not?
3. Are there other employment activities not very far from the village?
Yes No which ones
4. Do these activities both in this village and nearby provide full time employment during:
(a) the rainy season Yes __-_- No
activity
(b) the dry season
activity
5. Do these activities provide enough income both cash and in kind for you?
Yes -____ No _-__- If no, specify reason (do not prompt)
(i) We do not produce enough because we do not have sufficient manpower as the most ablebodied have migrated.
(ii) We do not have the necessary inputs to improve the productivity.
Page 9
(iii) We do not get a good price for hwat we produce.
(iv) Other specify.
6. Over the past 12 months:
Yes Nomore people have left the village than is normal?more people have moved into the village than is normal?the movement of people has stayed the same?
7. Why do you think this has been happening?
8. How much roughly would a person performing typical activities earn a month/season/annually?
ACTIVITY TYPE OF INCOME: monthly seasonal CASH KIND
9. Who carries out these activities, children, men, women?
Activity Only Children Only Men Only Women All Three
10a. Are there activities only carried out by women? Yes --_ No
10b. If yes, which ones and why?
Activity Reason
Page 10
E. TRANSPORTATION AND COUNICATIONS
1. How far away is the nearest bus stop? kms.
2. How far away is the nearest taxi stand? __--_ kms.
3. Of these two which do you use most and why?
4. Where is the nearest place to buy fuel?
5. Do you experience fuel shortages?
------rarely sometimes often _
6. What is the price of a litre of petrol? ---------- Today ---------- Last year
Litre of diesel
7. How much does it cost to get from here to --------- by
bus
taxi
8. Is the road always in good condition during?
the rainy season Yes ___-_ No
the dry season
9. How many households own radios?
none a few some most all
10. Is it easy to obtain a good reception?
easy _____ not so easy __--- difficult ---_ very difficult
11. Does everyone have the opportunity of listening to programmes of interest to them?
Yes No
12a. How many households have electricity?
None a few some most all
12b. What is the average monthly bill? -_-__ Dalasis
13. How far away is the nearest bank, credit or savings institution? _-_-- kms.
14. How far away is the nearest market where products of this area can be sold? kms.
Pgge 12
F. COJMNITY ORGANIZATION
1. What different village organizations do you have? Are they set up for any specificpurpose?
Organization Purpose Membership
2. How do they carry out this objective?
3. Does this involve expenditure? Yes _____ No
4. How is the money collected and kept?
Activity Mode of collection and keeping (contributor. type of payment, who keeps)
5. Do you have any special methods of deciding on:
membershipexecutive committee members (e.g. VDC)length of office
6. What are some of the difficulties which face village organizations?
P~ag 13
6. PRICES AND AVAILABILITY OF FOOD
1. What food itmes are most commonly consumed in this village? How much do they cost? Do youhave difficulties in obtaining them (either through home production or purchasing them)?
Price Availability1 -- Home produce 1 -- always available
Items consumed 2 -- Bought 2 -- usually available3 -- Both 3 -- sometimes available
100 kg bg rice1 litre oil50 kg bag millet1 kg beef1 kg onionssmall tin tomatoes1 kg sugar1 kg cornpint of milksmall tin milk
2. For the items you have to buy, which places do you normally buy from?
Item within village neighbouring village nearestsh22 market neighbour/friend shoo market town
3. Are there price differences between these sources? Yes -__-_ No
4. Who has the lowest and the highest for these items?
Item Lowest Highest
5. Are non food items, e.g. soup, easily available?
Always available Usually available Sometimes available Never available
6. What is the cost of a small bar of soap? _____ Dalasis
Distribution
A - Staff - health centres (HC), mission clinics (MC), dispensaries(Dis), revised version for hospitals and privateclinics.
B - Outpatient clinic - hospitals (Hos), private clinics (PC), health centres,mission clinics, dispensaries Q14-17 only forAFPA clinics
C - Inpatient Facilities - hospitals, private clinics, health centres,mission clinics, Q8-12 only for MCH clinics only
D - Laboratory - hospitals, private clinics, private laboratories (PL)
E - Surgery - hospitals, private clinics
F - Pharmacy - hospitals, health centres, dispensaries, private drug
stores (PDS)
G - Transportation - hospitals, health centres, mission clinics, dispensaries
H - Water availability - health centres, mission clinics, dispensaries
I - Community participation - health centres, mission clinics, dispensaries
J - Changes over time - all units where applicable
HC MC Dis Hos PC PL PDS
A x x xB x x x x
C x x xD x x xE x xF x x x x
G x x x xH x x xI x x xj x x x x x x x
2
DErERMINANWS ANl CONSEQUENCES OF HE.ALTH CARE AMFAMILY PLANNING UTILIZATION
SERVICE PROVIDER QUESTIONNAIRE: INSTrIIONS
Sample Area
District Division
Name of facility
Type of facility
Distance from kms
How long has this facility been in operation
Interviewer's name
Date of Interview
Time started
Time ended
3
A. STAFF
1. Can you give me the following details for all the health personnel workingin this facility?
Total
2. How many of these people are on duty today?
3. Are any problems experienced receiving your salary on time regularly?
4. Are any problems experienced receiving allowances on time regularly?
4
B. OUPATIENT CLINIC
1. What are the outpatient clinic's days and hours of working
Days Open HoursMonday Yes No toTuesday Yes No to
Wednesday Yes No to
Thursday Yes No to
Friday Yes No toSaturday Yes No to
Sunday Yes No to
2. a) Do you often have a queue in the
Yes Typical waiting period No(mins)
- mornings?- afternoons?
- rainy season?
- dry season?
- harvesting period?- periods of irregulary
drug/stock supplies
3. b) What is the typical waiting period? (fill in table above)
How many people normally work in this outpatient clinic every day?(daily number)
4. How many people worked in the clinic when it was last held?
5. How many patients were seen on that day for both curative and attending MCHclinics
Curative I M C H I TotalImothers infants I
actual figures Iestimate I
6. How many patients were seen during the last week?curactive I M C H I Total
Imothers infants Iactual figures
estimates
7.a) Do patients pay a consultation fee?Yes [ I No [ ]
5
b) If yes, how much do they pay forAmountD B
1. first consultation2. second or more consultation
11. Do women come to the clinic for reasons other than delivery or treatment of asick child?
Yes No
12. If yes, what do they come for? and how often?
fre uencyseldom I sometimes regularly
i. ante-natal consultationsii. post-natal consultations
iii. immunizationiv. tetanusv. DPT
vi. measlesvii. polio
viii. tuberculosisix. yellow feverx. collect contraceptives
13. How does this facility handle cases of:
moderate diarrhoea
severe diarrhoea
moderate malnutrition
severe malnutrition
6
malaria
14. Which methods of family planning are available?
available usually sometime rarelyanytime available available available
condoms
pills
injectable (Dipo-Provide)
other (specify)
15. In what units are they given out and how much do they cost?
Commodities I Quantity I Frequency Unit cost
I II I I II I I II I I -
16. What, if any are the restrictions on their use?
1. No restrictions2. Age restrictions3. Restriction based on parity
17. Is the doctor consulted?Yes No
If yes, under what circumstances
18.a) Against which infectious diseases are vaccines given?b) How much is paid for a complete dosage?c) Which vaccines are held in stock today?d) Are there problems having this in stock? (Tabulate answers below)
Vaccine I Cost of complete I In stock I Are there problems inDisease given I dosage I today I maintaining this stock
Inever/seldom/often/alwaysSI I I
Tetanus I I I IDPT I
7
--------- -- --- --- ----------- --Measles
Polio
TuberculosisI
Yellow Feveri
Other I I I I
8
C INPATIENT FACII3TIES
l.a) Do you have any in-patient beds/delivery bedsYes [ I No [ I(If no go into D)
b) If yes, how many beds?
2. How many beds were occupied yesterday?beds
3. How many people have been hospitalized during the last week?people
4.a) Do the patients have to pay an in-patient fee?Yes [ I No(]
b) If yes do they payYes Amount No
D B
1. flat hospital fee2. per night
3. private bed fee4. other expenses
5.a) During hospitalization who provides food for the patients?
1. this health unit2. the patient's family3. other
b) If the health unit, what is the in-patient charge for food per day?
6. What types of cases were hospitalized over the last year
7. How are cases of diarrhea, malaria and malnutrition handled in the facility?diarrheamalariamalnutrition
8. How many delivery beds do you have?(number)
9. How many women have delivered during the last week?
9
(number)
10. In general after having delivered, how long do they remain here?
a They return home straight awayb They stay a few hoursc They stay a nightd They stay two nights
e They stay three nights or more
11a. Do the women pay to deliver in this clinic?
Yes No
b. If yes, what types of cost do they pay and how much?Yes Amount No
i. deliveryii. midwife _...
iii. bed --iv. other
12a. What is the main reason women come here to deliver as opposing to delivery at
home?
b. Do they come here because
Yes No
i. They do not have a traditional midwife
ii. The traditional midwife is too expensive
iii. They have more confidence in the midwife
at the clinic than the traditional midwife
iv. They have (or have had) complications
during pregnancy or deliveryv. They have a history of _ prematurity
or stillbirthsvi. They prefer the clinic for delivery of
their first child
c. Of all the above reasons, which is the most important?
10
D. LABORAMOfl
la. Is there a laboratory in this unit?Yes [ ] No l
If No go on to E
b. If yes, do patients have to pay for tests?
Yes [ I No [ IIf No go on to E
c. If yes how much do they pay for the following tests?
Test A.ountD B
1. urine2. blood3. sputum4. xray5. other
2. Who carries out these tests?(cadre of personnel and number of personnel involved)
3a. Do you have the following equipment? (see table)
Yes [ I No [ I
b. Is it in good working condition?
Equipment Works but not Does not
(Standard list to be provided) In good working order in good order work
4a. Do you have a sufficient supply of reagents and other products necessary for
tests?Yes [ ] No [ I
b. What is the availability of the following items?
Item Often Sometimes Occasionally Seldom
(Standard list available available available available
to be provided) (60-100%) (40-60%) (20-40%) (10-20%)
5. How many tests were carried out last week?
And last month?
Last week Last month
Urine
------------------------ -
11
Blood
Sputum
Xray
12
R. SURGEtY
la. Do you carry out surgery here?Yes [ I Not here but elsewhere, No [
If No go on to I
b. If yes, or elsewhere, what type of surgery are you equipped to carry out?Yes No
i. minor surgery(teeth, small tumours, cysts)
ii. herniaiii. caesariansiv. append ic it isv. other
2a. Do the patients have to pay for surgery?Yes [ I No [ I
If No, go on to I
b. If yes how much do they pay for?AmountD B
i. minor surgeryii. major surgery
iii. anesthesiaiv. other costs
13
F. PHARMAC!
(Fill in answers in table below)
1. How many different pharmaceutical products should you have in stock?
2. How many do you already have in stock today?
3a. Do you have problems in having them stocked?
3b. How often do you receive new supplies of pharmaceutical products?
Different Pharma-ceutical ProductsThat Should Be Actual Pharmaceutical Problems In Stocking Frequency ofIn Stock Products In Stock Products Supplies Product
Seldom - 0Sometimes - 1Often - 2
4. How often do you draw up an inventory?
5. How far away is the nearest alternative source of drugs? kms
6. Is this source privately owned - 1a government health institution - 2a mission clinic - 3other - 4
7. Do you have the following today?
Item Frequency of Supplies IPrice I Limit I Substitute available--- ----------------------------- I ---- I---------------I1-------
1/52 2/52 4/52 6/52 8/52 12/52 Yes No
(standard useto be provided)
SII I i
8. If item is not available does it have a substitute in stock today? (fill in
14
table).
9. What do most of the patients do who come here when you do not have the drug or
product they need?
1st 2nd
buy a substitute herebuy from another government health unit
buy from the private sectorbuy from a local shop/drug storebuy from the marketdo nothingsee a traditional healerother (specify)
15
G. TRANSPORATION
1. Do you have official vehicles here?
Yes[] No [ IIf No, go into H.
2. What type do you have, how many of each type? Of these how many are in good
working condition? (fill in table).
Type I Number I Number in working condition
I I
3a. For what purposes are they used?
Yes No
(a) patient evacuation(b) trekking(c) vaccination campaigns(d) collecting supplies(e) personal use
3b. Is there enough fuel to enable this to take place?
Yes No
4. If no, what has been the problem?
(a) inadequate allocation(b) fuel not available(c) other
5. How often does the team trek and where to?
Rainy Season
Area Distance Frequency
--- --------lililllsilimlll ---------meam mmin- - - -1=111411=iiam oi ----------------
(c) shortage of personnel(d) shortage of supply(e) other reasons
If Yes, explain
7. What forms of transport are most used by patients coming here.
Rainy season Dry Season- - - - - ------------ -----
most common most common most common most common
foot - -
bicycle -- -~~ ~
donkey cart ---- - - ~ ~
car/bus -~-~-~-------------------- -----------
other - ~~~ ~-~-~
17
H. WATER AVAITABILITY
1. How far away is the nearest
Distance (kms) Never Seldom Often Always
(a) We ll -(b) Standpipe -------------------------------------------(c) Stream ------- -
(fill in table)
2. Do you use this source? (fill in table above)
18
I. COMMUNITr PARUICIPATION
1. (a) Did the people nearby participate in the construction of this facility?
Yes [ I No [ I(Go to 2)
(b) If yes, how did they participate?
Yes No
- manual work --- financial participation -- -- total amount
-- participation in kind --
2. Do the people nearby participate in its maintenance?
Yes[I No [ I(Go to 4)
3. If yes, in what way?
Yes No
manual work -- -- Number of persons
financial participation - Number of days per person
participation in kind -- -- Amountover what period
4. (a) Is there any community health ed'acation?
Yes ___ No
(b) If yes, specify
19
J. CHANGES OVER TIM
1. How does the situation this past year compare with the situation over theprevious five years?
More Less Same
(a) Number of outpatients seen ----
(b) Amount of guening --- --- - -
(c) Number of beds occupied --- ----
(d) Number of complicated deliveries --- ----
(e) Number of lab tests - --
(f) Number of drug supplies(g) Number of referrals received -- -(h) Number of referrals made(i) Availability of vehicles in working order ---- -
(j) Availability of vehicles -(k) Availability of equipment(1) Other
Interviewer
-- Describe the physical condition and cleanliness of the dispensary-- Are there many patients-- Did you have any difficulties in finding a someone in charge. Was
he/she cooperative?- Other observations
DETERMINANTS AND CONSEQUENCES OF HEALTH CAREAND FAMILY PLANNING UTILIZATION
SERVICE PROVIDER QUESTIONNAIRE:
TRADITIONAL BIRTH ATTENDANTVILLAGE HEALTH WORKERTRADITIONAL HEALER
Sample area
District Division
Type of health personneL
Distance from
INTRODUCTION
1. What is your name?
2. Sex Male Female
3. When were you born?Can you name an event that took place around that time?
4. What ethnic group do you belong to? _
5. Can you write, for example can you write a letter?
Yes No
6. Can you read a letter written to you?
Yes No
7. What different activities do you carry out for a living? 8. About howmuch do you earn for this month/season? 9. Do you carry them outseasonally or all year round?
Monthly Per Season ActivityActivities cash kind cash kind seasonal permanent
7 8 8 9
10. Which of these activities is your principal activity?
11. What training have you received that enables to perform as an expert oncertain health matterslearnt from parent/guardian only.....1learnt from other as apprentice only...2learnt from parent/guardian/apprenticeships, also received short
training from Medical & Health/mission/NGO.....3
12. What is your area of expertise as a specialist on health matters (donot prompt)?
delivery ..... 1bonesetting .... .2advising on family planning ..... 3mental problems ..... 4attending to the following ailments ..... 5 (see VHW list)other - specify ..... 6
Page 3
13. How long have you been working as an expert on these health problems?
-. years
14. How many patients did you see last week?
15. And last month?
16a. What percentage of your patients came from outside this village? _____%
16b. How far away do they come from?
17a. Are you available all the time every day?
Yes No
17b. If no, how often do you receive patients?
- - days a week mornings onlyafterno6ns onlyevenings only
18. Are you busier this year than last year?
Yes No No
more patients less patients the same number
of patients
19. Are you busier during the rainy season than the dry season?
Yes more patientsNo less patientsNo the same number of patients
20. Most frequent 21. Treatment 22. Payment received 23. Amountillnesses Y = 1 N = 0 received
:Consul. Treat.
Page 4
20. For what problems do you recieve the most patients? (insert answers intable above)
21. How do you treat these problems?
22. do you receive payment?
23. How much do you receive?
24. Do you receive the same payment from all your patients alike?
25. What if the patient is unable to pay?
26a. Do you use western treatment at all?
b. Yes No
c. If Yes, what do you use?
d. Do you have some in stock today? Yes No
e. Do you have a reliable supply? Yes No
f. Where do you get your supplies from?
27a. Do you receive patients who come to you for help in family planning?
Yes No
b. If yes what kind of help?
28. Are these patients mostly male or female?
mostly male _____ mostly female _-___ neither
29. What do you do?
30. What do you do if you cannot handle a patient's problem? (Any problemnot last related to family planning specifically)
refer to health centre ..... 1refer to other traditional healer ..... 2other (specify) .....
Pag e 5
31. Do you refer patients to the health centre? (Skip if already stated inreply to Q26)
Yes No
32. Can you give examples of cases you have referred to the healthcentre/dispensary?
33. How often do you see these cases?
rarely __ sometimes --__- often _
34. How many of your patients here died over the last year?
A. HOUSEHOLD SCHEDULE
(Ask the head of the household or any other responsible member of thehousehold who is able to give information on other household members)
Introduction (explain purpose of survey)
We would like to have some information about everyone who is a memberof this household. We would like to include only usual residents of thishousehold, including the usual residents who are temporarily away andexcluding those who are here very temporarily.
1. Please give me the names of all the persons who usually sleep in andeat at your household.For each person (insert answers in table).
2. Sex -- Male/Female
3. What is the relationship of this person to the household head?
4. What is his/her relationship to the compound head?
5. Who is his/her mother (relationship to household head/compound head).
6. Is she still alive?
7. What did she die of?(Now to go back to ..... (name of person on whom questions are beingasked))
8a. When was he/she born?(Note whether verified with document or by event or not)
8b. How old is he/she?
9. Where was he/she born?
10. What is his/her present marital status?(If married is he/she polygamously or monogamously married)
11. To what ethnic group does he/she belong?(If other check it is not a subgroup A 1-8)
12. What religion is he/she?
13. Has he/she attended school?
14. Can h/she write a simple letter?(In English, Arabic, Mandanka, or any other language)
Pag~e 2
15. Can he/she write a simple letter?(In English, Arabic, Mandanka, or any other language)(If no, go into 18)(Check if there are any other members of the household who aretemporarily away, e.g. small children or infant, domestic servants,friends, or lodgers and record some information on them).
16. What was the highest level of schooling completed?
17. (For children of school going age only, above 6 but less than 20) Ishe/she attending school?
18. Where is his/her principal activity?
19. Out of the last twelve months, how many months has he/she been livingin this household?
20. How many other households live in this compound?
househoLds
21. What is the relationship between these household heads and the compoundhead? (insert reply in table below).
Other households in compound 3 -- grandson/wife of grandson
Health of household 1
Health of household 2
Health of household 3
PEag~e 3
ID.NO. Name Sex ReLationship To Household Head1 2 3
M=1F=2 head of household - 1
wife of household head - 2child of household head - 3grandchild of household head - 4father/mother of household head - 5sister/brother of household head - 6niece/nephew of household head - 7son/daughter-in-law of household head - 8brother/sister-in-law of household head - 9other relative of household head or - 10
spouse of household headservant of household head or his/her - 11
relativestenant of household head or his/her - 12
relativesother persons not related to household - 13
head or spouse of household head
PMge 4
Mother's ReLationshipRelationship To Compound Head To HousehoLd Head
4 5
compound head - 1 1 - only wifewife of compound head - 2 2 - 1st wifechild of compound head - 3 3 - 2nd wifegrandchild of compound head - 4 4 - 3rd wifefather/mother of compound head - 5 5 - 4th wifesister/brother of compound head - 6 6 - motherniece/nephew of compound head - 7 7 - mother-in-lawson/daughter-in-law of compound head - 8 8 - auntbrother/sister-in-law of compound head - 9 9 - sisterother relative of compound head or spouse of - 10 10 - sister-in-Law
compound head 11 - daughterservant of compound head or his/her relative - 11 12 - daughter-in-lawtenant of compound head or his/her relative - 12 13 - grandmotherother persons not related to compound head - 13
or spouse of compound head
P~Age 5
MaternaL SurvivaL Cause of Death Month & Year of Birth Is Age Verified6 7 8(a)
Y =1N 0
Page 6
Age At Last Birthday PLace of Birth Present arital Status8(b) 9 10
1 - in this village 1 - never married2 - in another vilLage in 2 - married
this division (monogamous)3 - in other division 3 - married
Do members of your household own the following?(Ask quantity owned and current value of each item)
Item Quantity Size Current Value
CarTruckTractorMiniVanMotorized bentMotorcycleCanoeBicycleDonkey cartTV setAir conditionerFanRefrigeratorSewing machineCooker/StoreRecord PlayerRadio CassetteRadioWatchCows/BullsDonkeySheepLand (specify size of and owned)HouseTools and equipment(to be specified)
Page 17
0. INCOME
1. From what activities do members of your household desire their mainsources of income? Include income which accrues to household, e.g.home grown food from household production activities.
Activit7 HousehoLd Members Involved (use ID.NO.)
1. Farming2. Vegetable gardening3. Livestock4. Fishing5. Blacksmithing6. Carpentry7. Masonry8. Weaving9. Tie Dying10. Sowing11. Petty trading12. Retail13. Business14. Domestic work15. Hotel work16. Clerical work17. Administration18. Professional
Other
(Insert answers to 2 and 3 in table)
2. (a) Were these activities performed last month? Yes _..__ No. _____(b) If yes, what was monthly income?(c) Over the last 12 months, the activities you have been carrying on
are mainly seasonal, casual or permanent throughout the year?
(d) What would you say was the average combined annual income?
DaLasis
(e) What was the average combined annual income for the year before?
Dalasis
3. (a) Do members of your household receive other incomes?(b) What type of finances are these?(c) About how much is received annually from these sources?
age 18
4. (For households with more than one household per compound only)Do all these incomes we have been talking about -- to this householdonly or is some of its shared with the compound head and otherhouseholds in the compounds?
This HousehoLd Shared with Shared with other Shared withOnly Compound Head Households in Compound Others Elsewhere
5. (insert answers in table below)
(a) What type of income is shared? (e.g. cash, kind)(b) What proportion of total income is shared?(c) Of the amount shared who gets how much?
Type of Proportion of Total AvailabLeIncome Shared TotaL Income Shared for Sharing goes to
(a) (b) (c)
1 cash only 1 less than 25% A compound head2 kind only 2 25-50% B other households3 both 3 50-75% in compound
4 more than 75% C other 1 - less than 25%2 - 25-50%3 - 50-75%1 - less than 25%2 - 25-50%3 - 50-75%1 - less than 25%2 - 25-50%3 - 50-75%
Page 19
6. (for one household compounds only)
(a) Does this household share its income with other household members?
Yes No
(b) Type of income shared
(c) Proportion of income shared
(d) Persons with whom shared
Name (ID) Activity MonthlyA Household Performed Income Over Last 12 Months Activities
Member Last Month From This Undertaken Are1 2a 2b 2c
Yes - 1 (coding forNo - 2 income in
cash andkind to bedetermined)
mainly seasonal - 1(75% of total activitiesundertaken)mainly casual - 2(75% of total activitiesundertaken)mainly permanent employment - 3(75% of total activitiesundertaken)mixture of seasonal and - 4casual employment
Page 20
Average AverageCombined CombinedAnnual Income Annual IncomeFrom These From These Type of Annual TotalActivities Activities Other Income Income Received AnnualThis Year Last Year Received Received Annually Income
2d 2e 3a 3b 3c 2d+3cYes - 1 Rental -1 (code toNo - 2 Pension -2 be
Remittance -3 deter-mined)
Pg 21
E. UTILIZATION OF HEALTH CARE
Prices and Utilization
1. What are the costs involved in seeking treatment at the followingplaces for malaria, for example
Transportation Outpatient fee Purchase of DrugD B D B D B
village health post - - - - - -sub dispensary/MCH clinic - - - - - -dispensary - - - - - -health centre - - - - - -local shop/drug store - - - - - -
2. In your view are these costs
reasonable I J
too high 1 3
3. If too high, which particular costs are too high
transportation E ]
out patients fee [ ]
purchase of drugs C ]
4a. Where do you normally go for treatment of malaria?
b. How far away is it?
5. What do you think about the service you receive at the following place
Poor Fair Good Very Good Excellent
village health post
sub dispensary/MCH clinic
dispensary
health centre
Pge 22
6. What do you like about the service
efficient .............................. 1
easily avaiabLe........e..............2
inexpensive.............................3easy identification with staff..........4
other...................................5
7. What do you not like about the service
too much waiting........................1
unsympathetic staff.....................2
insufficient drugs......................3
not enough staff........................4
other............................... 5
8. What suggestions do you have for improving the service
additionaL staff........................1
improved staff attitudes................2
increased availability of drugs.........3
more frequent clinics...................4
other...............................5
9. Would you be prepared to pay more to help bring this about?
Yes [ ] No C 3
10a. How much more and in what way
out-patient fee purchase of drugs otherD B D B D B
Page 23
b. Where is your nearest reliable source of drugs?
village health post
local shop/drug store/market
dispensary/health centre
other
11. Do you have a local traditional healer?
yes C I No C ]12a. For what illness do you go for consultation and for treatment
................... ...... 1
....................... 2
...................... 3
........................4
12b. Is there a fixed consultation fee?
yes no
12c. Is there a fixed fee for treatment?
yes no
12d. Can the price vary accordingly to the patient's income?
13. About how much do you pay for a course of treatment?
Illness AmountD B
1 - -
2 - -
3 - -
4 - -
Page 24
14. What factors do you take into account when deciding whom to go to for treatmentof an illness? (tick those mentioned)
a) Nature of illness
b) quantity of illness
c) familiarity with person to be consulted
d) accessibility of person dispensing treatment(distance)
e) cost of obtaining treatment(travel, fee)
Pge 25
F. WILLINGNESS TO PAY FOR HEALTH CARE
la. Do you have your own village health care worker who has been trained to diagnoseand treat minor illnesses which occur frequently in this village?
Yes No
lb. (If yes, continue.If no, go to lb)
Imagine that a village health worker who is performing averagely. He/she waschosen by the village to receiving training to become their own village worker.He has returned from training and his performance is as expected. He knows howto diagnose the following different diseases --- __________-_-__--__-___ and heknows the correct treatment to be administered. Because he comes from thevillage and was chosen by the village he is usually always available when he isneeded.
Imagine, however, that this villages health worker is seriously thinking ofdiscontinuing his work as village health worker. The reason for this is that heis not earning enough from his main economic activity and he is thereforethinking of moving to a bigger village in search of work.
Imagine that around this time one of your children falls ill with fever. Thisfever remains continuously high for three days. How much would you be preparedto pay this village health worker to ensure that he remains in the village wherehe is easily available to treat cases such as y6ur child's case?
Dalasis
Would you be prepared to pay slightly more?
Yes Norepeat If no, end
If yes what would be the most you would be prepared to pay?
Dalasis
(lb) If no.
Imagine your child is ill with a high fever. This feverish condition continuesfor 3 days successively without any signs of improvement. If you had a villagehealth worker this is one of the illnesses he has received training to diagnoseand treat. Because he is a member of the village he/she is known to you and canbe available at almost any time.
Would you be prepared to pay to obtain the services of such a village healthworker in your own village?
Page 26
Yes No
If yes, how much do you think you would pay for a health worker who coulddiagnose and treat this specific condition?
Dalasis
Would you be prepared to pay any more than that amount?
Yes No
If yes, how much more? ----- DaLasis
What would be the most you would be prepared to pay to ensure that you had ahealth worker who could treat this kind of illness?
Dalasis
2. Imagine there has been an increase in mosquitoes due to the heavy rains.Everyone in the village is falling ill with malaria and the bouts of illness lasttypically 4-6 days.
Because so many people have been ill, your village health worker and or yourlocal supply has run out of antimalarial medici'ne (both tablets and injectibles)and you will now need to bring antimalarial drugs from another source.
About how much will you be prepared to pay to buy the drugs required for acomplete course of treatment?
Dalasis
Would you be prepared to pay a bit more? Yes _-_-- No _
How much more? Dalasis
page 1
A. SUUMARY
INTRODUCTION
I would like to ask you about some of the main events in your life,
such as getting married, giving birth, moving home and working.
A. Education
i) Did you attend school/college/institute/polytechnic/university at any
time after your 18th birthday?
If yes
ii) At what age did you complete your education?RECORD
B. Marriage
At what age were you first married?RECORD
C. Births
i) How many children have you had?Ask for each child
ii) At what age did you have your (first/next) child?RECORD
D. Moving homes
i) How many times have you moved homes since you were 18?Ask for each move.
ii) At what age did you (first/next) move home?RECORD
E. Employment
i) Have you ever had any job, either full-time or part-time which paid a
wage or salary, either in cash or in kind?
ii) Have you ever had your own business or worked in a family business or
family farm, whether you were paid in cash, kind or not paid at all?
Pgge 2
iii) Have you ever earned any income in cash or in kind from any home
industry or activity such as selling/trading fruit, vegetables or
animals? Making things to sell/trade such as water ices, meat pies,
tie-dye? Performing services for other people such as laundry, sewing,
housework?
NOTE EACH ACTIVITY ON SUMMARY SHEET AND ASK
iv) Which was the first of these activities (job) you did after your 18th
birthday/after you finished schooling/after you were first married? (as
appropriate)
v) At what age/in what year did you begin that activity (job)?
vi) At what age/in what year did you change activity (job)?
(Start another activity (job) in addition or in replacement, stop an
activity (job)?
REPEAT Question (vi) for each work change.
vii) Were there any periods when you did not do any of these types of work
for a period of 1 month or longer?
REVIEW WORK HISTORY AND PROMPT AS APPROPRIATE RECORD AGE/YEAR AND NOTE
UNEMPLOYED
spondent Name :_Case No. Interviewer no.
2 - FEMALE RETROSPECTIVE Summary '
o e 0 o 0
0 lu -C
AGE EVENT EVENT
TICK) (DESCRIBE) (TIC ) (DESCRIBE)
MF2 / / Al
Pge 3
B. MARRIAGE HISTORY
No. Questions amd Filters Coding Categories Skip To
1 Record the time Hour.........Minutes......
2 Have you ever been married Yes.................1or lived with a man? No..................2 -A 520
3 Are you now married, or Living MARRIED...............1with a man, or are you widowed, LIVING TOGETHER.......2divorced or not living together? WIDOWED...............3
DIVORCED..............4NOT LIVING TOGETHER...5
4 Have you been married or lived ONCE..................1with a man only once or more than MORE THAN ONCE........2once?
5 In what month and year did you start MONTH..............living with your (first) husband or DK MONTH..............98partner? YEAR.................
DK YEAR...............98 -9 607
6 How old were you when you started AGE...................living with him?
7 Are your father and mother still YES NOalive? WOMAN'S MOTHER...1 2
WOMAN'S FATHER...1 2
8 Are your first husband's/partner's YES NO DKfather and mother still alive? FIRST HUSBAND'S
No. Questions and Filters Coding Categories Skip To
10 Was (MENTION PARENTS NOT ALIVE YES NONOW) alive at the time you began WOMAN'S MOTHER... 1 2living together with your (first) WOMAN'S FATHER...1 2husband or partner? FIRST HUSBAND'S
11 Check:Some parent alive No parent aliveAt Marriage [ I AT Marriage C I
[skip to 519)
12 At the time you began livingtogether, did you and your (first) YES..................1husband (or partner) live with any NO...................2 -* 614of these parents for at least sixmonths?
13 For about how many years did you YEARS............... Elive together with a parent at UP TO THE PRESENT.... 97 -t 615that time?
14 Are you now living with any YES....................1parents? NO.....................2
15 In how many localities have you NUMBER OFlived for six months or more since LOCALITIES......... E ]you were first married (startedliving together) including thisplace?
Page 5
C. PREGNANCY HISTORY
Explain to the woman that you are going to record alL her pregnancies in the
order that they occurred beginning with her very first pregnancy and ending up with
her most recent pregnancy. Emphasize the importance of getting each pregnancy in
order and that the woman must include all abortions (pregnancies ending before 7
months) and still births (pregnancies ending after 7 months).
1) When was your first pregnancy and how long were you pregnant for?(Record date of end of pregnancy in table.)
2a) What was the outcome of your pregnancy?(If the child was born alive ask the full name of the child and write it down)(If the child died before the naming ceremony write neonate)
b) Was baby male or female?
3a) Did you become pregnant again?(Record date of end of pregnancy)
b) What was the outcome of that pregnancy?repeat 3a & b to include all pregnancies.
c) Sum up total of all live births. Just to make sure that I have this right,you have had a total of live births during your life. Is that correctYes ____ No(If No probe or correct)
For live births only -
4a) Is still alive?
b) If no what was the likely cause of death?
c) How old was when he/she died?
For live births in 198 or more recently
5a) Did you see anyone or go anywhere for a check on this pregnancy?
b) If yesWhen did you see/where did you go
c) When during the pregnancy did you first see someone?
d) How often did you see someone?
EpEqe 6
6a) Where was delivered?
b) Who assisted with the delivery?
7. When you were pregnant with were you given an injection to
prevent the baby from getting convulsions, that is an anti-tetanus shot?
8. Do you have a health card for this child?If yes, may I see it please
Determine immunizations from health cardIf no determine from mother
9. Has this child ever been immunized, that is given injections to prevent him/herfrom getting diseases.
10a) Have you ever given powdered milk or animal milk such as cow's orgoat's milk on a regular basis?
b) If yes how old was when you started on a regular basis.
11a) Have you ever given him/her solid or mushy food on a regular basis?
b) If yes how old was when you started on a regular basis?
12a) For last birth: Are you still breastfeeding? Yes No ?
b) For earlier births after 198 . For how many months did you breastfeedhim/her?
Page 7
1 2a I 2b 4a I 4b I 4c | 5a I 5bDate of end I Outcome of I Is child Ilikely chancelAge at lAntenatallService provider Iof pregnancy I pregnancy I Sex IstilL alivelof death Ideath Ivisit IconsuLted I
Month Year 11. Live birth I jY = 1 1 I ,Y = 1 IHospital -1 1I (name) I IN = 0 1 I IN = 0 IHeaLth centre -2 I12. neonate I I I I I IMCH clinic -3 113. stilL born I I I I I IDispensary -4 114. abortion I I I I I IMission clinic -5 115. currently I I I I I IGFPA -6 11 pregnant I I I I I IPrivate clinic -7 1I 1 1 1 1 1 IPharmacist -8 1I 1 1 1 1 1 IOther heaLth I
II I I I I lInstitution -9 1ITBA -101ITraditional -11I Midwife I
IIII I ReLative -121I1 lother
Pag~e 8
5c 5 5d I 6a I 6bFirst antenal INo. of antenatal Ivisit after - Ivisits before I Place of I Deliveredpregnancy Idelivery delivery I by
1 month - 1 lonce 1 IHospitaL -lihospital midwife -12 " - 2 Itwice 2 IHeaLth centre -2lhealth centre midwife -23 " - 3 13 times 3 Imission clinic -31mission clinic midwife -34 " - 4 14 times 4 Iprivate clinic -4|private clinic5 " - 5 15 times 5 lother health I midwife/doctor -46 " - 6 16 times 6 I institute -51TBA -57 " - 7 17 times 7 lat home -61traditional midwife -68 " - 8 18 times 89 - 9 19 times 9
110 times 10I etc
Page 9
7 I8 9Tetanus I Ilmmunizationvaccine IHeaLth Irecord from fromreceived Icard Icard mother
I IY = 1 IY = 1 I(to beN = 0 IN = 0 Iprovided)
I II II II II II II I
Page 10
10a I 10b 11a I lb I 12b IProvided milk I ISoLid I INormalLy Ianimal milk I IMushy food I lbreastfeeds Igiven on regular lAt what Igiven on lAt what Ifor I
basis I age Iregular basis I age Imonths_ _ _ _ _ I _ _ _ _ _ _ I _ _ _ I _ _ _
Yes 1 I I I INo 0 I I I I
I I I I II I I I II I I I II I I I II I I I II I I I I
I I I I II I I I II I I I II I I I II I I I II I I I II I I I II I I II I I I II I I I I
Pge 11
D. FOSTER CHILDREN/ANTHROPORETRY
Apart from any children that you have given birth to
Do you look after any children aged 10 years or less? (Does this involve them
living with you)
Probe any children born to relatives or children who are in your care?
Yes No __
How many such children under ten years of age who you look after, live with
you?
number
For each child ask
a) How old is this child?
b) Male/Female?
c) How old was he/she when he/she first started living with you?
a) b) c)Name of child Age Sex Age when first started
living with you
For each living child born and foster child living with respondent aged 3 oryounger, record
Name Date of Height Weight in Triceps Armbirth in cms grams skinfold circum-
thickness ference(mms) in cms
(tonearest 0.1cm)
Plge 12
E. MORBIDITY AND HEALTH CARE UTILIZATION CHILDREN BORN AFTER 198
The following questions on common childhood diseases to be asked for all Livingchildren born after 198__
a) Name of child
b) Has this child had diarrhea in the last year?If No go on to g
c) How long did it last?
d) Is child still sick?
e) Did you or anybody else do something to treat the diarrhea?
f) What was the child treated with? PROBE, anything else?
g) Has this child had diarrhea in the last month?
For each treatment not already mentioned ask whether the child was treated withthe following (see table)
h) Was advice or treatment sought from anyplace/anyone outside the household?
i) From where or from whom was advice or treatment sought. Probe for type ofperson and record most qualified.
j) How far is that place/person from here?
k) How long does it take to go there?
L) What form of transportation is used?
m) What/How much does it cost to travel there?
n) Once there, how long does it take to obtain advice/supplies?
o) What/how much does it cost to obtain advice/supplies?
p) What do you feel about the nature of services rendered at that place/person?
q) What do you like about the services?
r) What don't you like about the services?
Page 13
a I b I c I d I e I f IChild I I I Child I I
Name of I suffered from I Length of I Treatment still I Treatment Ichild I I illness I taken I sick I received I
_ _ _ _ _ _ _ _ _ I _ _ _ _ I Ii ii IDays Monthsl Y = 1 IY = 1 I Y = 1 I
Ilast last 1___ 1 N = 0 IN = 0 1 N = 0 IIyear month I I I
Page 14
g I h I i I ITreatment not I Advice sought I From where I Distancealready I from every place I From who I frommentioned I anyone I respondent(different codefor each illness) |
1- Sugar, salt and I Y - 1 I1- Hospitalwater solution I N - 0 12- Health centre I
2- Solution made 1 13- Dispensary Ifrom special I 14- MCH clinic Ipacket I 15- Mission clinicI
3- some other I 16- private clinicIsolution I 17- other health I
4- liquid through I I institutiona needle from a I 18- TBAbottle 19- VHW
5- Tablets in 110- pharmacist Iinjections
PEgg 15
K L m I n o pTime taken ITransportation I Cost of I WaitinglCost of Opinion ofto get there I used I traveLLingl time iconsuLtation I serviceI there I land treatment I (to be coded)
Page 16
F. MORBIDITY AND HEALTH CARE UTILIZATIONS(Adults and Children born after 198 only)
la. Has anyone in your household been sick recently?(over the last week) (Probe)
Yes No
b. If no, has anyone in your household been sick during the last month (Probe)If yes
2. Which member? (fill in name in table)
3. How old is ? (fill age in table)
4. Male/Female
5. Do you know what he/she is suffering from?
a) Yes (insert illness)
b) No, could you describe symptons (insert)
6. How long has she/he been ill/was he/she ill?
7. What treatment was received?
8. Was advice or treatment sought from any place/anywhere outside the household?
9. From where or from whom was advice or treatment sought. Probe for type ofperson and record most qualified.
10. How far is that place/person from here?
11. How long does it take to go there?
12. What form of transportation is used?
13. What/How much does it cost to travel there?
14. Once there, how long does it take to obtain advice/supplies?
15. What/how much does it cost to obtain advice/supplies?
16. What do you feel about the nature of services rendered at that place/person?
17. What do you like about the services?
Page 17
18a. What treatment was given?
b. Were drugs prescribed?
c. Were prescribed drugs available?
d. How much did they cost?
19. Did you need to go there more than once?
20. How much do you estimate was spent in all in curing this patient?
Pag 18
Name I When Sick I Age I Sex I Nature of I Length of I Advice/I I I ilLness I ilLness I Treatment II I I I received II I I I ______________ I _____________
11 This week/I I I IYes -1 II Last week I I I INo -2 I12 last monthl I I I
Pag~ 19
9 - 17 I 17 Drugs I Prescribed I Cost of j Frequency Totalcopy P12 i-p I Treatment prescribed drugs I availabLe I of I cost of
I I available I prescribed! consultation I illnessI I drugs I
____________ I I I I ____
I I I I I II I I I II I I I I
I I I II I I I I
I I I I II I I II I I I I II I I I II I I I II I I I
I I II I I I II I I I II I I II I I I
I I II I I I I
I I I I I II I I II I I I I II I I I II I I I
PjQe 20
6. FOR CHILDREN BORN AFTER 198 WHO HAVE DIED
Name, A child CID
a) In what month did die?Probe. In what season?
b) Did the baby/child suckle normally after birth?
c) Did the baby/child stop suckling in the (three) days before death?
d) Did the baby/child stop crying or stop opening its mouth in the (three) daysbefore death?
e) Did the baby/child have convulsions or seizures or a stiff body in the threedays before death?
f) Did the baby/child have diarrhea in the (three) days before death?
Pge 21
a b I c I d I e IfIDid baby/ I Did baby/ I Did baby/ IDid baby/child I Did baby/Ichild sucklel child stop I child stop Ihave convulsions/ I child haveInormally I suckLing 2 I crying/ Iseizures/stiff I diarrRIeaIafter birth I days before I opening Ibody _ days I in ___days
month of ISeason I I death I mouth _dayslbefore death I before
death lof deathl I I before deathl I deathI _ _- - - i I I I __I
2-February IDS -2 IN = 0 IN = 0 IN = 0 IN = 0 IN = 0
3-March4-April5-May6-June7-July8-August9-Septemberl10-October I11-Novemberl I12-Decemberl I
I I II_ _ _ _ _ _ _ _ _
Page 22
H. FERTILITY PREFERENCES
1. CURRENTLY MARRIED NOT CURRENTLYOR HAS A PARTNER [ ] MARRIED OR DOES
NOT HAVE A PARTNER E ]
2. RESPONDENT NEITHEROR PARTNER [ ] STERILIZED E ]STERILIZED (SKIP TO 607)
3. I now have some questions about the future.
IF CURRENTLY PREGNANT: After the child that you are expecting, would you liketo have another child in about a year, or wait a few years and then have achild, or not have any more children?
IF NOT CURRENTLY PREGNANT: Would you like to have (a, another) child in about ayear, or wait a few years and then have a child, or not have (any, any more)chiLdren?
IN ABOUT A YEAR..........1WAIT A FEW YEARS..........2
NO MORE..........3
4. How many years would you like to wait before you have (a, another) child?PROBE: How old would your youngest child be? (CONVERT TO YEARS TO WAIT)
(YEARS TO WAIT)
5. Suppose you did get pregnant sooner, would you be very unhappy or not caregreatly?
VERY UNHAPPY...........1NOT CARE GREATLY.......2
6. What is the best interval to have between thebirth of one baby and the birth of the next?
YEARSOTHER (SPECIFY)...........
7. What should a woman do to avoid becomingpregnant sooner than (BEST INTERVAL)?
Pg 23
8. For how Long should a couple wait before startingsexual intercourse after the birth of a baby?
YEARSor
MONTHS
9. (IF NO HUSBAND/PARTNER, SKIP TO 511)Apart from this period following a birth, have you(and your husband/partner) ever gone without sexfor several months because you did not want tobecome pregnant?
YES...........1NO............2
10. If you could choose exactly the number of children to have in your whole life,how many would that be?
NUMBER
R BETWEENAN andGE
OTHER (SPECIFY) -------------------------
11. If you have that number of children and all of them were girls, would you haveadditional children in hope of having a boy?
YES............. 1NO ............. 2
12. If you had that number of children and all of them were boys, would you haveadditional children in hope of having a girl?
YES.............1NO ............. 2
13a. For last birth: Have your periods returned since the birth of this child?Yes No
b. For earlier births after 198 : How many months after the birth of this childdid your periods return?
Earlier births (months)(months)(months)
Page 24
14a. For Last birth: Have you resumed sexual relations since the birth of thischild?
Yes No
b. For earlier births: After 198 : How many months after the birth of thischild did you resume sexual relations?
Earlier births (months)(months)(months)
15. When during her monthly cycle do you think a woman has the greatest chance ofbecoming pregnant during her period?
during her period 1right after her period has ended 2in the middle of the cycle 3just before her period begins 4at any time 5other 6
Presence of others at this point
children under 10 Yes Nohusband Yes Noother males Yes No-other females Yes No
3 tHave you ever used anything or tried IYES....................1 Iin any way to delay or avoid getting INO.....................2-1-338Ipregnant? I II I _ _ _ _ _ _ I
I 1 1__ _ _ _
4 IWhat have you used or done? I (SPECIFY)
5 IEVER USED _EVER USED PERIODICIPERIODIC L[ 1ABSTINENCEIABSTINENCE I4 I
(skip to
6 IThe last time you used periodic IBASED ON CALENDAR........1labstinence, how did you determine on IBASED ON BODY IIwhich days you had to abstain? ITEMPERATURE..............211 lBASED ON CERVICAL MUCUS I
I(BILLINGS METHOD)........31IBASED ON BODY TEMPERATURE IlAND MUCUS................41OTHER ..... 51_I (SPECIFY)
7 IHow many living children, if any, did INUMBER IIyou have when you first did something or IOF CHILDREN........lused a method to avoid getting pregnant?IIF NONE: ENTER 00
8 ICEECK 225 AND 304:ISHE/HE STERILIZED NOT STERILIZED
PREGNANT I NOT PREGNANTOR NOT SURE
(SKIP TO ) (SKIP TO )
9 JIn what month and year did you (he) IMONTH .............Ihave the operation? YEAR .......... [ | -- 320
PEAg 26
10. Are you currently using any method of contraception?
YES...........1
NO............2 (SKIP TO 409)
11. Which method are you using?
PILL....................1IUD.....................2INJECTIONS..............3OTHER FEMALE SCIENTIFIC.4CONDOM..................5WITHDRAWAL.............6 -RHYTHM..................7 (skip to 410)OTHER 81
(SPECIFY) 8
12. For how Long have you been using this method(current method) continuously?
years _ months
since last birth
13. Where did you (or your partner) obtain this method(the last time you got supplies)?
(coded list from 303)
(Repeat 334 to 342 as 441 to 449)and insert 442(a)
14. How often do you go to that place/person?
every weeksevery days
P!iu 27
15 Have you experienced any problems IYES.......................1 1Ifrom using (CURRENT METHOD)? INO........................ .2 1326
16 lWhat is the main problem you IMETHOD FAILED.............1Iexperienced? IHEALTH CONCERNS...........2 1 IAVAILABILITY/ACCESS.......3 1
17 IDo you regularly use any other method IYES.......................1 1Ithan (CURRENT METHOD) during the same INO........................2 1328Imonth?
18 Which method is that? IPILL.....................01 1IIUD......................02 1IINJECTIONS...............03 1IVAGINAL METHODS..........04 1
19 IHave you ever used any other method IYES........................ I1or done anything else (since your INO.........................2 1342Ilast birth) before (CURRENT METHOD) IIto avoid getting pregnant? I
II20 Which method did you use before IPILL.......................01 I
21 IFor how long had you been using that IMONTHS............ IImethod before you stopped using it IYEARS....................II (last time)? I
_ _ I _ _ _ _ _ _ __ _ I __ _ _ _ _ _ I _I I
22 IWhat was the main reason you stopped IMETHOD FAILED..............02 Ilusing (METHOD BEFORE CURRENT) then? lINFREQUENr SEX.............03 I
IPARTNER DISAPPROVED........04 IIHEALTH CONCERNS............05 IIMETHOD NOT AVAILABLE.......06 -*342ICOST.......................071IFATALISTIC.................08 1IINCONVENIENT...............09 1IOTHER 10 1I I (SPECIFY)DK.........................981
23 ICheck 212: ANY BIRTHS?YES NO
I ~l El I(SKIP TO 334)
24 ISince your last birth have you done IYES.........................1 1Ianything or used any method to avoid INO..........................2 1 338Igetting pregnant? I 2I I
25 IWhich was the last method you used? IPILL.......................01 1IIUD........................02 1IIN.ECTIONS................ 03 1IVAGINAL METHODS............04 1ICONDOM.....................05 1IPERIODIC ABSTINENCE........08 11 WITHDRAWAL.................09 1IPER.ABST.& WITHDRAWAL .... 10 IIPER ABST.9 CONDOM.........11 IICONDOM & WITHDRAWAL........12 IIOTHER 131
(SPECIFY)
26 IFor how long had you been using (LAST IMONTHS.............._J_[IMETHOD) before you stopped using it IYEARS........... .... [ |(last time?) II I _ _ _ _ _ _ _
P!ig 29
27 IWhat was the main reason you stopped ITO BECOME PREGNAN.........01 Itusing (LAST METHOD) then? IMETHOD FAILED..............021
IiNFREQUENT SEX.............03IPARTNER DISAPPROVED........04 IIHEALTH CONCERNS............05 IIM ETHOD NOT AVAILABLE.......06 IICosT.......................07 1IFATALISTIC.................08 IIINCONVENIENT..............,09 1IOTHER 10 1I I (SPECIFY)IDK.........................98 1
ICHECK 225, 314,316I PREGNANT NOT PREGNANT
OR NOT SURE
(SKIP TO 528) EP NOT USINGUSING [TI(SKIP TO 528) I
28 IWould you mind if you became pregnant IYES........................1 Iin the next few weeks? INO.........................2 1528
29 tWhat is the main reason that you are IINFREQUENT SEX............01not using a method to avoid IPOSTPARTUM/BREASTIpregnancy? IFEEDING................02 I1 IMENOPAUSE/SUBFECUND ....... 03 I1 ILACK OF KNOWLEDGE/ II ISOURCE....................04 11 IDIFFICULT ACCESS TO
IM ETHODS...................05 IIRELIGION..................06 I
I IPARTNER'S OPPOSITION ..... .07 I1 IFEAR OF SIDE EFFECTS ...... 08 I
IFATALISTIC................ 09 IOPPOSED TO FAMILY I
I PLANNING..................10 IIWANTED TO BECOMEIPREGNANT..................11 IOTHER 12 11 (SPECIFY) IIDK........................98 1
Paiu 30
ES ENO30 IPRESENCE OF OTHERS AT THIS POINT ICHILDREN UNDER 10....1 2
31. Do you intend to use a method to avoid or delay pregnancy within the next year,after waiting one or more years, or do you never intend to use any method?
WITHIN NEXT YEAR...........1AFTER ONE OR MORE YEARS...........2
MALE STERILIZATION.............7WITHDRAWAL.............8
RHYTHM.............9 (skip to 501)OTHER ............ 1
(SPECIFY)
33. Where or to whom will you go to get advice or supplies?PROBE FOR TYPE
I 1 134. (Some women do not want to become ILACI OF KNOWLEDGE..........1
Ipregnant but do not use any method 1PARTNER OPPOSED............1 Ito avoid pregnancy. What do you (COST TOO MUCH..............1 IIthink are the main reasons for this? IHEALTH CONCERNS............1 1 1HARD TO GET METHODS........1 I(CIRCLE ALL MENTIONED) IRELIGION...................1 1(PROBE: Any others? (OPPOSED TO FAM. PLANNING...1 I
la tHave you heard IDo you know of a I IDistanceMETHOD lof this method Iplace or person I Ifrom
I lwhere you could I IrespondentI lobtain this method[Who or Where lin kms
_ _ _ _ I I _ _ 1 I__ _ I _ _ _ 1 __
lYes - spontaneous 1 lYes 1 |1- Hospital IlYes- probed 2 INo 2 12- Health centre INo 3 1 13- MCH clinic I
1 1 14- Mission clinic I I1 1 15- GFPA I
16- Other healthI inst itut ions17- drug store18- TBA I
Pill (women canitake a pill Ievery day)
IUD (Women canhave a loop or coilplaced by adoctor ornurse)
injections(women can havelan injectionby a doctor ornurse whichstops her frombecomingpregnant for
several months
Other femalescientific
(women canplace a spongeor depositoryor diaphram orjelly or creaminside thembeforeintercourse)
Paxe 32
la (cont'd)
Waiting Time ICost of lopinion of IFemale SterilizationIconsultationiservice (tol(Women can have anland lbe coded) loperation which stopsIcommodities I Ithem having
The World Bank 18ISHStreetNW (202)477-1234NTERNATIONAL BANK FOR RECOf3TRUCTON 1,1- DEVELOPMENT Washington. D C 20433 Cable Address INTBAFRADINJTERNATIONAL DEVELOPMENT ASS3ClATINU S A Cable Address INDEVAS
September 11, 1986
Dr. David A. RossLondon School of Hygiene and Tropical MedicineKeppel Street (Gower Street)London WCIE 7HT11.K.
Dear Dr. Ross,
Since my letter of August 29, there has been considerable discussionabout your research proposal for it has aroused considerable interest as anidea. However, as I suggested may be the case, the Bank is not in aposition to provide direct financial assistance for your proposed researchwork. Currently, the Bank is in the final stages of preparing a healthproject in The Gambia, and there is the modest amount of $60,000 allocatedfor research. During the preparation of the project there was considerableconcern among Bank staff about the amount of uncoordinated research beingconducted by a number of agencies in The Gambia, particularly in thenutrition field. The Gambian authorities and the Bank agreed that it isnecessary to establish policy guidelines for research and that researchpriorities must be set to reflect Gambian interests. hethat 4 ub-enomitee for farily health and nutrition will be established bJanuary 1, 1987, with decision making and budgetary authority and with aspectrum of responsibilities, including the preparation of a nutritionaction plan. Research proposals will be considered by the sub-committeeunder the plan, and your proposal, if favorably reviewed, would then becomeeligible to receive assistance through the Bank project (although, as Iindicated earlier, the allocated funds for this purpose are quite limited).
I hope this information is of help to you.
Yours sincerely
Michael J. PolkerPopulation, Health and Nutrition Department
Division One
cc: N. BirdsaLL, PHNPRA. Berg, PHNDRJ. Bumgarner, L. Domingo, PHND2
MPorter:jr
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The World Bank / 1818 H Street, N.W., Washington, D.C. 20433, U.S.A. a Telephone: (202) 477-1234 * Cables: INTBAFRAD
July 14, 1986
Mr. Abdou N'JiePermanent SecretaryMinistry of Economic Planning id lndust rial DevelopmentGovernment of The GambiaBan.ju IThe Gambia
Dear Mr. N'Jie,
Thank you so much for permitt ing the release of your staff member,Ms. Eliza Jones, to join me at the Bank in developing the surveyquestionnaires for the research project on the determinants and consequencesof health care and family planni.ng utilizations. Her presence here was mostvaluable; without her help we could not have made the considerable progresswe did.
Several steps must st i II be taken before we can finalize the proposaIand ask for the formal approval of the Government. Staff of the RovalTropical Inst ituoe in the NH t herlands -ire interpted in co il :bora 1 rig in tiieresearch, and would seek fi.naneig from the Dutch Government 0 part i cpat e.The nature and ex tent If the ir part i c ipat ion must bh- worked out. We w itlneed some agreement with the Medical Research Counc I to assure access tothe demographic and morbihdi tv data they have col lected trni certainhouseho I ds. We w i tI neied to make f i1aI arrarngemen s on the i w s 5f
work i nig w it h iii t erv iew t; ff oFt the Ctent r-il ' t at K Il ,I iII SHrilm t .
Due Lo the oress of other respons ibi t I. I do ni, Tex J I nri
'he proposaf unt ii 1 1-487 and n yv need t [ %'tve , ' If h I ir:l r;i rd ThI
Ga mbia in order t o ito so. ll(w-V-[r, JIn th i n I r m woui. :s ofrm'col j (f w1 L Iave rnv i iIIII! in rV r''01 I i ()!S >m .n f.I' I s it
,he drait proposal which is nCilosel. in the colitrso the rs I-arproject, we wi H w;-Inlt to) w'ork closelv wiith Gai nS 'erhapa . v"-w ioip
ofI government officials, ( oordinated biv MEPI, CoUd ji d ormed oprovide amechanism for our doing so. Work'ng with ich t irorip wid i Iltw iom ihcstrengthenirng of exi s t inPiflh ian apafi hi jies through i vo iYvmen at eve--lit age ii t he resear-I II 0-00 . S.hnit i d vall loin opuch iI 0Do wolId
weIlcome their reat 1InsI5 tth dra ft inposl im in l si-'r'"
mon t ihs.
nt it I r- -VHn I. e, Io-. h a rf o'- L I l, ( )w pi s-
d S CuL'Ss 0i11S Wit I r :r n Gwenwo "(d, Ind e ur n s n Ig I III
Page 2
We anticipate we will need to have a full-time survey director inGambia over a period of about eight months to manage the process of datacollection: pilot testing, training of field staff, overall supervision ofdata processing. Such a person should have experience in West Africa indata collection, training in economics and demography, and demonstratedcompetence in social science methods. I would welcome the curriculum vitaeof any suitable Gambians. I enclose the curriculum vitae of one eligiblecandidate whom Ms. Jones has met, Mr. Martey S. Dodoo (who may or may not beavailable).
Finally, let me note that our goal is to have this research contributein the long run to the process of reform and strengthening of the nationalhealth systems being undertaken in the context of the Bank-sponsored projectnow being prepared. For that reason, and to keep him informed, I am copyingthis letter to Mr. Sol Ceesay.
My best regards.
Sincerely,
Nancy Bir allDirector
Policy & Research DivisionPopulation, Health, & Nutrition Department
Attachments
cc: Mr. Sol CeesayPermanent SecretaryMinistry of Labor & Social WelfareGovernment of The GambiaBanjulThe Gambia
bcc and cleared with: Mr. R. Bumgarner (PHND2)
bcc: Mss. I. Husain (PHND2), B. Bruns (WA2DB)Mr. D. Mahar (PHND2)Ms. Julie daVanzoMr. Martey S. Dodoo
NBirdsall:am
82v ,, WORLD BANK OUTGOING MESSAGE FORM Cable, TelexIMPORTANT- PLEASE READ INSTRUCTIONS BELOW BEFORE TYPING FORM
TypewrittenCharacterMust FallCompletely in TEST NUMBER
PAGE OFFiCIAL DEPT DIV MESSAGE NUMBER (FOR CASHIERS USE ONLY)
OF E i [-11 1 1 1
START
2 HEE MS. ELIZA JONES, MINISTRY OF PLANNING AND INDUSTRIAL
DEVELOPMENT, BANJUL, THE GAMBIA.
4
IN HOPES YOUR GOVERNMENT IS ALLOWING YOU TO TRAVEL, WE HAVE
5REQUESTED OUR TRAVEL OFFICE TO ISSUE TICKETS TO YOU THROUGH
BRITISH CALEDONIA AIRWAYS FOR EITHER MAY O 'E OR JUNE 2
FLIGHT OUT OF BANJUL. THE BRITISH CALEDONIA OFFICE IN BANJUL WILL
CONTACT YOU AS SOON AS THEY RECEIVE AUTHORIZATION FROM WORLD BANK.
REGRET WE CAN1OT SEND YOU TRAVEL ADVANCE THROUGH SAME OFFICE; YOU
CAN PICK IT UP HERE. PLEASE INFORM IF ANY DIFFICULTIES WITH THIS
PROCEDURE. REGARDS, NANCY BIRDSALL, WORLD BANK
ENr2
OFTEXT
E 0~O T B E ~A 1
TeLex 2204PREFOFGV May 21, 19861
Gambia Research Project N. BirdsaLL 6-1581
-hxALkin 4 -Acting Divisinn thiif
-~ -- PfM~ _ __
OFFICE MEMORANDUMF October 18, 1985
Ms. Phi Anh Plesch, VPERS
Nancy Birdsa i, ChiefJ PHNPR
61581
Gambia Research Proposal
I spoke today with my collaborator on the above proposal, Julie
DaVanzo, and would like to clarify several items on which I was not as
clear as I might have been in our discussion yesterday with REPAC members,
Johannes Linn and Steve O'Brien.
o Our comparison of restrospective data (from respondents) and
prospective data (of the Medical Research Council) would deal primarily
with fertility and mortality, and only secondarily with morbidity. It will
be of great benefit to know how good survey responses on pregnancy
histories and family mortality are.
o With 1000 compounds, we are likely to have as many as 2000
children born within the last three years. With infant mortality at 100
per thousand (a conservative estimate), we could expect as many as 200
reported deaths. This would permit analysis of determinants of infant
mortality (though not of adult mortality--where the frequency of deaths in
this size sample would be too small).
o On the difficult issue of measurement of morbidity, we are
benefitting already by Julie DaVanzo's participation on the Scientific
Advisory Committee for the AID-sponsored Demographic and Health Surveys
Project (DHS). The DHS will sponsor surveys in up to 25 developing
countries over the next several years. The questionnaire for that survey
will include a component on morbidity, and Julie has been working on it
with epidemiologist Robert Black (Johns Hopkins). We will also be able to
seek advice from Jean-Pierre Habicht of Cornell University, who is at Rand
on sabbatical working with her. He managed morbidity survey work in
Guatemala for several years and is a preeminent physician/nutritionist.
cc: Messrs. J. Linn (AEADR), S. O'Brien (WANVP)
Ms. J. DaVanzo,Rand Corporation
NBirdsall:lcj
(Signed in Nancy Birdsall's absence)
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INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D.C 20433 Cable Address INTBAFRAD
INTERNATIONAL DEVELOPMENT ASSOCIATION U S A Cable Address INDEVAS
March 26, 1986
Mr. Sol CeesayPermanent SecretaryMinistry of Health, Labour
arift Social WelfareGovernment of The GambiaBanjul, The Gambia
Dear Sol:
Enclosed is a copy of a research proposal I have been working on overthe last year, and a letter to Mr. N'Jie of MEPID asking if Eliza Jonesmight work with me on the project. I hope the letter is self-explanatory.I would be very pleased to see this project go forward and hope for yoursupport. At the least it would assure me that I would continue to work inThe Gambia, something I would like very much.
I understand from Dick Bumgarner that progress on the proposed healthproject is good. I hope he has told you I had a baby boy February 12, threeweeks early, and that that is why you have heard so little from me. SamuelJames is beautiful and healthy. I think my trips to The Gambia duringpregnancy were good for him!
My very best regards.
Sincerely,
Nancy Birdsall -Chief
Policy and Research DivisionPopulation, Health & Nutrition Department
Enclosures
ITT 440098 RCA 248423 WU 64145 Y-7040
The World Bank 1818 H Street. N W (202) 477-1234
INTERNATIONAL BANK FOR RECONSTRUCTION ANO DEVELOPMENT Washngton. 0 C 20433 Cable Address INTBAFRADINTERNATIONAL DEVELOPMENT ASSOCIATION U.S.A Cable Address INDEVAS
March 26, 1986
Mr. Abdou N'JiePermanent SecretaryMinistry of Economic Planning and
Industrial DevelopmentGovernment of The GambiaBanjulThe Gambia
Dear Mr. N'Jie,
You may recall that in January, during the appraisal mission for theproposed health project, I spoke briefly to you about the possibility ofEliza Jones participating in the research project we would like to carry outin The Gambia. The research project has two principal objectives:
(1) analysis of the effects of public and private health and familyplanning services on health and fertility outcomes; and
(2) analysis of the price elasticity of demand for these services.
The results of these analyses will allow (1) evaluation of theeffectiveness of the government's village-based primary health care systemand recommendations for improved design and targetting of the health andfamily planning system; and (2) recommendations on the extent to which thereis scope for increasing fees to help finance the system without reducingutilization by the poor.
A copy of the research proposal is enclosed, and provides more detailon its objectives, its link to government policy needs, and the methods tobe employed.
Given Eliza's social science background, her interest in human resourceissues, her experience with survey work and statistical analysis, and herknowledge of The Gambia, her participation would be a great help. We wouldobviously benefit from having someone who is Gambian participate and I hopeshe and the Government would benefit from the experience. Participationwould mean working on questionnaire preparation, sample design and fieldwork for a household and community survey, and in subsequent analysis, allto the greatest extent her normal responsibilities would allow.
I write now to ask whether it would be possible for Eliza to come toWashington for two weeks, May 27 to June 6, to work with me in completing adraft questionnaire and preparing a note describing the sample design andfield work arrangements. These need to be completed before we can formallyapply for research funds within the World Bank. We are of course notassured of funding and so cannot at this stage make any further commitment.
ITT 440098 RCA 248423 WfA 64145 Y.7040
Page 2
We will also need to secure the agreement of the Medical Research Council,since we hope to use some of their data and to include in the sample wepropose some of the households they have studied. However, if the projectis funded I would hope the field work could begin sometime in 1987. (Werethis to conflict with any study leave Eliza might be taking, we would haveto adjust our schedule.) Although it is difficult to say exactly, we mightbe talking about Eliza spending a total of 8 weeks over the first 12-monthperiod of the project, and a subsequent 3-4 weeks in the second year to workon analysis. Recognizing her other responsibilities, we would of coursereduce this amount if necessary.
If Eliza were able to come in May-June, we would pay her travel andother expenses.
I should assure you that the MHLSW is aware of this research proposal.Copies were sent before the January appraisal mission to Mr. Jobarteh and toDr Oldfield. I did not discuss the proposal with Mr. Ceesay, since I didnoc. wish to take any of his time from the principal work of appraisal, butby copy of this letter I am informing him of our effort. We will of coursenot proceed without continuing support from both Government health andplanning officials.
My best regards,
Nancy BirdsallChief
Policy and Research DivisionPopulation, Health & Nutrition Department
Attachment
cc: Mr. Sol CeesayPermanent SecretaryMinistry of Health,
Labor and Social WelfareGovernment of The GambiaBanjul, The Gambia
bcc: Ms. Julie DaVanzoMs. Eliza Jones
Pagre 2
We will also need to secure the agreement of the Medical Research Council,since we hope to use some of their data and to include in the sample wepropose some of the households they have studied. However, if the projectis funded I would hope the field work could begin sometime in 1987. (Werethis to conflict with any study leave Eliza might be taking, we would haveto adjust our schedule.) Although it is difficult to say exactly, we mightbe talking about Eliza spending a total of 8 weeks over the first 12-monthperiod of the project, and a subsequent 3-4 weeks in the second year to workon analysis. Recognizing her other responsibilities, we would of coursereduce this amount if necessary.
If Eliza were able to come in May-June, we would pay her travel andother expenses.
I should assure you that the MHLSW is aware of this research proposal.Copies were sent before the January appraisal mission to Mr. Jobarteh and toDr. Oldfield. I did not discuss the proposal with Mr. Ceesay, since I didnot wish to take any of his time from the principal work of appraisal, butby copy of this letter I am informing him of our effort. We will of coursenot proceed without continuing support from both Government health andplanning officials.
My best regards,
Nancy BirdsallChief
Policy and Research DivisionPopulation, Health & Nutrition Department
Attachment
cc: Mr. Sol CeesayPermanent SecretaryMinistry of Health,
Labor and Social WelfareGovernment of The GambiaBanjul, The Gambia
bcc: Ms. Julie DaVanzoMs. Eliza Jones
Page 2
We will also need to secure the agreement of the Medical Research Council,since we hope to use some of their data and to include in the sample wepropose some of the households they have studied. However, if the projectis funded I would hope the field work could begin sometime in 1987. (Werethis to conflict with any study leave Eliza might be taking, we would haveto adjust our schedule.) Although it is difficult to say exactly, we mightbe talking about Eliza spending a total of 8 weeks over the first 12-monthperiod of the project, and a subsequent 3-4 weeks in the second year to workon analysis. Recognizing her other responsibilities, we would of coursereduce this amount if necessary.
If Eliza were able to come in May-June, we would pay her travel andother expenses.
I should assure you that the MHLSW is aware of this research proposal.Copies were sent before the January appraisal mission to Mr. Jobarteh and toDr. Oldfield. I did not discuss the proposal with Mr. Ceesay, since I didnot wish to take any of his time from the principal work of appraisal, butby copy of this letter I am informing him of our effort. We will of coursenot proceed without continuing support from both Government health andplanning officials.
My best regards,
Nancy BirdsallChief
Policy and Research DivisionPopulation, Health & Nutrition Department
Attachment
cc: Mr. Sol CeesayPermanent SecretaryMinistry of Health,
Labor and Social WelfareGovernment of The GambiaBanjul, The Gambia
bee: Ms. Julie DaVanzoMs. Eliza Jones
March 28, 1986
Dr. Nancy BirdsallPHNPRWorld Bank1818 - H Street, N.W.
Washington, D.C.
Dear Nancy:
Congratulations on the birth of Samuel. I hope you're all enjoying
him.
What's new regarding the Gambian research? Is Eliza coming to
Washington to discuss the survey? If so, could we make it at least a
week later than we discussed. I have a big proposal due June 1st andcouldn't possibly come before then.
I look forward to hearing from you.
With best wishes,
Julie DaVanzo
JDV:d a
/
/*
I
*7
9A
The World Bank 1818 H Street, N.W. (202) 477 1234
INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D.C. 20433 Cable Address INTBAFRAD
INTERNATIONAL DEVELOPMENT ASSOCIATION U S A Cable Address. INDEVAS
March 26, 1986
Mr. Sol CeesayPermanent SecretaryMinistry of Health, Labour
anti Social WelfareGovernment of The GambiaBanjul, The Gambia
Dear Sol:
Enclosed is a copy of a research proposal I have been working on over
the last year, and a letter to Mr. N'Jie of MEPID asking if Eliza Jones
might work with me on the project. I hope the letter is self-explanatory.I would be very pleased to see this project go forward and hope for your
support. At the least it would assure me that I would continue to work in
The Gambia, something I would like very much.
I understand from Dick Bumgarner that progress on the proposed health
project is good. I hope he has told you I had a baby boy February 12, three
weeks early, and that that is why you have heard so little from me. Samuel
James is beautiful and healthy. I think my trips to The Gambia duringpregnancy were good for him!
My very best regards.
Sincerely,
Nancy BirdsallChief
Policy and Research DivisionPopulation, Health & Nutrition Department
Enclosures
ITT 440098 RCA 248423 WUI 64145 Y -7040
The World Bank 1818 H Street. N W (202) 477-1234
INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D,C 20433 Cable Address INTBAFRAD
INTERNATIONAL DEVELOPMENT ASSOCIATION U.S.A Cable Address. INDEVAS
March 26, 1986
Mr. Abdou N'JiePermanent SecretaryMinistry of Economic Planning and
Industrial DevelopmentGovernment of The GambiaBanjulThe Gambia
Dear Mr. N'Jie,
You may recall that in January, during the appraisal mission for theproposed health project, I spoke briefly to you about the possibility ofEliza Jones participating in the research project we would like to carry outin The Gambia. The research project has two principal objectives:
(1) analysis of the effects of public and private health and familyplanning services on health and fertility outcomes; and
(2) analysis of the price elasticity of demand for these services.
The results of these analyses will allow (1) evaluation of theeffectiveness of the government's village-based primary health care systemand recommendations for improved design and targetting of the health andfamily planning system; and (2) recommendations on the extent to which thereis scope for increasing fees to help finance the system without reducingutilization by the poor.
A copy of the research proposal is enclosed, and provides more detailon its objectives, its link to government policy needs, and the methods tobe employed.
Given Eliza's social science background, her interest in human resourceissues, her experience with survey work and statistical analysis, and herknowledge of The Gambia, her participation would be a great help. We wouldobviously benefit from having someone who is Gambian participate and I hopeshe and the Government would benefit from the experience. Participationwould mean working on questionnaire preparation, sample design and fieldwork for a household and community survey, and in subsequent analysis, allto the greatest extent her normal responsibilities would allow.
I write now to ask whether it would be possible for Eliza to come toWashington for two weeks, May 27 to June 6, to work with me in completing adraft questionnaire and preparing a note describing the sample design andfield work arrangements. These need to be completed before we can formallyapply for research funds within the World Bank. We are of course notassured of funding and so cannot at this stage make any further commitment.
ITT 440098 RCA 248423 WUI 64145 Y-7040
Page 2
We will also need to secure the agreement of the Medical Research Council,since we hope to use some of their data and to include in the sample wepropose some of the households they have studied. However, if the projectis funded I would hope the field work could begin sometime in 1987. (Werethis to conflict with any study leave Eliza might be taking, we would haveto adjust our schedule.) Although it is difficult to say exactly, we mightbe talking about Eliza spending a total of 8 weeks over the first 12-monthperiod of the project, and a subsequent 3-4 weeks in the second year to workon analysis. Recognizing her other responsibilities, we would of coursereduce this amount if necessary.
If Eliza were able to come in May-June, we would pay her travel andother expenses.
I should assure you that the MHLSW is aware of this research proposal.Copies were sent before the January appraisal mission to Mr. Jobarteh and toDr. Oldfield. I did not discuss the proposal with Mr. Ceesay, since I didnot wish to take any of his time from the principal work of appraisal, butby copy of this letter I am informing him of our effort. We will of coursenot proceed without continuing support from both Government health andplanning officials.
My best regards,
Nancy Birdsall -Chief
Policy and Research DivisionPopulation, Health & Nutrition Department
Attachment
cc: Mr. Sol CeesayPermanent SecretaryMinistry of Health,
Labor and Social WelfareGovernment of The GambiaBanjul, The Gambia
bcc: Ms. Julie DaVanzoMs. Eliza Jones
*9II
* 0
* 51
* S
* 5
*
'THE WO~LDANK IN' T 1N," 1(I)NAL P INANCE CdRPORA TI.
OFFICE MEMORANDUMNovember 1, 1985
Mr. John North, Director, PHN
Deepak Lal, Chairman, REPAC
33481
Research Proposal: "Health Care and Family Planning in the Gambia:
Determinants and Consequences of Service Utilization"
The above proposal was considered by REPAC at its meeting on
October 24. It had been reviewed by a REPAC subcommittee, two Bank
staff and two external referees whose reports are attached.
As the subcommittee noted in its report, all the reviewers
supported the objectives of the proposal, but expressed concerns about
certain aspects of it, in particular, about: the sample design and
survey approach; the quality and coverage of data; the survey
questionnaire which has not been developed yet; the incomplete
specification of the proposed analytical model and related problems; the
usefulness of the methodological explorations, the impact of the project
on government's analytical capacity; the size of the budget; and about
the propriety of the research being contracted out to Rand.
REPAC members shared the reviewers' concerns about the
methodological issues but like the subcommittee did not emphasize their,
importance, as they are expected to be dealt with satisfactorily in the
project. The high level of experience and competence of the researchers
involved was noted, so technically the project could be sound. Also
REPAC felt that the topics addressed by the research could be important
to Africa. It however expressed doubts about i) whether this study
investigating a single elasticity at a cost of $300,000 in a country
with a population of only 71)0,000 was justified; and ii) whether The
marginal returns of this expenditure were high given that there have
been already ongoing attempts to estimate similar elasticiti s in Ivory
Coast (and outside of Africi in Peru), and a pending proposal analyzing
the same issues for Sierri Vone. REPAC felt it could not answer these
questions short of a state-ent from PHN that would attempt to put this
research proposal - and othtrs in the pipeline - in perspective which
takes account of past and 'I g work.
In addition to K.n )ve issues REPAC expressed two strong
reservations about the hott- )f the proposal:
1) REPAC had gr nt-i in earLier request from PHN for $15,650
to fund the preparation of t<Is research proposal on the explicit
condition that the sponsors d seek financial support from non-RSB
P 1866
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sources for the main research project. REPAC had put that condition in
order to conform with the new RPC research priorities which deemphasize
the use of research funds for large data gathering. It had thought that
this research with its large data requirements would be worthwhile only
if it piggy-backed into the evaluation component of the IDA-project.
Ms. Birdsall in accepting the above condition had indicated that she
anticipated that much of the costs of the survey work would be funded
through the IDA project. However REPAC was disappointed that in thecurrent proposal it was asked to support the full cost of the research,
including the cost of the design and execution of the survey. REPAC was
not satisfied with Ms. Birdsall's explanation for her failure to seek
co-financing from the IDA project; her main reasons being personalconflict of interest, and the general interest of the research extending
beyond Gambia's immediate interest. REPAC noted the tentativearrangements by Ms. Birdsall for some minor financial support from other
sources such as the Norwegian Ministry of Developing Cooperation($10,000) and Ford Foundation (sum unknown). But it felt strongly that
the issues of co-financing remained largely unresolved.
2) Secondly, there was the question raised about the
appropriateness of contracting most of the work to a private developed
country institution.
In conclusion, notwithstanding minor methodological concerns
and its doubts about the marginal returns of the proposed expenditures,
REPAC felt that the project is technically sound. However because of
its strong reservations about the budget, REPAC decided to recommend
rejection of the proposal with its present financial arrangements.
Mrs. Krueger has noted the above recommendation which according
to REPAC's rules was sent to her for information.
cc: Messrs./Mmes. N. Birdsall. S. PatelREPAC Members
PAP/sv
OFFICE MEMORANDUMfATF October 21, 1985
To All REPAC Members
PHOM F. S. O'Br&tnd Johannes Linn'T-
EXTFNSION 72065
SUBJECT Research Proposal: Health Care and Family Planning in the Gambia
1. This project has been reviewed by a panel of Bank and externalreviewers which we have coordinated. All of the reviewers were supportiveof the general objectives of the project, but at the same time they allexpressed concerns about certain aspects of-the proposal. These reviewers'reports have already been circulated to you; we have summarized their mainpoints below:
(a) country choice - whether sufficient useful generalizations canbe drawn from the Gambia, a small, poor country;
(b) sample design and survey approach - problem of the nationalcensus as a basis for sample selection; whether sample will berepresentative; will sample contain sufficient ohnervations forboth community and compound variables;
(c) quality and coverage of data, conceptual and measurementproblems that may arise for certain variables; these concernsare linked to the fact that the survey questionnaire has notbeen developed yet, so that reviewers cannot judge howeffectively the relevant information will be obtained throughthe survey method;
(d) possible problems with the analyticAl model to be employed -incomplete specification, interdependence problems, possibledifficulties in defining lags;
(e) whether the methodological explorations (contingent valuationand measurement of recall) will prove useful;
(f) impact of the project on government's analytical capacity;
(g) minor questions about the budget\
2. We met with the principal supervisor of the project, Ms.Birdsall, on October 16 to go over all'of the above points. We werereasonably satisfied that most of the above concerns are either notsignificant or can be dealt with satisfactorily in the project. Furtherclarifications were provided in Ms. Birdsall's memo of October 18 which hasbeen circulated to you. However, we were still left with major concernsabout:
(a) timing - can all of the preparatory work of questionnairedesign, training of field staff, drawing up the sample frameand pilot testing the questionnaire be carried out between now
P-1 868
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and February 1986, when the first full field survey isscheduled to start;
(b) whether there will be adequate time to examine the usefulnessof the data obtained from the questionnaire before beginningthe analysis phase of the study.
On these questions we have had further discussions with Ms. Birdsall andhave suggested a compromise approach which would adequately address ourconcerns. This alternative approach would break the project into twophases: Phase I, which would include questionnaire preparation, trainingof field interviewers, design of the sample frame, and pilot testing of thequestionnaire would last approximately from November 1985 to May 1986.Phase II, to begin in approximately June 1986, would comprise the remainingstages of the study - a first round survey conducted in the rainy season,the second round survey conducted in the following dry season, and dataprocessing, analysis and report writing. Note that the dry season/wetseason ordering of field surveys would be reversed, and the overall studywould be put back some six months from the schedule in the proposal. Theestimated budget for Phase I is about $110,000 with the balance of about$200,000 allocated to Phase II. 1/ We recommend that the prolect besupported by REPAC on the basis of this two-phased approach.
3. We propose that there be a brief review of progress on theproject at the end of Phase I to determine whether proceeding with Phase IIis justified. A Steering Committee should be established for this purpose,and the original reviewers could be asked to review the output of the firstphase. REPAC could decide either to fund the entire project with releaseof the second tranche to be dependent on approval by the SteeringCommittee, or fund only the first tranche at this time with approval of thesecond tranche to be dependent on reapplication to REPAC. We recommend theformer course.
4. Other issues.
(a) Clearly, success of this project depends critically on the fullcollaboration of the British Medical Research Council (MRC).The MRC has been fully informed about the project and theirfull participation has been sought, but Ms. Birdsall is stillwaiting for their response. She informs us that she expects tohave their answer by the end of October. Since, in our view,the project cannot be carried out without full MRC cooperation,we recommend that the final notification of approval by REPACbe withheld until the Chairman has been informed that MRC isparticipating in the manner described in the proposal.
(b) Cofinancing - Ms. Birdsall was requested to seek cofinancingand she has clearly made an effort to do so. She expects to
L/ Ms. Birdsall is preparing a revised budget providing exact costestimates; these will be available before the REPAC meeting.
-3-
have support from MRC and UNICEF and has possibilities of
support from the Norwegian government and one or two othersources. The West Africa Region strongly supports the projectand will contribute staff time, but does not have funds tocontribute. We do not feel that part of the cost of thisresearch should be transferred to the government through theproposed IDA credit for health, nor do we feel that approval ofthe project should be delayed merely in order to prolong thesearch for cofinancing.
(c) Budget. We have only one question concerning the budget andthat relates to the Rand Corporation overhead--69% of salarycosts. This item represents 22% of the total cost of theproject. What is REPACs position on paying overheads todeveloped country research institutions?
MIMI:REPAC
#4
Reviewer Report: Health Care and Family Planning in The Gambia: Determinants
and Consequences of Service Utilization. World Bank Research Program.
Significance: This project is designed to investigate the determinants of
health and fertility focusing on the role of medical care (including family
planning programs). Its unique characteristics include a link to an ongoing
project sponsored by the British Medical Research Council (MRC), which is
doing a prospective study of fertility outcomes and health, and a tie in to
the program iniatives by The Gambia which include new medical services in
several villages and a large proposal to increase medical resources including
drugs to be financed by the IDA. The project directors claim that this study
will be useful in: 1). designing medical and family planning programs in
The Gambia.as well as other developing countries, 2)> in appraising
retrospective data on health, health care utilization, and fertility and
3). in appraising contingent valuation methodology as a measure of willingness
to pay in a developing country.
Comment: The authors claim that The Gambia has one of the very highest infant
and maternal mortality rates in the World. This may limit the usefulness of
generalizing from these results. A country at a further stage of development
with greater variance in infant mortality rates and some success at reducing
these rates may be a better base for this type of research. Second, the
ongoing MRC study may itself serve as A sufficient base to evaluate the new
iniatives described above. Third, infAnt mortality, morbidity, etc. are likely
to be affected by factors other than those listed in the proposal, These
include specialized education (training) for nutrition and/or for infant care,
having providers visit compounds for education, subsidy or direct supply of
village training centers, etc.. Why spend research resources in order to
investigate only medical resources when other, possibly less expensive
alternatives may be more effective?
Sample Design: The plan is to survey 4 areas of The Gambia including those
already being surveyed by the MRC. The justification for this is 1). to build
upon the already collected data, and 2). use the reenumeration that has been
done for this area to draw the sample. The MRC areas include 3 of the 4 areas
selected. For the additional communities, the research team will do a
reenumeration prior to drawing the sample.
Comment: If, as the researchers claim, the Gambian Census is somewhat out of
date, and this is the justification for the sample design, it is difficult to
see how the 4 area survey will be designed "to achieve representation of all
ethnic or income groups in the country" (p.17). This will not be a weighted
representative sample of the country if the Census cannot be used to establish
weights.
Data: Compound based data to be collected includes infant and child
mortality, morbidity, pregnancy outcomes as well as fertility history,
health care utilization, health habits, infant feeding practices and
willingness to pay formedically related goods and services, income, and
socioeconomic characteristics of the individuals in the compound. Village
data includes availability of medical services, schooling availability, water
condition, etc. No detail is presented on the exact measures to be employed.
Comment: The lack of specificity makes it difficult to evaluate the
appropriateness of the data to be collected. This reviewer is particularly
concerned with the health (morbidity) data. The team does not include any
experts on health status. Will antropometric measures be collected? days
bedridden? incidence of specified diseases? etc. Since one of the primary
goals of the proposal is to evaluate the influence of medical availability,
prices, etc. on health status, health status seems to be a vital measure and
must be spelled out in more detail. Related to my concerns above, more data on
education-specific training, etc. should be included. And, the role of
community acceptance of family planning, new medicines should be incorporated
in the data and the model. Attitudinal information seems clearly lacking as
well as level of knowledge. For example, does the individual know about
family planning method x? About the location of medical services? Is any
family member a health care provider? Did an infant death lead to a change in
behavior? (And thus is this a time of efficient intervention?). In other
words, in order to be useful, the data set should be broader than suggested by
the proposal.
Model: The model is a simple production function approach for health. The
authors seem familiar with on going work in the area. On the basis of my
knowledge of their other work, I am reasonably confident that the model used
will be appropriate for these questions, if the data are sufficient.
Unfortunately, the model is incompletely specified in the proposal so it is
difficult to offer very constructive Kmments,
Comment: An issue the researchers should address is the endogeneity of family
size and the effect of family size on health. Related to this is the question
of the appropriate income concept--- $4000 for 4 persons represents a
different income constraint than $4000 for 12 persons. Income is itself
endogenous if any of it is family produced since larger families mean both a
larger labor supply and more persons to provide for. Will any of this be
included in the analysis? Migration is not included any where in the model.
Is this because there is very little migration in The Gambia -- or migration
between or to rural villages? If this is not the case then some attention
should be paid to migration. Finally, there is an implicit assumption made in
the model that a broader range of pharmaceutical products is higher quality.
This is certainly debatable for some drugs and suggests the need for
subgrouping of pharmaceuticals and a modification of the hypothesis.
Methodological Explorations: The researchers plan to test the reliability of
retrospective questions on fertility, mortality and illness by a comparison to
prospective data collected by MRC. Second, they plan to test the usefulness
of contingent valuation as a measure of willingness to pay for public services,
Comment: The planned comparison of retrospective data is to monthly
prospective data. If, the goal of the comparison is to find low-cost means to
collect data on fertility, mortality and morbidity, why only compare these two
very different alternatives? What about biannual prospective data, data from
medical providers? But, the comparison itself may be faulty: an individual
who has been asked monthly about fertility may, knowing this information has
already been asked, be more concerned with providing consistent information
than had s/he never been asked. If this is so, a comparison of interviewer
retrospective and prospective information will not yield appropriate
statistics for judging the use of retrospective information alone.
On the question of contingent valuation, it is not clear how responses to
contingent valuation questions will be evaluated. An important aspect of
contingent evaluation is to present simple clear understandable description(s)
of the good(s) to be evaluated. It is difficult to see how this can
satisfactorily be achieved in describing services not previously provided to a
population with limited education.
Personnel: Julie DaVanzo is a senior researcher with considerable expertise
in demographic issues in developing countries. John Haaga is a nutrition
expert. It is not clear that he can adequately serve as health expert on this
proposal.
Budget:
1). Is there a problem with the planned use of PC's since in some areas
of The Gambia being surveyed there is limited availability of electricity?
2). The computer budget seems high, especially if PC's are used.
3). Is there a potential problem if field interviewers are paid at
different rates? ($5.00 to MRC interviewers, $3.00 to Central Bureau
Statistics interviewers.)
4). Is it cost effective to allocate $372,451 for a research project that
analyses a country with a small population that is unique in a number of ways,
particularly since an ongoing project (MRC) will enable some analyses of the
issues to be addressed by this proposal?
1676L
Comments on the research proposal on ''Health Care and Family Planning
in the Gambia: Determinants and Consequences of Service Utilization''
1. General Comments (specific comments follow)
This is a very ambitious and very fashionable piece of research, especially
given its emphasis on estimating price elasticities of demand for medical
and family planning services. There is no doubt this question is important
if one wants to recover from consumers some of the cost of publicly-provided
services, but there seem to be three reasons why the emphasis on price res-
ponses is overdone: (i) the social-cost arguments in favor of restrictingfertility are so strong that even a very small reduction in contraception
as a result of fees or prices would represent a net loss--the government of
The Gambia is, I believe, entirely correct to insist that contraceptive
services be provided free; (2) sheer availability of services may be much
more important than their money cost, in determining utilization. This is
recognized in the proposal, so far as time-costs are to be considered, but
it is proposed to do this by valuing time at local wage rates, and no one
knows whether consumers value their time this way; and (3) the emphasis on
willingness-to-pay is on paying fixed, predictable amounts for a village
health worker or for water supplies--the proposal does not mention response
to price for unpredictable medical needs, but these could be larger and have
considerable effect on utilization unless the highest prices ever faced are
still quite low. Since I do not know The Gambia, I don't know whether con-
sumers ever consult private practicioners, either modern or traditional; butif they do, some effort should certainly be made to learn their prices and
how those prices affect utilization.
Apart from the price emphasis, the proposal is curiously one-sided in its
emphasis on women's decisions (and their incomes) and on health care for
women (pregnancy-related) and children only. Don't older children or adult
men ever get sick in The Gambia, or ever suffer accidents ? There is no
doubt that maternal and child care is basic, and that it is a large part ofprimary health care, but that i's not all there is to the matter; and even
when it is a matter of caring for a sick woman or child, it is odd to treat
men's income as exogenous and their decisions as irrelevant, when illness
may affect a man's income because of time taken to get medical help for his
family, take over his wife's chores, etc. The analytical model seems exces-
sively narrow in this regard.
The proposed sample of about 1000 households is almost surely too small for
some of the purposes mentioned, Particularly for estimating infant and child
mortality and their determinants or for explaining fertility. It is obvious
that the research will build on the longitudinal data obtained by MRC--infact, it is that possibility which justifies the research project--but it is
not clear that the new sample datn will always add much to those data, in
medical terms, What the sample should allow is a good understanding of the
determinants of ordinary medical-care utilization, and that is probably reason
enough for the project. Other subjects may be intractable, or may be feasible
to study only with the MRC data.
I have not reviewed the budget carefully, but one general comment seems in
order there: it is hard to believe the Rand researchers can possibly accom-
plish all they propose in the small number of days allocated to the project.
If they will actually pat in more time and save the Bank money, well and good;
but the estimates do not look very realistic, even given the good experienceof prior MRC work and the success in quickly obtaining and starting to analyzedata from the LSMS project in the Ivory Coast.
I I. Specific*Comments (by page numbers in the proposal)
i the sample may be very small for eliciting meaningful responses tohypothetical questions about willingness to pay, unless the populationis fairly uniform in its responses,
ii merely undertaking the project in cooperation with the government doesnot guarantee "strengthening of analytical capacity'; it's a necessarybut not a sufficient condition. Teaching people in poor countries toanalyze their own data in any but the most pedestrian way is orders ofmagnitude harder than teaching them to collect it. Would this projectbe considered worth while if there were no increase in local analyticcapacity, which is a plausible outcome ?
4 the justification for including MRC and non-MRC households in the surveyis not clear. How are they expected to differ ? What sort of refusal ordrop-out rates are expected ? Will the MRC households studied be a rep-resentative sample of the original MRC group, or will there have beensignificant differential attrition among them ?
5 the formal analytical model makes a number of questionable assumptions,summarized in the view that women make all the relevant decisions andtreat any male variables as exogenous. Aside from the question whetherthis is correct, is it necessary ? Couldn't full household behavior bebetter modelled ? The model also assumes that formal schooling is agood proxy for efficiency in household production of health, which isdoubtful. There is no harm in including schooling to see if it has anyeffect, but the assumptions of the model are over-strong.
6 what is meant by ''production of N" ? Getting pregnant ? It does notlook easy to model this process with any variables reflecting medicalcare, except maybe for the existence of family planning services in thevillage. And even then, interpreting the data will surely require somedata on knowledge and attitudes about contraception, but these are notmentioned in describing the questionnaire contents.
6 equation (3) is not very clear or persuasive. What is TN--time spentpregnant ? What is the relation between TZ and T : does the latter referonly to wage labor, where the ormer would include making things for sale,or is TZ only time spent rakin things consumed in the household ? Why
are the T . summed across chY Jren ? This makes sense if the time is
only thatHlime spent actually :aring for a (single) sick child or takinghim or her to the clinic, but the additivity assumption does not make
sense if this is time spent "producing health'' by feeding the childrenadequately, etc. Here again, the model seems both quite ambitious andoddly incomplete.
7 it is hard to model demand for family planning services in a one-periodframework; it's quite different from wanting medical care now because
one's child is sick or hurt now. Treating the two alike confuses matters.
8 it is only necessary for the errors from the model to be normal.
11 can reliable data on health habits be obtained from a questionnaire ?Won't the answers be biassed toward people's best (occasional) behavior,or toward what they think the interviewer wants to hear--who's going toadmit to not washing his hands ?
13 what is meant by "perceived quality'' of schools, and what use would thisvariable be ? It sounds as though the model is being asked also to talkabout demand for education.
15 why restrict the sample to villages where treatment for malaria is notavailable ? Couldn't the availability of treatment for one problem(malaria) affect people's willingness to seek treatment for other prob-lems, by demonstrating that the service is useful ?
16 maternal deaths can indeed cause bias, but so can simply moving awayfrom the village; surely over a span of a few years, this second sourceof bias is likely to be as important as maternal mortality.
17 the interviewing scheme means that MRC sites will be perfectly correlatedwith MRC interviewers. Isn't this dangerous ? Wouldn't it be better tomake the interviewer's association with MRC independent of where he or sheworks ?
19 retrospective data for five years may be useful for major events likebirths and deaths, but will be quite unreliable for minor episodes ofillness and consequent utilization of medical services. A recall periodof half a year is probably the maximum that can be trusted, adn eventhen there will be a bias toward more serious sicknesses and the dateswon't be very reliable.
19 the government records referred to may show that a health facility wasopened or that a health worker was posted to a village, but they willnot measure actual availability--hours per day, days per week, diligenceof the health worker, times when medicines were unavailable, etc.
20 ''health endowment'' is unobservable, but that doesn't mean that it's astable, mostly genetic condition which can be treated as stable throughtime and exogenous to the model. In particular, getting malaria canpermanently reduce one's health endowment, amking it endogenous to pastillness episodes and treatmen ts for them.
22 the idea that the sample data can be "corrected"--read, imputed--may besafe at the level of the entire population, where rates of incidence orprevalence are concerned, but it cannot be applied to individual observa-tions safely. Knowing that H!lness was under-reported by ten percentdoes not tell one who was sick and forgot to tell the interviewers.
23 asking people about their willingness to pay to have a village healthworker available, in the hypothetical situation of a currently verysick child, mixes a momentary crisis with a permanent response to it.It is possible parents would declare a high willingness to pay, if thealternative seems like being the child's death; but if they don't expectthat hypothetical situation to materialize, then they won't actually beprepared to pay for the health worker. Methodological research into the
usefulness of WTP questions is one answer to this problem, as proposed;
but it also seems necessary to elicit more information at the time ofthe interview. How often do people anticipate needing a health worker ?Do they value the preventive services such a person would also provide ?This is also a place where leaving out adult illness and accident maybe a problem--people might be appreciably more, or less, willing to paywhen the health of the breadwinner is at stake.
24 of course consumers are partly uninformed. The more serious reason whythere may not be a private market is simply that the population of in-
terest is too poor to afford adequate private care, so that care willbe provided only if it is subsidized. This is consistent with the aimof recovering some part of cost, but not necessarily total (or even fullmarginal) cost.
25 it seems very unlikely that strategic bias is of any importance here--and
it could as easily be a downward bias, as people could expect that when
they declare a low willingness to pay, the government will provide thecare anyway at no cost to them. Hypothetic bias--not understanding thehypothetical situation the same way the researchers do--is the seriousproblem. If there are :many actual episodes of illness and consultationin the sample, maybe actual behavior can be checked against declared be-
havior in hypothetical circumstances, but there will still be difficultiesin knowing how seriously people regard the hypothetiel case.
29 time saved in the second (rainy-season) round of interviews is likely to
be very slight, since the morbidity and utilization data still have to begathered. Already it is worrisome that the second round will be only a
2/3 subsample; if time savings are over-estimated, the actual resultscould be still smaller.
111. Comments on the PHN Project this research is to support
Study of the brief on the PHN project in The Gambia which this research ismeant to support raises three issues which the research ought to try to address,even though they complicate the work. First, the foreign exchange constraintseems to be more binding than-the domestic resource constraint. Even if thereis substantial cost recovery in local currency, this may not make any moredrugs available. Second, this kind of domestic vs. foreign cost problem can
easily lead to imbalance of inputs--too few drugs and relatively too many doc-
tors or nurses. Is this the case in The Gambia ? and if it is, isn't it atleast possible that cost recovery ould actually make the imbalance worse, if
the foreign exchange constraint n't loosened ? Third, the reference toallocation of gasoline suggests thrt someone is deciding how many gallons a
month the health services can Have , instead of adopting a budget and lettingthe people responsible for the trucs buy fuel for them as needed. If thisis the case, ending the physical i;location and subsuming it into the budget
could by itself bring a real imprcvement in provision of services.
SUBJECT: Comments on the Research Proposal, Health Care and Family Planningin The Gambia: Determinants and consequences of Service Utilization
This is a well written, well argued research proposal, in
spite of complexities in its design (involving different kinds of
variables), data collection procedures and analysis plan. I see four
major objectives (and possible outcomes) of the proposed research:
(a) collection of data and a descriptive report on levels of
expenditures and willingness to pay, health status and
health care utilization, fertility and contraceptive
practice and so on;
(b) methodological lessons on the quality of retrospectively
collected data and on the validity of data on
willingness-to-pay for public services;
(c) multivariate analysis of determinants of service utilization
and its impact on health and fertility outcomes;
(d) Impact analysis of Government's village-based health
program.
I find great utility of the objective (a) because in most
African countries, the data base is poor and a systematic data
collection will be a valuable contribution. A descriptive analysis of
the data on health and fertility behaviors, on the health and
fertility outcomes, along with household and community characteristics
that influence these outcomes, will be of great relevance to policy
makers. But can this objective alone justify the use of research
funds? I think so. Because the findings in the report have some
wider applicability in the region and the data collection and the
descriptive report can be replicated elsewhere (with greater local
participation). Moreover, the data set, after it has been cleaned and
its internal consistency and validity proven, can become a useful
basis for further research, whose results can then have wider
application.
The objective (b)--to derive methodological lessons--is
useful, but I wonder whether the Gambia, where the collection of
household data has been limited, is the right place to derive the
methodological lessons.
-2-
I have more serious reservations about the objective (c). Ahousehold choice model, which is derived from the economic theory ofhousehold behavior, provides the framework for various multivariateanalyses. But the statistical results will be very difficult tointerpret, given the problems of interdependence of explanatoryvariables. Experience shows that in such situations the regressioncoefficients of explanatory variates vary widely, depending on thekind of variables included in the equation, and thus provide verylittle guidance for policy interventions. Moreover, unless thevariables are carefully dated (with a clear understanding of the lagstructure), the results can not show any cause-effect sequence (as forexample, in perceived relations between health service utilization andhealth status).
The precise definition of variables in this kind of analysiscan pose a problem. Experience elsewhere shows that such "outcome"variables such as the health status of an individual poses seriousconceptual and measurement problems. The outcome variables are oftenbetter represented by group rates, such as morbidity and mortalityrates. But the use of a group variable in the household analysisposes a problem. Perhaps more work should go into the definition andmeasurement of variables such as health status, health habits, qualityof services and so on, to give us more confidence in the results ofmultivariate analyses.
The objective (d) appears important, though it is not acentral theme in the proposed research project.
I am also concerned about the total cost of the project;$307,000 is proposed to be spent in a country with less than 700,000people. About two-thirds of the cost is a fee for the RandCorporation. Perhaps this is the most efficient use of the money, butit will not contribute to strengthening the analytic capacity in thecountry, as the proposed research aims at achieving (p ii).
Overall, this is a good, but expensive research project.One part of the proposed research, namely multivariate analysis, isnot likely to produce any meaningful guidance to policies. I wouldrecommend that the proposed research be scaled down--or divided intotwo phases--to first concentrate on the data collection andpreparation of a descriptive, operationally relevant report, includingsome impact analysis. If the decision is taken to complete theresearch in two phases, the second phase should begin only after acareful evaluation of the data and its suitability for multivariateanalysis.
-2-
Comments on "Research Proposal - health Care and Family Planning in the
Gambia: Determinants and Causes of Service Utilization"
This proposal addresses important, policy relevant questions. Its
analytical framework is sound, appropriate, and, at a general level,
sufficiently well articulated. The methods proposed for collecting and
analyzing data are -- again at a general level -- well suited to the task.
What is less clear, through, is whether key practical issues have
been adequately thought through.
One such issue is whether the sample design will suffice to provide a
reasonable basis for estimating the large number of structural and reduced
form equations that "Analytical Framework" section refers to, given the large
numbers of variables that the "Survey" section cites as important. All of the
data are to come from 50 communities (p.4 ), a substantial proportion of which
are located in one area -- Farafenni -- of the country. (At one point, pp.14-
15, it seems to be suggested that 42 of the surveyed communities will be in
Farafenni, implying that only 8 communities will be included from other
areas.) Does this number and configuration of sites guarantee enough
variation in community settings to assure that the proposed analysis will in
fact be feasible? Considering the 'n7--rumental variables approach to be
applied in the multivariate analvsi , and the crucial need to get sufficient
variation in the suolyni cOara:t - -. of health and planning services (m:n'y
price, availability of differc7t of private services, etc.), one
wonders.
Another practical issue is wQether the sample size -- 1000 households
in the 50 communities -- is sufficient given the rarity of some of the events
being studied. The problem here is not the incidence of infant and child
-3-
deaths per se, but rather the combination of many factors. Out of the
targeted 1000, the final usable sample will undoubtedly be smaller, due to
incomplete or implausible responses, interviewer error, data processing
problems, and possibly also complications associated with returning to the
same sites in both the rainy and dry seasons. In that smaller sample, few of
the relevant events (infant deaths, visits to health services by type) are
likely to have occurred within the recent past at the time of the interview
(e.g., within the preceding two weeks, month, or three months). True, one can
increase the number of events by extending the retrospective time period
covered; but then the quality of the data falls off rapidly due to recall
error -- as the proposal correctly notes (p.16 ). And while recall error is a
concern for fertility or mortality survey, it is much more problematic for
questions about utilization of and expenditure on services: who remembers how
long they waited for well baby care received six months ago, or how much they
spent then at a pharmacy? Epidemiologists often argue that two weeks is the
maximum viable recall period for questions about morbidity episodes. In the
end, it is not clear that the data set will credibly support the multi-
variable, multi-equation analysis envisioned.
Possibly these concerns have been resolved already, but the proposal
then should convey that fact. In the present version, there is no compelling
evidence that consideration has be- civen to the implications for the
analvsis of sample shrinkazte, of the relevant events (given tre
analysis planned), or the suit - of the 5u chosen sites to generate
adequate variation in the imp'r riables. Since the Medical Research
Council has apparently been collec-i< data in the Gambia for years, there
ought to be some pertinent data avai'able on these issues. Why not present
some of that in the proposal?
-4-
Another concern is the limited progress so far in preparation of the
questionnaire. Until the highly general list of desired variables (pp. 10-13)
is translated into prototype questions, it is difficult to assess how well the
research will be able to meet its intended objectives. How will the length of
the recall period be resolved? What will be asked about morbidity -- e.g.,
will an attempt be made to determine the apparent cause of the problem and its
severity? How will the availability or nonavailability of each type of
service be gauged (if people are willing to travel far enough, every service
is available in principle)? The timeframe allowed to work out the details of
the questionnaire seems rushed. And while the proposal says that use will be
made of the questionnaires from other recent surveys, the list of surveys
mentioned (p.1 4 ) focuses mainly on ones that have not been designed to produce
the full range of demand study planned. There is no evidence anywhere in the
proposal that the authors are aware that the Bank research committee funded
another study not too long ago on health demand issues in Peru. Presumably
the survey forms used in that study and the deliberations that led to their
design might he of some help.
All in all, there is potential here for an excellent piece of
research. But not enough homework has been done so far to evaluate whether
that potential can indeed be successfully realized.
THE WORLD BANK INTtEHNATIONAL FNANCE CORPORATION
OFFICE MEMORANDUMDATE October 22, 1985
TO Mr. Johannes Linn, AEADR
FROM Nancy Birdsal P P
EXTENSION 61581
SUBJECT Gambia Research Proposal
As you requested, here are the budget and other implications of more
explicit phasing a phase 1 and a phase 2) of the above proposed research,
listed under two alternatives. (The relevant budget pages from the proposal
are attached for reference.
(1) A phase I to cover data colLection and descriptive analysis,
followed by a phase 2 for analytic work. This implies a first phase of (at
least) 15 months and a second phase of 9 months. Using the budget
categories shown on pp 31 32 of the proposal, the breakdown would be:
Phase 1 Phase 2 Total
1. Hand subcont Iraict 105, 671 86,114 191,751
2. Travel 25,7002 ,S0 :',1,750
2. Other costs at Bank 10,000 5 000 :35,000
4. Consul tant s It),000 10,000
5. Field costs 29,260 29,260
b. (on t i 1gen y -i) 000 10- 00
TOTAL 180,597 127,164 307,761
This option would a- 1low a Ie'hnicaI review by UHPAC of sampling and
data questions before we proceeded to analysis. However, even with the bulk
of the budget committed iri Phi-iso , is option surimps soriewhat on time for
the descriptive data analysis.
1Equals cost of en t ire linsi ,ear of subcontract 1$76,932) pius 1 4 of
second year.
2 Covers items L, 2, 2 pius L 2 of item 4 !listed in proposal).
P-i186
(2) A phase I to cover (a) questionnaire finalization, including apilot field test; (b) finalizing of sample, including household enumeration
and selection in sampling areas; (c) training of field staff -- followed bya phase 2 for remainder of work (2 rounds of interviews, data processing,analysis). The budget breakdown would be:
Phase 1 Phase 2 Total
1. Rand subcontract 51,5443 140,207 191,751
2. Travel 18,0004 13,750 31,750
3. Other costs at Bank 10,000 25,000 :35,000
4. Consul t ants 10,000 10,000
5. Field costs 17,0005 12,260 29,260
6. Contingency --- _-- 10,000 10,000
TOTAL 106,544 201,217 307,761
This second alternative addresses better your and our) concern abouttiming, i.e. whether- we could in fact get into the field within a fewmonths, and if not whether we need to start immediately. It allows us theoption of beginning immedvitely (thus keeping our team together), butprov ides for t he poss ib I it y we cannot. complete quest ionnaire and sampl ingdesign ;nd training by the beginning of February. We could surely do so byearly April, allowing us to start full sampling in the rainy season. If wewere able to proceed more q uickly we would, so as to begin with dry season
ri t ervi ews) . Akt romp et ioo of these phase I activities, we could submit abrief report f5-10 paes) to REPAC, with 2 annexes the final questionnaire,a note on sampling). I be ieve these would clarify many questions raised inthe review. However, we would hope if this option is chosen, that REPACeould assure a relatively quick triggering mechanism for release of phase 2funds, as This would he necessary to keep the field operation going.Perhaps one of the original internal or ext ernal reviewers (ou'1d at that
time revi ew what we submit ted for ifs aceeptab iIi tv.
Contingency at 10% (excluding Rand subcontract) 10,000
GRAND TOTAL $307,761
_/ We hope to use Juan Munoz, who designed the format and data entry
programs for the Living Standards Measurement Study, if the timing does
not conflict with his LSMS duties.
THE WORLD BANK INTERNATIONAL FINANCE CORPORATION
OFFICE MEMORANDUMDATE October 22, 1985
TO Mr. Johannes Linn, AEADR
FROM Nancy Birdsal PR
EXTENSION 61581
SUBJECT Gambia Research Proposal
As you requested, here are the budget and other implications of more
explicit phasing (a phase 1 and a phase 2) of the above proposed research,
listed under two alternatives. (The relevant budget pages from the proposal
are attached for reference.)
(1) A phase I to cover data collection and descriptive analysis,
followed by a phase 2 for analytic work. This implies a first phase of (at
least) 15 months and a second phase of 9 months. Using the budget
categories shown on pp 31-32 of the proposal, the breakdown would be:
Phase 1 Phase 2 Total
I. Rand subcontract 105,6371 86,114 191,751
2. Travel 25,7002 6,050 :1,750
3. Other costs at Bank 10,000 25,000 35,000
4. Consultan t s 10,000 ---- 10, 000
5. Field costs 29,260 ---- 29,260
6. Contingency -- ~- I000 10,000
TOTAL 180,597 127,164 307,761
This option would allow a tec hnical review by REPAC of sampling and
data questions before we proceeded to analysis. However, even with the bulk
of the budget committed in Phase [, this option scrimps somewhat on time for
the descriptive data analysis.
1Equals cost of entire first year of subcontract ($76,932) plus 1/1 of
second year.
2Covers items 1, 2, 3 plus 1 2 of item 4 (listed in proposal,.
P-1867
(2) A phase 1 to cover (a) questionnaire finalization, including apilot field test; (b) finalizing of sample, including household enumerationand selection in sampling areas; (c) training of field staff -- followed bya phase 2 for remainder of work (2 rounds of interviews, data processing,analysis). The budget breakdown would be:
Phase 1 Phase 2 Total
I. Rand subcontract 51,5443 140,207 191,751
2. Travel 18,0004 13,750 31,750
3. Other costs at Bank 10,000 25,000 :35,000
4. Consultants 10,000 -- 10,000
5. Field costs 17,0005 12,260 29,260
6. Contingency -10000 10)000
TOTAL 106,544 201,217 307,761
This second alternative addresses better your (and our) concern abouttiming, i.e. whether we could in fact get into the field within a fewmonths, and if not whether we need to start immediately. It allows us theoption of beginning immediately (thus keeping our team together), butprovides for the possibility we cannot complete questionnaire and samplingdesign and training by the bwginning of February. We could surely do so byearly April, allowing us to start fill sampling in the rainy season. If wewere able to proceed more quickl v we would, so as to begin with dry seasoninterviews). At completion of* these phase L act ivities, we could submit abrief report (5-10 pages) to REPAC, with 2 annexes (the final questionnaire,a note on sampling). T believe these would clarify many questions raised inthe review. However, we would hope if this option is chosen, that REPACcould assure a relatively uiiick triggering mechanism for release of phase 2funds, as this would be necessary to keep the field operation going.Perhaps one of the original internal or 4x-ternal refviewers ouid at 1 hat
time review what we submitted for its acceptability.
At t. achrment
c': Phi Anh Plesch, VPERSStephen 0' Br i en, WANVP
This option would allow a technical review by REPAC of sampling and
data questions before we proceeded to analysis. However, even with the bulk
of the budget committed in Phase 1, this option scrimps somewhat on time for
the descriptive data analysis.
1 Equals cost of entire first year of subcontract ($76,932) plus 1/I of
second year.
2 Covers items 1, 2, 3 plus 1/2 of item 4 (listed in proposal).
P-1867
2
(2) A phase 1 to cover (a) questionnaire finalization, including apilot field test; (b) finalizing of sample, including household enumerationand selection in sampling areas; (c) training of field staff -- followed bya phase 2 for remainder of work (2 rounds of interviews, data processing,analysis). The budget breakdown would be:
Phase 1 Phase 2 Total
1. Rand subcontract 51,5443 140,207 L91,751
2. Travel 18,0004 13,750 31,750
3. Other costs at Bank 10,000 25,000 :35,000
4. Consultants 1(,000 - 10,000
5. Field costs 17,0005 12,260 29,260
6. Contingency - 10,000 10_000
TOTAL 106,544 201,217 307,761
This second ailternative addresses better your fand our) concern abouttiming, i.e. whether we could in fact get into the field within a tewmonths, and if not whether we need to start immediately. It allows us theopt ion of beginning immediately (thus keeping our team together), butprovides for the possibility we cannot complete questionnaire and sampling
design and training by the beginning of February. We could surel y do so by
early April, atlowing us to start full sampling in the rainy season. If w-were able to proceed( more qiickly we would, so as to begin with dry seasoninterviews;. kt CoMplet ion of these phase I activities, we could submit abrief report (5-10 pages) to REPAC, with 2 annexes (the final questionnaire,a note on sampting). I believe these would clarify many questions raised inthe review. However, we would hope if this option is chosen, that REPACcould assure a reiatively quick triggering mechanism or release of phase 2funds, as ibis would be necessary to keep the field operation going.Perhaps one of the original internal or ext ernat reviewers couild at that
time review what we submitted for its acceptability.
A t t atcumen
':Phi Anh Pliesch, VPERSM ehenO' r ienW.ANVP
Jutie avno:in Hliaga
NB: lbs
3 T 2 of t lie t i r-st Vr subcontract
4 Approximately tem 1, 1 2 item 2, 1 /2 item 3, 1/2 item 4.
5 1 t em 1, $2,000: tem 2, $2, 000: item 3, $3,000; it em 4, $ 10,000.
T,,rNAEN: REPAC-Jdv (R)P: 34
- 31 -
IV. B U D G E T
Rand subcontract 1/
1. Salaries and benefitsDaVanzo (114 days)Haaga (134 days)programmer (30 days)research assistant (114 days)clerical support (76 days)editorial support (3 days) 111,3412/
4. 3 IBM/PCs (for data entry andediting in Banjul) 15,000
Total 29,260
TOTAL 297,761
Contingency at 10% (excluding Rand subcontract) 10,000
GRAND TOTAL $307,761
/ We hope to use Juan Munoz, who designed the format and data entryprograms for the Living Standards Measurement Study, if the timing doesnot conflict with his LSMS duties.
OFFICE MEMORANDUMOctober 18, 1985
Ms. Phi Anh Plesch, VPERS
Nancy Birdsa , Chief ,rPHNPR
61581
Gambia Research Proposal
I spoke today with my collaborator on the above proposal, Julie
DaVanzo, and would like to clarify several items on which I was not as
clear as I might have been in our discussion yesterday with REPAC members,
Johannes Linn and Steve O'Brien.
o Our comparison of restrospective data (from respondents) and
prospective data (of the Medical Research Council) would deal primarily
with fertility and mortality, and only secondarily with morbidity. It will
be of great benefit to know how good survey responses on pregnancy
histories and family mortality are.
o With 1000 compounds, we are likely to have as many as 2000
children born within the last three years. With infant mortality at 100
per thousand (a conservative estimate), we could expect as many as 200
reported deaths. This would permit analysis of determinants of infant
mortality (though not of adult mortality--where the frequency of deaths in
this size sample would be too small).
o On the difficult issue of measurement of morbidity, we are
benefitting already by Julie DaVanzo's participation on the Scientific
Advisory Committee for the AID-sponsored Demographic and Health Surveys
Project (DHS). The DHS will sponsor surveys in up to 25 developing
countries over the next several years. The questionnaire for that survey
will include a component on morbidity, and Julie has been working on it
with epidemiologist Robert Black (Johns Hopkins). We will also be able to
seek advice from Jean-Pierre Habicht of Cornell University, who is at Rand
on sabbatical working with her. He managed morbidity survey work in
Guatemala for several years and is a preeminent physician/nutritionist.
cc: Messrs. J. Linn (AEADR), S. O'Brien (WANVP)
Ms. J. DaVanzo,Rand Corporation
NBirdsall:lcj
(Signed in Nancy Birdsall's absence)
P 1866
... )41 F) kAN K INi THNA NAL f INANG RPOdN
OFFICE MEMORANDUM HNovember 1, 1985
Mr. lohn North, Director, PHN
Deenak Lal, Chairman, REPAC k
N N 33481
Research Proposal: "Health Care and Family Planning in the Gambia:
Determinants and Consequences of Service Utilization"
The above proposal was considered by REPAC at its meeting onOctober 24. It had been reviewed by a REPAC subcommittee, two Bankstaff and two external referees whose reports are attached.
As the subcommittee noted in its report, all the reviewers
supported the objectives of the proposal, but expressed concerns about
certain aspects of it, in particular, about: the sample design andsurvey approach; the quality and coverage of data; the survey
questionnaire which has not been developed yet; the incompletespecification of the proposed analytical model and related problems; the
usefulness of the methodological explorations, the impact of the project
on government's analytical capacity; the size of the budget; and about
the propriety of the research being contracted out to Rand.
REPAC members shared the reviewers' concerns about themethodological issues but like the subcommittee did not emphasize their
importance, as they are expected to be dealt with satisfactorily in the
project. The high level of experience and competence of the researchers
involved was noted, so technically the project could be sound. Also
REPAC felt that the topics addressed by the research could be important
to Africa. It however expressed doubts about i) whether this studyinvestigating a single elasticity at a cost of $300,000 in a country
with a population of only 700,000 was justified; and ii) whether the
marginal returns of this expenditure were high given that there have
been already ongoing attempts to estimate similar elasticities in Ivory
Coast (and outside of Africa in Peru), and a pending proposal analyzing
the same issues for Sierra Leone. REPAC felt it could not answer these
questions short of a statement from PHN that would attempt to put thisresearch proposal - and others in the pipeline - in perspective which
takes account of past and ongoing work.
In addition to the above issues REPAC expressed two strong
reservations about the budget of the proposal:
1) REPAC had granted an earlier request from PEN for $15,650
to fund the preparation of this research proposal on the explicit
condition that the sponsors would seek financial support from non-RSB
P 1866
-2-
sources for the main research project. REPAC had put that condition inorder to conform with the new RPC research priorities which deemphasize
the use of research funds for large data gathering. It had thought thatthis research with its large data requirements would be worthwhile only
if it piggy-backed into the evaluation component of the IDA-project.
Ms. Rirdsall in accepting the above condition had indicated that sheanticipated that much of the costs of the survey work would be funded
through the IDA project. However REPAC was disappointed that in thecurrent proposal it was asked to support the full cost of the research,
including the cost of the design and execution of the survey. REPAC was
not satisfied with Ms. Birdsall's explanation for her failure to seek
co-financing from the IDA project; her main reasons being personalconflict of interest, and the general interest of the research extending
beyond Gambia's immediate interest. REPAC noted the tentativearrangements by Ms. Birdsall for some minor financial support from other
sources such as the Norwegian Ministry of Developing Cooperation($10,000) and Ford Foundation (sum unknown). But it felt strongly that
the issues of co-financing remained largely unresolved.
2) Secondly, there was the question raised about the
appropriateness of contracting most of the work to a private developedcountry institution.
In conclusion, notwithstanding minor methodological concernsand its doubts about the marginal returns of the proposed expenditures,REPAC felt that the project is technically sound. However because of
its strong reservations about the budget, REPAC decided to recommend
rejection of the proposal with its present financial arrangements.
Mrs. Krueger has noted the above recommendation which according
to REPAC's rules waS sent to her for information.
cc: Messrs./Mmes. N. Birdsall. S. PatelREPAC Members
PAP/sv
OFFICE MEMORANDUM[JATF October 21, 1985
To All REPAC Members
FHOM F. S. O'BrA4nd Johannes Linnj 1-
FXTFNSION 72065
SuBACT Research Proposal: Health Care and Family Planning in the Gambia
1. This project has been reviewed by a panel of Bank and externalreviewers which we have coordinated. All of the reviewers were supportiveof the general objectives of the project, but at the same time they allexpressed concerns about certain aspects of the proposal. These reviewers'reports have already been circulated to you; we have summarized their mainpoints below:
(a) country choice - whether sufficient useful generalizations canbe drawn from the Gambia, a small, poor country;
(b) sample design and survey approach - problem of the nationalcensus as a basis for sample selection; whether sample will berepresentative; will sample contain sufficient ohmervations forboth community and compound variables;
(c) quality and coverage of data, conceptual and measurementproblems that may arise for certain variables; these concernsare linked to the fact that the survey questionnaire has notbeen developed yet, so that reviewers cannot judge howeffectively the relevant information will be obtained throughthe survey method;
(d) possible problems with the analytical model to be employed -incomplete specification, interdependence problems, possibledifficulties in defining lags;
(e) whether the methodological explorations (contingent valuationand measurement of recall) will prove useful;
(f) impact of the project on government's analytical capacity;
(g) minor questions about the budget.
2. We met with the principal supervisor of the project, Ms.Birdsall, on October 16 to go over all of the above points. We werereasonably satisfied that most of the above concerns are either notsignificant or can be dealt with satisfactorily in the project. Further
clarifications were provided in.Ms. Birdsall's memo of October 18 which hasbeen circulated to you. However, we were still left with major concernsabout:
(a) timing - can all of the preparatory work of questionnairedesign, training of field staff, drawing up the sample frameand pilot testing the questionnaire be carried out between now
P-1866
-2-
and February 1986, when the first full field survey isscheduled to start;
(b) whether there will be adequate time to examine the usefulnessof the data obtained from the questionnaire before beginningthe analysis phase of the study.
On these questions we have had further discussions with Ms. Birdsall andhave suggested a compromise approach which would adequately address ourconcerns. This alternative approach would break the project into twophases: Phase I, which would include questionnaire preparation, trainingof field interviewers, design of the sample frame, and pilot testing of thequestionnaire would last approximately from November 1985 to May 1986.Phase II, to begin in approximately June 1986, would comprise the remainingstages of the study - a first round survey conducted in the rainy season,the second round survey conducted in the following dry season, and dataprocessing, analysis and report writing. Note that the dry season/wetseason ordering of field surveys would be reversed, and the overall studywould be put back some six months from the schedule in the proposal. Theestimated budget for Phase I is about $110,000 with the balance of about$200,000 allocated to Phase II. 1/ We recommend that the project besupported by REPAC on the basis of this two-phased approach.
3. We propose that there be a brief review of progress on theproject at the end of Phase I to determine whether proceeding with Phase IIis justified. A Steering Committee should be established for this purpose,and the original reviewers could be asked to review the output of the firstphase. REPAC could decide either to fund the entire project with releaseof the second tranche to be dependent on approval by the SteeringCommittee, or fund only the first tranche at this time with approval of thesecond tranche to be dependent on reapplication to REPAC. We recommend theformer course.
4. Other issues.
(a) Clearly, success of this project depends critically on the fullcollaboration of the British Medical Research Council (MRC).The MRC has been fully informed about the project and theirfull participation has been sought, but Ms. Birdsall is stillwaiting for their response. She informs us that she expects tohave their answer by the end of October. Since, in our view,the project cannot be carried out without full MRC cooperation,we recommend that the final notification of approval by REPACbe withheld until the Chairman has been informed that MRC isparticipating in the manner described in the proposal.
(b) Cofinancing - Ms. Birdsall was requested to seek cofinancingand she has clearly made an effort to do so. She expects to
1/ Ms. Birdsall is preparing a revised budget providing exact costestimates; these will be available before the REPAC meeting.
-3-
have support from MRC and UNICEF and has possibilities ofsupport from the Norwegian government and one or two othersources. The West Africa Region strongly supports the projectand will contribute staff time, but does not have funds tocontribute. We do not feel that part of the cost of thisresearch should be transferred to the government through theproposed IDA credit for health, nor do we feel that approval ofthe project should be delayed merely in order to prolong thesearch for cofinancing.
(c) Budget. We have only one question concerning the budget andthat relates to the Rand Corporation overhead--69% of salarycosts. This item represents 22% of the total cost of theproject. What is REPACs position on paying overheads todeveloped country research institutions?
MIMI:REPAC
Reviewer Report: Health Care and Family Planning in The Gambia: Determinants
and Consequences of Service Utilization. World Bank Research Program.
Significance: This project is designed to investigate the determinants of
health and fertility focusing on the role of medical care (including family
planning programs). Its unique characteristics include a link to an ongoing
project sponsored by the British Medical Research Council (MRC), which is
doing a prospective study of fertility outcomes and health, and a tie in to
the program iniatives by The Gambia which include new medical services in
several villages and a large proposal to increase medical resources including
drugs to be financed by the IDA. The project directors claim that this study
will be useful in: 1). designing medical and family planning programs in
The Gambia as well as other developing countries, 2). in appraising
retrospective data on health, health care utilization, and fertility and
3). in appraising contingent valuation methodology as a measure of willingness
to pay in a developing country.
Comment: The authors claim that The Gambia has one of the very highest infant
and maternal mortality rates in the World. This may limit the usefulness of
generalizing from these results. A country at a further stage of development
with greater variance in infant mortality rates and some success at reducing
these rates may be a better base for this type of research. Second, the
ongoing MRC study may itself serve as a sufficient base to evaluate the new
iniatives described above. Third, infant mortality, morbidity, etc. are likely
to be affected by factors other than those listed in the proposal. These
include specialized education (training) for nutrition and/or for infant care,
having providers visit compounds for education, subsidy or direct supply of
village training centers, etc.. Why spend research resources in order to
investigate only medical resources when other, possibly less expensive
alternatives may be more effective?
Sample Design: The plan is to survey 4 areas of The Gambia including those
already being surveyed by the MRC. The justification for this is 1). to build
upon the already collected data, and 2). use the reenumeration that has been
done for this area to draw the sample. The MRC areas include 3 of the 4 areas
selected. For the additional communities, the research team will do a
reenumeration prior to drawing the sample.
Comment: If, as the researchers claim, the Gambian Census is somewhat out of
date, and this is the justification for the sample design, it is difficult to
see how the 4 area survey will be designed "to achieve representation of all
ethnic or income groups in the country" (p.17). This will not be a weighted
representative sample of the country if the Census cannot be used to establish
weights.
Data: Compound based data to be collected includes infant and child
mortality, morbidity, pregnancy outcomes as well as fertility history,
health care utilization, health habits, infant feeding practices and
willingness to pay formedically related goods and services, income, and
socioeconomic characteristics of the individuals in the compound. Village
data includes availability of medical services, schooling availability, water
condition, etc. No detail is presented on the exact measures to be employed.
Comment: The lack of specificity makes it difficult to evaluate the
appropriateness of the data to be collected. This reviewer is particularly
concerned with the health (morbidity) data. The team does not include any
experts on health status. Will antropometric measures be collected? days
bedridden? incidence of specified diseases? etc. Since one of the primary
goals of the proposal is to evaluate the influence of medical availability,
prices, etc. on health status, health status seems to be a vital measure and
must be spelled out in more detail. Related to my concerns above, more data on
education-specific training, etc. should be included. And, the role of
community acceptance of family planning, new medicines should be incorporated
in the data and the model. Attitudinal information seems clearly lacking as
well as level of knowledge. For example, does the individual know about
family planning method x? About the location of medical services? Is any
family member a health care provider? Did an infant death lead to a change in
behavior? (And thus is this a time of efficient intervention?). In other
words, in order to be useful, the data set should be broader than suggested by
the proposal.
Model: The model is a simple production function approach for health. The
authors seem familiar with on going work in the area. On the basis of my
knowledge of their other work, I am reasonably confident that the model used
will be appropriate for these questions, if the data are sufficient.
Unfortunately, the model is incompletely specified in the proposal so it is
difficult to offer very constructive comments.
Comment: An issue the researchers should address is the endogeneity of family
size and the effect of family size on health. Related to this is the question
of the appropriate income concept-- $4000 for 4 persons represents a
different income constraint than $4000 for 12 persons. Income is itself
endogenous if any of it is family produced since larger families mean both a
larger labor supply and more persons to provide for. Will any of this be
included in the analysis? Migration is not included any where in the model.
Is this because there is very little migration in The Gambia - or migration
between or to rural villages? If this is not the case then some attention
should be paid to migration. Finally, there is an implicit assumption made in
the model that a broader range of pharmaceutical products is higher quality.
This is certainly debatable for some drugs and suggests the need for
subgrouping of pharmaceuticals and a modification of the hypothesis.
Methodological Explorations: The researchers plan to test the reliability of
retrospective questions on fertility, mortality and illness by a comparison to
prospective data collected by MRC. Second, they plan to test the usefulness
of contingent valuation as a measure of willingness to pay for public services.
Comment: The planned comparison of retrospective data is to monthly
prospective data. If, the goal of the comparison is to find low-cost means to
collect data on fertility, mortality and morbidity, why only compare these two
very different alternatives? What about biannual prospective data, data from
medical providers? But, the comparison itself may be faulty: an individual
who has been asked monthly about fertility may, knowing this information has
already been asked, be more concerned with providing consistent information
than had s/he never been asked. If this is so, a comparison of interviewer
retrospective and prospective information will not yield appropriate
statistics for judging the use of retrospective information alone.
On the question of contingent valuation, it is not clear how responses to
contingent valuation questions will be evaluated. An important aspect of
contingent evaluation is to present simple clear understandable description(s)
of the good(s) to be evaluated. It is difficult to see how this can
satisfactorily be achieved in describing services not previously provided to a
population with limited education.
Personnel: Julie DaVanzo is a senior researcher with considerable expertise
in demographic issues in developing countries. John Haaga is a nutrition
expert. It is not clear that he can adequately serve as health expert on this
proposal.
Budget:
1). Is there a problem with the planned use of PC's since in some areas
of The Gambia being surveyed there is limited availability of electricity?
2). The computer budget seems high, especially if PC's are used.
3). Is there a potential problem if field interviewers are paid at
different rates? ($5.00 to MRC interviewers, $3.00 to Central Bureau
Statistics interviewers.)
4). Is it cost effective to allocate $372,451 for a research project that
analyses a country with a small population that is unique in a number of ways,
particularly since an ongoing project (MRC) will enable some analyses of the
issues to be addressed by this proposal?
1676L
Comments on the research proposal on 'Health Care and Family Planningin the Gambia: Determinants and Consequences of Service Utilization''
1. General Comments (specific comments follow)
This is a very ambitious and very fashionable piece of research, especiallygiven its emphasis on estimating price elasticities of demand for medicaland family planning services. There is no doubt this question is importantif one wants to recover from consumers some of the cost of publicly-providedservices, but there seem to be three reasons why the emphasis on price res-ponses is overdone: (i) the social-cost arguments in favor of restrictingfertility are so strong that even a very small reduction in contraceptionas a result of fees or prices would represent a net loss--the government ofThe Gambia is, I believe, entirely correct to insist that contraceptiveservices be provided free; (2) sheer availability of services may be muchmore important than their money cost, in determining utilization. This isrecognized in the proposal, so far as time-costs are to be considered, butit is proposed to do this by valuing time at local wage rates, and no oneknows whether consumers value their time this way; and (3) the emphasis onwillingness-to-pay is on paying fixed, predictable amounts for a villagehealth worker or for water supplies--the proposal does not mention responseto price for unpredictable medical needs, but these could be larger and haveconsiderable effect on utilization unless the highest prices ever faced arestill quite low. Since I do not know The Gambia, I don't know whether con-sumers ever consult private practicioners, either modern or traditional; butif they do, some effort should certainly be made to learn their prices andhow those prices affect utilization.
Apart from the price emphasis, the proposal is curiously one-sided in itsemphasis on women's decisions (and their incomes) and on health care forwomen (pregnancy-related) and children only. Don't older children or adultmen ever get sick in The Gambia, or ever suffer accidents ? There is nodoubt that maternal and child care is basic, and that it is a large part ofprimary health care, but that i's not all there is to the matter; and evenwhen it is a matter of caring for a sick woman or child, it is odd to treatmen's income as exogenous and their decisions as irrelevant, when illnessmay affect a man's income because of time taken to get medical help for hisfamily, take over his wife's chores, etc. The analytical model seems exces-sively narrow in this regard.
The proposed sample of about 1000 households is almost surely too small forsome of the purposes mentioned, particularly for estimating infant and childmortality and their determinants or for explaining fertility. It is obviousthat the research will build on the longitudinal data obtained by MRC--infact, it is that possibility which justifies the research project--but it isnot clear that the new sample data will always add much to those data, inmedical terms, What the sample should allow is a good understanding of thedeterminants of ordinary medical-care utilization, and that is probably reason
enough for the project. Other subjects may be intractable, or may be feasible
to study only with the MRC data.
I have not reviewed the budget carefully, but one general comment seems inorder there: it is hard to believe the Rand researchers can possibly accom-plish all they propose in the small number of days allocated to the project.If they will actually pat in more time and save the Bank money, well and good;
but the estimates do not look very realistic, even given the good experienceof prior MRC work and the success in quickly obtaining and starting to analyzedata from the LSMS project in the Ivory Coast,
I1. Specific Comments (by page numbers in the proposal)
I the sample may be very small for eliciting meaningful responses tohypothetical questions about willingness to pay, unless the populationis fairly uniform in its responses.
ii merely undertaking the project in cooperation with the government doesnot guarantee "strengthening of analytical capacity"; it's a necessarybut not a sufficient condition. Teaching people in poor countries toanalyze their own data in any but the most pedestrian way is orders ofmagnitude harder than teaching them to collect it. Would this projectbe considered worth while if there were no increase in local analyticcapacity, which is a plausible outcome ?
4 the justification for including MRC and non-MRC households in the surveyis not clear. How are they expected to differ ? What sort of refusal ordrop-out rates are expected ? Will the MRC households studied be a rep-resentative sample of the original MRC group, or will there have beensignificant differential attrition among them ?
5 the formal analytical model makes a number of questionable assumptions,summarized in the view that women make all the relevant decisions andtreat any male variables as exogenous. Aside from the question whetherthis is correct, is it necessary ? Couldn't full household behavior bebetter modelled ? The model also assumes that formal schooling is agood proxy for efficiency in household production of health, which isdoubtful. There is no harm in including schooling to see if it has anyeffect, but the assumptions of the model are over-strong.
6 what is meant by "production of N" ? Getting pregnant ? It does notlook easy to model this process with any variables reflecting medicalcare, except maybe for the existence of family planning services in thevillage. And even then, interpreting the data will surely require somedata on knowledge and attitudes about contraception, but these are notmentioned in describing the questionnaire contents.
6 equation (3) is not very clear or persuasive. What is T N--time spentpregnant ? What is the relation between T and T : does the latter referonly to wage labor, where the former would include making things for sale,or is TZ only time spent making things consumed in the household ? Whyare the T . summed across children ? This makes sense if the time isonly thatH ime spent actually caring for a (single) sick child or takinghim or her to the clinic, but the additivity assumption does not makesense if this is time spent ''producing health" by feeding the childrenadequately, etc. Here again, the model seems both quite ambitious andoddly incomplete.
7 it is hard to model demand for family planning services in a one-periodframework; it's quite different from wanting medical care now becauseone's child is sick or hurt now, Treating the two alike confuses matters.
8 it is only necessary for the errors from the model to be normal.
11 can reliable data on health habits be obtained from a questionnaire ?Won't the answers be biassed toward people's best (occasional) behavior,or toward what they think the interviewer wants to hear--who's going toadmit to not washing his hands ?
13 what is meant by "perceived quality" of schools, and what use would thisvariable be ? It sounds as though the model is being asked also to talkabout demand for education.
15 why restrict the sample to villages where treatment for malaria is notavailable ? Couldn't the availability of treatment for one problem,(malaria) affect people's willingness to seek treatment for other prob-lems, by demonstrating that the service is useful ?
16 maternal deaths can indeed cause bias, but so can simply moving awayfrom the village; surely over a span of a few years, this second sourceof bias is likely to be as important as maternal mortality.
17 the interviewing scheme means that MRC sites will be perfectly correlatedwith MRC interviewers. Isn't this dangerous ? Wouldn't it be better tomake the interviewer's association with MRC independent of where he or sheworks ?
19 retrospective data for five years may be useful for major events likebirths and deaths, but will be quite unreliable for minor episodes ofillness and consequent utilization of medical services. A recall periodof half a year is probably the maximum that can be trusted, adn eventhen there will be a bias toward more serious sicknesses and the dateswon't be very reliable.
19 the government records referred to may show that a health facility wasopened or that a health worker was posted to a village, but they willnot measure actual availability--hours per day, days per week, diligenceof the health worker, times when medicines were unavailable, etc.
20 ''health endowment" is unobservable, but that doesn't mean that it's astable, mostly genetic condition which can be treated as stable throughtime and exogenous to the model. In particular, getting malaria canpermanently reduce one's health endowment, amking it endogenous to pastillness episodes and treatments for them.
22 the idea that the sample data can be "corrected"--read, imputed--may besafe at the level of the entire population, where rates of incidence orprevalence are concerned, but it cannot be applied to individual observa-tions safely. Knowing that illness was under-reported by ten percentdoes not tell one who was sick and forgot to tell the interviewers.
23 asking people about their willingness to pay to have a village healthworker available, in the hypothetical situation of a currently verysick child, mixes a momentary crisis with a permanent response to it.It is possible parents would declare a high willingness to pay, if thealternative seems like being the child's death; but if they don't expectthat hypothetical situation to materialize, then they won't actually beprepared to pay for the health worker. Methodological research into theusefulness of WTP questions is one answer to this problem, as proposed;
but it also seems necessary to elicit more information at the time ofthe interview. How often do people anticipate needing a health worker ?Do they value the preventive services such a person would also provide ?This is also a place where leaving out adult illness and accident maybe a problem--people might be appreciably more, or less, willing to paywhen the health of the breadwinner is at stake.
24 of course consumers are partly uninformed. The more serious reason whythere may not be a private market is simply that the populat on of in-terest is too poor to afford adequate private care, so that care willbe provided only if it is subsidized. This is consistent with the aimof recovering some part of cost, but not necessarily total (or even fullmarginal) cost.
25 it seems very unlikely that strategic bias is of any importance here--andit could as easily be a downward bias, as people could expect that whenthey declare a low willingness to pay, the government will provide thecare anyway at no cost to them. Hypothetic bias--not understanding thehypothetical situation the same way the researchers do--is the seriousproblem. If there are :many actual episodes of illness and consultationin the sample, maybe actual behavior can be checked against declared be-havior in hypothetical circumstances, but there will still be difficultiesin knowing how seriously people regard the hypotheticll case.
29 time saved in the second (rainy-season) round of interviews is likely tobe very slight, since the morbidity and utilization data still have to begathered. Already it is worrisome that the second round will be only a2/3 subsample; if time savings are over-estimated, the actual resultscould be still smaller.
1I1. Comments on the PHN Project this research is to support
Study of the brief on the PHN project in The Gambia which this research ismeant to support raises three issues which the research ought to try to address,even though they complicate the work. First, the foreign exchange constraintseems to be more binding than-the domestic resource constraint. Even if thereis substantial cost recovery in local currency, this may not make any moredrugs available. Second, this kind of domestic vs. foreign cost problem caneasily lead to imbalance of inputs--too few drugs and relatively too many doc-tors or nurses. Is this the case in The Gambia ? and if it is, isn't it at
least possible that cost recovery would actually make the imbalance worse, ifthe foreign exchange constraint isn't loosened ? Third, the reference toallocation of gasoline suggests that someone is deciding how many gallsons a
month the health services can have, instead of adopting a budget and lettingthe people responsible for the trucks buy fuel for them as needed. If thisis the case, ending the physical allocation and subsuming it into the budget
could by itself bring a real improvement in provision of services.
SUBJECT: Comments on the Research Proposal, Health Care and Family Planningin The Gambia: Determinants and consequences of Service Utilization
This is a well written, well argued research proposal, inspite of complexities in its design (involving different kinds ofvariables), data collection procedures and analysis plan. I see fourmajor objectives (and possible outcomes) of the proposed research:
(a) collection of data and a descriptive report on levels ofexpenditures and willingness to pay, health status andhealth care utilization, fertility and contraceptivepractice and so on;
(b) methodological lessons on the quality of retrospectivelycollected data and on the validity of data onwillingness-to-pay for public services;
(c) multivariate analysis of determinants of service utilizationand its impact on health and fertility outcomes;
(d) Impact analysis of Government's village-based healthprogram.
I find great utility of the objective (a) because in mostAfrican countries, the data base is poor and a systematic datacollection will be a valuable contribution. A descriptive analysis of
the data on health and fertility behaviors, on the health and
fertility outcomes, along with household and community characteristics
that influence these outcomes, will be of great relevance to policymakers. But can this objective alone justify the use of research
funds? I think so. Because the findings in the report have some
wider applicability in the region and the data collection and the
descriptive report can be replicated elsewhere (with greater local
participation). Moreover, the data set, after it has been cleaned and
its internal consistency and validity proven, can become a useful
basis for further research, whose results can then have widerapplication.
The objective (b)--to derive methodological lessons--isuseful, but I wonder whether the Gambia, where the collection ofhousehold data has been limited, is the right place to derive the
methodological lessons.
I- 2 --2-
I have more serious reservations about the objective (c). Ahousehold choice model, which is derived from the economic theory ofhousehold behavior, provides the framework for various multivariateanalyses. But the statistical results will be very difficult tointerpret, given the problems of interdependence of explanatoryvariables. Experience shows that in such situations the regressioncoefficients of explanatory variates vary widely, depending on thekind of variables included in the equation, and thus provide verylittle guidance for policy interventions. Moreover, unless thevariables are carefully dated (with a clear understanding of the lagstructure), the results can not show any cause-effect sequence (as forexample, in perceived relations between health service utilization andhealth status).
The precise definition of variables in this kind of analysiscan pose a problem. Experience elsewhere shows that such "outcome"variables such as the health status of an individual poses seriousconceptual and measurement problems. The outcome variables are oftenbetter represented by group rates, such as morbidity and mortalityrates. But the use of a group variable in the household analysisposes a problem. Perhaps more work should go into the definition andmeasurement of variables such as health status, health habits, qualityof services and so on, to give us more confidence in the results ofmultivariate analyses.
The objective (d) appears important, though it is not acentral theme in the proposed research project.
I am also concerned about the total cost of the project;$307,000 is proposed to be spent in a country with less than 700,000people. About two-thirds of the cost is a fee for the RandCorporation. Perhaps this is the most efficient use of the money, butit will not contribute to strengthening the analytic capacity in thecountry, as the proposed research aims at achieving (p ii).
Overall, this is a good, but expensive research project.One part of the proposed research, namely multivariate analysis, isnot likely to produce any meaningful guidance to policies. I wouldrecommend that the proposed research be scaled down--or divided intotwo phases--to first concentrate on the data collection andpreparation of a descriptive, operationally relevant report, includingsome impact analysis. If the decision is taken to complete theresearch in two phases, the second phase should begin only after acareful evaluation of the data and its suitability for multivariateanalysis.
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Comments on "Research Proposal - health Care and Family Planning in the
Gambia: Determinants and Causes of Service Utilization"
This proposal addresses important, policy relevant questions. Its
analytical framework is sound, appropriate, and, at a general level,
sufficiently well articulated. The methods proposed for collecting and
analyzing data are -- again at a general level -- well suited to the task.
What is less clear, through, is whether key practical issues have
been adequately thought through.
One such issue is whether the sample design will suffice to provide a
reasonable basis for estimating the large number of structural and reduced
form equations that "Analytical Framework" section refers to, given the large
numbers of variables that the "Survey" section cites as important. All of the
data are to come from 5,) communities (p.4), a substantial proportion of which
are located in one area -- Farafenni -- of the country. (At one point, pp. 14 -
15, it seems to be suguested that 42 of the surveyed communities will be in
Farafenni, implying that only 8 communities will be included from other
areas.) Does this number and configuration of sites guarantee enough
variation in community settings to assure that the proposed analysis will in
fact be feasible? Considering the instrumental variables approach to be
applied in the multivariate analysis, and the crucial need to get sufficient
variat-ion in the suppl characteristics of health andc planning services (money
price, availability of different types of private services, etc.), one
wonders.
Another practical issue is whether the sample size -- 1000 households
in the 50 communities -- is sufficient given the rarity of some of the events
being studied. The problem here is not the incidence of infant and child
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deaths per se, but rather the combination of many factors. Out of the
targeted 1000, the final usable sample will undoubtedly be smaller, due to
incomplete or implausible responses, interviewer error, data processing
problems, and possibly also complications associated with returning to the
same sites in both the rainy and dry seasons. In that smaller sample, few of
the relevant events (infant deaths, visits to health services by type) are
likely to have occurred within the recent past at the time of the interview
(e.g., within the preceding two weeks, month, or three months). True, one can
increase the number of events by extending the retrospective time period
covered; but then the quality of the data falls off rapidly due to recall
error -- as the proposal correctly notes (p.1 6 ). And while recall error is a
concern for fertility or mortality survey, it is much more problematic for
questions about utilization of and expenditure on services: who remembers how
long they waited for well baby care received six months ago, or how much they
spent then at a pharmacy! Epidemiologists often argue that two weeks is the
maximum viable recall period for questions about morbidity episodes. In the
end, it is not clear that the data set will credibly support the multi-
variable, multi-equation analysis envisioned.
Possibly these concerns have been resolved already, but the proposal
then should convey that fact. In the present version, there is no compelling
evidence that consideration has been given to the implications for the
analysis of sample shrinkage, the rarity of the relevant evcnts (given the
analysis pIanned), or the suitability of the 5() chosen sites to -enerate
adequate variation in the important variables. Since the Medical Research
Council has apparently been collecting data in the Gambia for years, there
ought to be some pertinent data available on these issues. Why not present
some of that in the proposal?
-4-
Another concern is the limited progress so far in preparation of the
questionnaire. Until the highly general list of desired variables (pp. 10-13)
is translated into prototype questions, it is difficult to assess how well the
research will be able to meet its intended objectives. How will the length of
the recall period be resolved? What will be asked about morbidity -- e.g.,
will an attempt be made to determine the apparent cause of the problem and its
severity? How will the availability or nonavailability of each type of
service be gauged (if people are willing to travel far enough, every service
is available in principle)? The timeframe allowed to work out the details of
the questionnaire seems rushed. And while the proposal says that use will be
made of the questionnaires from other recent surveys, the list of surveys
mentioned (p.1 4 ) focuses mainly on ones that have not been designed to produce
the full range of demand study planned. There is no evidence anywhere in the
proposal that the authors are aware that the Bank research committee funded
another study not too long ago on health demand issues in Peru. Presumably
the survey forms used in that study and the deliberations that led to their
design might he of some help.
All in all, there is potential here for an excellent piece of
research. But not enough homework has been done so far to evaluate whether
that potential can indeed be successfully realized.
RESEARCH PROPOSAL
Health Care and Family Planning in The Gambia:
Determinants and Consequences of Service Utilization
July 1986
Policy and Research Division
Population, Health and Nutrition Department
World Bank
Nancy Birdsall, Julie DaVanzo (Consultant)
- i -
SUMMARY
This proposal describes a research project in The Gambia thatwill complement a population, health, and nutrition project currently being
prepared by The Gambian Government for IDA financing. The research has two
related objectives: (1) analysis of the effects of public and private
health and family planning services on health and fertility outcomes; and
(2) analysis of the causes of utilization of services by the public,including the effects of fees for services and quality of services. The
results of these analyses will allow (1) evaluation of the effectiveness of
the government's village-based primary health care system and
recommendations for improved design and targetting of the health and family
planning system; and (2) recommendations on the extent to which there is
scope for increasing fees to help finance the system without reducing
utilization by the poor.
The research will also explore two methodological issues: (i) the
reliability of survey responses to retrospective questions on fertility,mortality, and morbidity in West Africa (via comparison of already-
collected prospective demographic surveillance data with retrospective
survey responses), and (ii) the reliability of questions on willingness to
pay for public services (via comparison of survey responses to such
questions with expenditure data). These are explained more fully below.
Analyses will be based primarily on data to be collected from a
representative sample of individuals, compounds, and communities in The
Gambia. A typical compound might include 10 to 15 people in three house-holds, each household including a married woman and children, all related
to each other through the compound head. Some income and expenditure
decisions are at the compound level, some at the household level. The
survey will collect information on households' (and compounds') use of andexpenditures on health and family planning services, and on their willing-
ness and ability to pay for these services. The last item will requireinformation on sources of income and on expenditures, which will fill an
important void since there has not been an income and expenditure survey inThe Gambia since 1968, and that survey took place only in the capital city,Banjul. The survey will also collect data on individual, household,compound, and community characteristics that may explain variation in
utilization of services, and expenditures on them.
The research will directly support the purposes of the larger
project being prepared for IDA financing. That project will provide opera-tional support to Gambian government efforts to maintain and develop basic
family planning, health, and nutrition services while initiating policies,including appropriate levels of user fees, to enhance the financial self-
reliance of these sectors.
The research project will complement the PHN project by providing
data on households' actual expenditures and willingness to pay for health
and family planning services, and information on how these are influenced
'XTNAME: RE1PA-Jdv (K)F: J/
- ii -
by the costs and availability of these services and by the social and
economic characteristics of households. This information will aid the PHN
project in the targetting of services and the design of effective
cost-recovery mechanisms. It will also provide baseline data for
subsequent evaluation of the project and, because it will be done in
cooperation with government, contribute to strengthening of analytic
capacity, especially for the design, fielding, and analysis of
socioeconomic surveys.
There will be four main products from this project:
(1) The data set per se.
(2) A descriptive report on levels of expenditures and willingness to
pay, health status and health care utilization, fertility and
contraceptive practice, etc.
(3) Report(s) of multivariate analyses of influences on family
planning and fertility, and health care utilization and health
status, with emphasis on effects of prices and access on service
utilization and of service utilization on health and fertility
outcomes.
(4) Methodological papers assessing the quality of the
retrospectively collected data (by comparing its implications
with those of prospectively collected data on the same
households) and the usefulness of data on willingness to pay for
public services.
(5) A separate report on the health effects of the government's
village-based primary health care system.
We expect item numbers (3) and (4) to include publishable papers.
HEALTH CARE AND FA14ILY PLANNING IN THE GAMBIA:DETERMINANTS AND CONSEQUENCES OF SERVICE UTILIZATION
I. OBJECTIVES AND STRATEGY
This proposal describes a research project in The Gambia that
will complement a population, health, and nutrition project currently being
prepared by The Gambian Government for IDA financing. The research has two
related objectives: (1) analysis of the effects of public and private
health and family planning services on health and fertility outcomes; and
(2) analysis of the causes of utilization of services by the public,
including the effects of fees for services and quality of services. The
results of these analyses will allow (1) evaluation of the effectiveness of
the government's village-based primary health care system and
recommendations for improved design and targetting of the health and family
planning system; and (2) recommendations on the extent to which there is
scope for increasing fees to help finance the system without reducing
utilization by the poor.
The research will also explore two methodological issues: (i) the
reliability of survey responses to retrospective questions on fertility,
mortality, and morbidity in West Africa (via comparison of already-
collected prospective demographic surveillance data with retrospective
survey responses), and (ii) the reliability of questions on willingness to
pay for public services (via comparison of survey responses to such
questions with expenditure data). These are explained more fully below.
Analyses will be based primarily on data to be collected from a
representative sample of individuals, compounds, and communities in The
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Gambia. (We use the term compound here because compounds will be the
sampling unit. A typical compound might include 10 to 15 people in three
households, each household including a married woman and children, all
related to each other through the compound head. Some income and expendi-
ture decisions are at the compound level, some at the household level.)
The survey will collect information on households' (and compounds') use of
and expenditures on health and family planning services, and on their
willingness and ability to pay for these services. (The last item will
require information on sources of income and on expenditures, which will
fill an important void since there has not been an income and expenditure
survey in The Gambia since 1968, and that survey took place only in the
capital city, Banjul.) The survey will also collect data on individual,
household, compound, and community characteristics that may explain
variation in utilization of services, and expenditures on them.
The research will directly support the purposes of the larger
project being prepared for IDA financing. That project will provide
operational support to Gambian government efforts to maintain and develop
basic family planning, health, and nutrition services while initiating
policies, including appropriate levels of user fees, to enhance the finan-
cial self-reliance of these sectors. The proposed government project also
includes a component for strengthening evaluation and applied research.
(The attached project brief [Appendix A] provides more detail on the
proposed PHN project and background on the health and population sectors in
The Gambia.)
The research project will complement the PHN project by providing
data on households' actual expenditures and willingness to pay for health
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and family planning services, and information on how these are influenced
by the costs and availability of these services and by the social and
economic characteristics of households. This information will aid the PHN
project in the targetting of services and the design of effective cost-
recovery mechanisms. It will also provide baseline data for subsequent
evaluation of the project and, because it will be done in cooperation with
government, contribute to strengthening of analytic capacity, especially
for the design, fielding, and analysis of socioeconomic surveys.
The research project will be carried out in cooperation with the
Government of The Gambia and the British Medical Research Council (MRC).
The MRC has research stations and related clinical services at several
sites in The Gambia, where data has been collected which will complement
the data to be collected under this project. Questionnaires will be
finalized in consultation with government staff and field work will be
carried out by staff of the government's Central Statistical Office.
The data will be collected in four major sampling areas: the
Farafenni area, a rural area on the north bank of The Gambia River in the
center of the country, where the MRC has been collecting demographic and
health data from households in 42 villages for the last two years; Sukuta,
a peri-urban area about 15 kilometers outside of Banjul in western Gambia,
where MRC has recently done a census and has ongoing demographic surveil-
lance, covering about 400 households; the rural areas around the town of
Basse, in the eastern part of the country, where MRC is also doing demo-
graphic surveillance; and the urban area of Banjul/Serrekunda. In each of
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the first three of these areas, we will geographically extend the sampling
area from which a random sample of compounds and communities will be taken
beyond that covered by MRC field work, so that our complete sample will
include both MRC and non-MRC households (and communities). (The urban area
of Banjul/Serrekunda has no MRC households.) These four areas will provide
representation of major ethnic and income groups in the country.
Altogether we expect a sample of about 1000 households in about 50
different community settings.
Funding for this research project from the Bank's Research
Support Budget will complement government inputs. It accords with the
Bank's research agenda calling for more project-related research. There
are several additional reasons for not relying entirely on funds the
Gambian Government will be borrowing under the project PRN project:
o The lessons learned in The Gambia are likely to be useful to the
Bank in its work in other countries. (Hence, it is unreasonable
to expect the Gambian Government to underwrite the full costs of
the research.)
o Survey and research activities have minimum fixed costs, and
would constitute a prohibitively large component of the total PHN
project cost, given that the proposed PHN project is relatively
small.
The two subsequent sections of this proposal explain the design
(including analytic framework, survey data to be colleted, estimation
issues and methodological explorations) and organization of the proposed
work.
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II. DESIGN
ANALYTIC FRAMEWORK
Our analytic framework derives from a model of consumer demand
and household production. In this section we present a simple form of the
model to illustrate what it implies about the relationships among the major
types of variables we will study. This illustrative form focuses on the
model's implications about children's health.
For simplicity, we will assume that the mother is the main
decisionmaker with respect to children's health and that she has a utility
function whose arguments are the number (N) and health status (Hi) of her
children and her consumption of other commodities (Z) and leisure (L):
(1) U = U (N, Hi, Z, L), i=1, ... , N; U' 0, U'' 0.
N, H, and Z are produced by inputs of goods (X,, where j=N, H, or
Z), for example nutritious food or immunizations in the case of health, and
time (T ), but are conditioned by personal and environmental characteris-
tics that affect the amount produced or the efficiency of production. For
example, in addition of time and goods inputs, health status may be
affected by the age and sex of the child (Ai), their "health endowment"
(inherent healthiness or fraility) (Ei), environmental conditions that
affect health (e.g., disease vectors) (C), and by the mother's efficiency
in combining inputs to produce health, as measured, say, by her schooling
(S). Hence, the production function for health can be written as:
(2) Hi = H (Xa, T H; A E., C, S).
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The mother's time is devoted to production of N, H, or Z or to
work (w) or leisure. Hence we can write her time constraint as:
(3) T T + .T . + T + T + L,N i Hi Z w
where T = the total amount of time available for these activities.
There is also a full income constraint, which indicates that full
income, (F = the value of available time + other household income), will be
spent on goods or in nonmarket production or consumption of leisure:
(4) F = WT + V = Pj Xij + W ( , j Tij + L),
where W = the mother's wage rate or value of time, V = other household
income, and Pj = prices of Xj.
Each commodity has a "full price" which includes its money price,
e.g., fees for health services, and its time price, e.g., the value of time
spent in traveling to the service and in waiting for its use. This can be
seen by rewriting (4) as
(4a) F = (PjXj + WTj) + WL.
(The subscript i is suppressed for simplicity.)
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Inputs are chosen so as to maximize utility subject to the
production functions for N, H, and Z, the time constraint, and the full
income constraint. This leads to derived demand functions for the inputs
Xij and Tij as a function of all exogenous variables in the model, e.g.:
(5) X = f(P , P , PZ, W, V, A., E., C, S, ... ).Hi H' N' Z' i
In estimating these derived demand functions for health inputs, we will be
particularly interested in the influences of money and time (access) costs,
and their relative roles, in affecting service utilization. The effect of
different fees and distance on choice of health service (public, mission,
private traditional, private modern, no service at all) is of particular
interest.1 /
Comparable demand functions for family planning, schooling and
other services can also be derived from this model. These functions also
will be expressed in terms of exogenous variables such as the price of
services (any fees), the distance and time costs, and wage rates of family
members. To a limited extent, the household expenditure data may also be
used to estimate "demand" functions. 2/
1/ For analyses of treatment choice in Africa see Mwabu (1984) andBirdsall and Chuhan (1983).
2/ If respondents cannot report quantities purchased but can report expen-ditures on traditional and modern medicine and on drugs, these can beanalyzed as a function of such variables as the "prices" of each(community distance from various types of services) and unearnedincome. Note that with expenditures we have as a dependent variablecash price times quantity, whereas the true dependent variable we wantfor health demand equations is quantity, with cash price on the right-
hand side of the equation, along with the implicit price in the form ofdistance (and thus travel costs). We are interested in whether and howmuch service fees and distance to services affect spending (negatively,if "price" matters). It may also be of interest to see whether and how
spending varies by type of sickness, particularly between modern andtraditional. (Many households report spending on both types.)
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There implicitly exist analogous reduced-form equations for
health status and other commodities, which have the same arguments as the
preceding demand equation. For example,
(6) H = H (P P P, W, V, A., E., C, S, ...).3/H' N' Z' i _
The parameters of these reduced form equations explaining
outcomes and utilization, (5) and (6), can be estimated consistently by
standard statistical methods, e.g., ordinary least squares, for a dependent
variable that is normally distributed.
One of the objectives of this research is to assess the effects
of utilization of public and private health and family planning services on
health and fertility outcomes. This entails estimating the production
functions (2) -- i.e., the effect of (the chosen) health inputs on health
status. To obtain consistent estimates of the production functions,
simultaneous equations methods must be used because health inputs are not
exogenous, but are the result of choice and may be influenced by unobserved
factors that also influence health status. For example, unobserved
inherent unhealthiness (low Ei) may increase both the likelihood of poor
health status and the use of inputs that improve health in an effort to
compensate; in such a case, the effectiveness of the input in producing
good health would be underestimated.4 / Simultaneous equations techniques
enable the researcher to purge the (chosen) health input variable of the
3/ Estimates of the coefficients of this reduced-form equation for health
status would reflect the combined effects of the technological
constraints (i.e., the production functions) and demand behavior.
4/ As another example, regarding fertility, couples may be less likely topractice contraception if they know their level of fecundity is low; in
this case the "effect" of contraception in reducing the conception rate
would be underestimated.
TEXXNAME: KEFAG-JdV K)P: UV
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portion of its variation due to variation in unobservable factors (e.g., E)
that affect both the input and the outcome. For this purpose, we need one
or more instrumental variables that account for the variation in X, but are
independent of E. This can be achieved, for example, if health inputs
depend on the prices of those inputs, but those prices per se do not enter
the health production function. For example, the use of prenatal care may
be determined both by the mother's anticipation of pregnancy problems and
by whether the MCH team visited her village. In measuring the effect of
prenatal care on pregnancy outcome, we want to purge the variable measuring
use of prenatal care of the variation due to the anticipation of pregnancy
problems, but retain the (exogenous) variation due to variation in the
trekking schedule. This underscores the importance of having community-
level data on prices (both time and money prices) to appropriately model
influences on health care utilization and health outcomes.
The preceding is, of course, a very simplified version of the
actual choices facing individual decisionmakers. An expanded version would
include a wider variety of commodities and their components, as well as
tradeoffs among household members and among time periods. For example, a
child's health status is "produced" by a number of behaviors, e.g.,
prenatal care, feeding, immunizations, use of uncontaminated water,
curative medical care, etc., which may to some extent substitute for one
another in producing good health.5 / Each of these in turn have "prices"
(time, money, and psychic) that affect the use of the service and that of
5/ For example, the price of hygienic water could affect breastfeeding
behavior because breastfeeding protects against infections borne by
unhygienic water; as good water becomes less expensive and more is
consumed, less breastfeeding is needed to produce a given level of
health (Butz, Habicht, and DaVanzo, 1984).
TEXTNAME: REPAC-Jdv (R)P: 1U
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their substitutes. However, this additional complexity in no way changes
the basic idea that health status is the result of interrelated household
behaviors, conditioned by prices, resources available, environmental and
biological factors, and tastes; it merely increases the number of these
factors that are relevant.
THE SURVEY
Types of Data to be Collected.
Estimation of the analytic model just described requires
information on health and fertility outcomes, on the behaviors that
influence these outcomes, and on individual, household, compound, and
community characteristics that affect either the outcomes and/or the
behaviors.
The household survey of compounds will collect the following
types of information:
o Health and fertility outcomes
- Infant and child mortality
- Morbidity of all compound members
- Pregnancy outcomes and fertility
o Health and fertility behavior
- Utilization of and expenditures (money and time) on health
care for all compound members, including:* modern public services (prenatal, well-baby, immunization,
curative)
* modern private services (mission clinics, private
physicians, nurse-dispensers)
* pharmacies and other drug outlets
- Utilization of and expenditures on family planning
services/contraception, including private and public, modern
and traditional
TEXTNAME: REPAC-Jdv (R)P:11
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- Health habits (e.g., washing hands, boiling water)
- Infant feeding
- Willingness to pay for goods and services (e.g., village
health worker, community well, drugs).
The items in the above list will be treated as endogenous variables. We
will seek to explain variations in them with information on the following
independent, exogenous variables:
o Influences on health behavior
- Income and its sources (e.g., agriculture, cottage industry,
remittances, ... ) (ability to pay for health care)
- Number of persons in the compound and their socioeconomic
characteristics, including age, education, ethnicity,
principal activity, secondary activity.
- Community (village-level) data on the availability, prices,
and type and quality of health and family planning services
offered in the public and private sectors and on other
community characteristics, such as schooling availability,proximity to major transportation, condition of water, that
may affect health and fertility behavior and outcomes.
The community or village-level data is particularly important for
both policy and estimation purposes: (1) Community data provide information
on factors affecting health care and survival that are often directly
manipulable by policies and programs; (2) community data are more likely
than most other factors affecting or measuring mortality and morbidity risk
to be exogenous to household decisionmaking. This also has an important
implication for sample design: There must be a sufficient number and
variety of communities to provide ample variation for analysis.
We will collect the following types of community and provider
data:
TEXTNAME: REPAC-Jdv (R)P: 12
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o Health and family planning programs: Availability, prices, and
type and quality of services offered in the public and private
sectors.
- Regarding availability, we would like information on how far a
community member must go to get services, how frequently those
services are available (number of days per month, number of
hours per day), and the extent to which there have been
problems with service availability (e.g., treks cancelled
because of shortages of fuel, supplies, or personnel,
particular drugs not available in pharmacies, and so on). We
know that these problems have occurred in some places in The
Gambia in recent years.
- For prices, information should be collected not only on money
costs, but also on time costs (both travel time and waiting
time). Efforts should also be made to collect information on
psychic costs; e.g., other things the same, people may be less
likely to use a service if the language or ethnic group of
service providers differs from their own (see, for example,Potter, 1985). We expect some variation in the money costs of
drugs among private outlets.
- Dimensions of quality of services offered include
* The training of service providers (e.g., Have birth
attendants been trained about appropriate methods for
cutting and treating the umbilical cord?), their time in
service.
* The types of procedures that can be performed (e.g., Can
cesarean sections or sterilizations be performed at the
nearest delivery point? It not, what are the mechanisms
for referrals of these or other problem cases to other
tiers of the health system? Is transportation readily
available for emergency referrals?)
* The methods and services available and restrictions on
their use (e.g., What drugs are available? What
contraceptive methods are available? Are certain methods
[particularly injectable contraceptives] only available to
women of a minimum age and/or parity?)
* The range of pharmaceutical products available and the
extent to which they have been consistently available over
time.
- The types of information in the above list will be collected
for the following types of services:
* Prenatal, delivery services, and well-baby care
TEXTNAME: REPAC-Jdv (R)P: 1
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* Family planning
* Private traditional services
o Prices and availability of food, including weaning foods forinfants.
o Labor markets: Availability of jobs in or near the community,
wages paid, compatibility of these jobs with child care. Theseaffect the wages and income of adults and children.
o Schools: Availability, prices, perceived quality.
o Prices and availability of electricity, soap, pesticides.
o Transportation
- Availabilities and prices of public transportation and of fuel
- Quantity and quality of roads
o Environmental conditions
- Prevalence of disease vectors
- Campaigns to control or eradicate particular diseases
- Climate
- Water supply, sewerage
o Communications--Radio, TV, newspapers, telephone.
o Community organization regarding collection and holding of money
for community purposes (e.g., to pay the village health worker,
to maintain a village well, to have festivals).
To the extent possible, we will collect community information not
only on the current status of items in the above list, but also information
on whether there have been important changes in these in the recent past
(say last 5-10 years), since we will be collecting information on many of
the dependent variables of interest over such a reference period.
In designing the survey, we will draw on the questionnaires from
a number of recent survey efforts. Project personnel have first-hand
experience with most of these surveys. They are:
XTNAME: REP&C-Jdv (R)P: 14
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" The Malaysian Family Life Survey (MFLS), an extensive
multi-purpose survey designed by Julie DaVanzo (and William P.Butz) and fielded in a nationally representative sample of
households in Pennisular Malaysia in 1976-77 (Butz and DaVanzo,
1978). The data have been the basis for a large number of
demographic, economic and health studies. Appendix B lists all
Rand publications based on the data. John Haaga, who will be in
The Gambia to oversee our survey, has used the MFLS data in
several analyses and has investigated their quality (Haaga,
1984).
o The Mali Household, Community and Service Provider Surveys,
designed by a World Bank team headed by Nancy Birdsall (and
Francois Orivel) and conducted in 38 villages in Mali in 1981 and1982. These have provided the basis for analyses of cost
recovery issues in health and schooling (see Appendix C).
o The Demographic and Health Surveys (DHS), a set of demographic
and health surveys that will be conducted in 35 countries, about
half of them in Africa. The surveys are being designed and
fielded by Westinghouse Public Applied Systems, with funding from
USAID. Julie DaVanzo is on the Scientific Advisory Committee for
the DHS project.
o Various surveys fielded by the British Medical Research Council
(MRC) in The Gambia, for example, the Farafenni Malaria Study,
the Bakau RBtavirus Study, and the Sukuta Measles Study.
o The World Bank Living Standards Measurement Study (LSMS) Surveys,one of which is being conducted in the Ivory Coast. The LSMS
Ivory Coast questionnaires will be helpful in designing questions
about sources of income and about expenditures for The Gambia.
(The Malaysian Family Life Survey, listed above, was itself an
important influence on the design of the LSMS.)
o The Amman Population and Health Surveys. The Second Amman
survey, which was fielded in early 1985, is being used to assess
the effects on children's health of an urban upgrading project(which is financed by a World Bank loan). The design and
fielding of this survey is being supported by Bank research
funds. Julie DaVanzo has advised on the design of the follow-upsurvey and on the empirical analyses.
Sample Design
The survey will take place in around 50 villages in 4 areas in
The Gambia. Three of these areas -- Farafenni, Sukuta, and Basse -- are
sites of on-going or upcoming field operations of the British Medical
Research Council (MRC). The Farafenni study area consists of 42 villages
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which are typical of rural areas in The Gambia.6 / Sukuta is a peri-urban
area near Banjul. 7 / Basse is the center of a rural area in the eastern
part of the country.8 / In these sites, we will be able to use the
up-to-date MRC sample frames and to build on the extensive data the MRC has
been collecting on individuals in these areas. The MRC has been doing
monthly demographic surveillance for one year in Sukuta and for several
years in Farafenni, and is just beginning such efforts in Basse. The
entire populations are reenumerated annually. Information is available on
the entire populations of 12,3000 in Farafenni and 6,700 in Sukuta and on
all births and deaths during the study periods, including cause of death
(from verbal autopsies) for all women and children.
In one-fifth of the compounds in Farafenni, morbidity data have
been collected monthly on all children under age seven. Information on
their utilization of health care (type of practitioner seen) is also
available, as are periodic anthropometric measurements. Hence, there is
exceptionally rich data available for around 600 children, representing
around 150 compounds.
6/ MRC has been doing a malaria prophylaxis study in Farafenni. Two-thirds of the villages have primary health care (PHC) and one-third do
not. One-half of the PHC villages are receiving malaria treatment andone-half are not. The non-PHC villages are not receiving treatment.We will restrict our sample to the non-treatment villages.
7/ Many of the adults in Sukuta commute to Banjul for work. However, thearea itself does not have modern amenities. For example, there is no
electricity in the area. MRC is doing a measles study in Sukuta. Thearea consists of 378 compounds. Detailed information is available on
710 children under the age of three.
8/ In Basse, MRC has been doing a project, but no clinical work. There
are several field workers already there, and a major project on
respiratory diseases will be beginning in April 1986. The populationof the Basse study area will be 2000-3000, living in 2-3 villages;500 children under the age of five are expected.
rrEXTNAME: REPAC-Jdv (R)P: 16
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Piggy-backing onto the MRC surveys will be a tremendous advantage
because (1) there is no up-to-date sample frame for The Gambia as a whole
or for specific areas other than those where MRC has field studies in
progress,9 / (2) the Farafenni study has gone to considerable effort to
figure the ages of the study population (by asking about key life events in
relation to the timing of salient national and community events), and (3)
the monthly prospective information MRC has been collecting on pregnancies,
morbidity, and mortality will be of higher quality than what we would be
able to collect in a retrospective survey. There are two reasons for this:
First, there is always the risk of recall error in a retrospective survey,
especially in a country like The Gambia, where ages and dates are not
particularly important to respondents and where registration of vital
events is incomplete. Second, retrospective surveys typically collect
information on pregnancy outcomes and child survival from women who are
present at the time of the survey. Such an approach misses all pregnancies
that occurred to women who are no longer alive at the time of the survey.
In most countries, maternal mortality rates are sufficiently low that this
will not seriously bias the data. However, data from The Gambia suggests
that maternal mortality rates there may be around 20/1000 (Lamb et. al.,
1984) -- among the highest in the world. We will also collect
retrospective survey data on fertility, mortality and morbidity in the MRC
villages, for comparison with prospective data, as explained below.
9/ The Gambian Census was fielded in 1983 and hence will be somewhat out
of date by the time we begin our field work. Though we will use it as
a basis for choosing communities to add to our MRC sample, we will have
to re-enumerate the residents of those communities prior to drawing a
sample.
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In addition the socioeconomic data our survey will collect will
complement the rich biomedical data MRC has collected, making it a richer
dataset for their purposes, as well as for ours.
As noted above, in each of these three areas, the sampling area
from which a random sample of households and communities will be taken will
be extended geographically beyond that covered by MRC field work, so that
our complete sample will include both MRC and non-MRC households (and
communities). In addition to sampling the urban area of Banjul/Serrekunda,
up to two additional sampling areas will be added if this is necessary in
order to achieve representation of all ethnic or income groups in the
country. Altogether we expect a sample of about 1000 households in about
50 different community settings.
Because there are two distinct seasons in The Gambia (the rainy
season between April and September and the dry season the rest of the year)
and morbidity, work, and diet patterns differ markedly between the
two, 10 /our survey will consist of two rounds, one in each season. We plan
to interview a random two-thirds subsample of compounds in the second
round.
Respondents for the Survey of Individuals and Compounds
In the villages that have already been enumerated by MRC, we will
interview the same compounds that have provided information for the MRC
intensive prospective surveys. In each of these compound, we will select
one ever-married woman of childbearing age to be the primary female
10/ For example, the 1979 World Bank Basic Needs Report on The Gambiaemphasized that greater energy demands, low (pre-harvest) income, andrainy conditions in the wet season combine to cause nutritionalproblems, especially for pregnant and lactating women.
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respondent and will collect data about her pregnancies, infant deaths, and
contraceptive use over the last five years. We will also ask about her
recent morbidity and health care use and those of her children who
currently live with her, including any children that are not her own that
she is caring for. We will also interview the male in each compound who
can best provide information about compound income and expenditures. Other
compound members may be interviewed if necessary to provide complete
information.
In the non-MRC villages we will select a sample of compounds to
be included in the study sample, and will follow the procedures just
described for the MRC villages.
Sources of Community and Provider Information
The data on communities (villages) and service providers will
come from four main sources:
(1) government records(2) interviews with service providers(3) interviews with groups of key village people (e.g., the village
council or village health committee)(4) observation (e.g., distances to service delivery points.1 1 /
As noted above, to the extent possible, we will collect data not
only on the current status of key community variables, but also on whether
there have been important changes in the recent past. Since many of our
individual-level variables of interest will come from retrospective surveys
that cover a reference period of up to five years, it is important that the
community data refer to the same points in time. For example, the primary
11/ In a geographically dispersed village or community, distance to
particular points may exhibit meaningful variation among compounds andmay need to be collected separately for subareas of the village.
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health care system has spread throughout The Gambia over the last five
years; villages that now have a trained birth attendant or drugs available
in the village may not have had these services readily available several
years ago. Such variation in community characteristics over time, some of
which is probably documented in government records, should help explain
variation over time in pregnancy outcomes and infant mortality.
ESTIMATION OF THE EMPIRICAL MODEL
The Analytic Framework section above has already discussed the
types of equations we will estimate: reduced-form equations for service
choice and utilization ("inputs") and for health and fertility outcomes,
as well as structural equations for the outcomes that use instrumental-
variable estimates of the endogenous inputs. The equation estimation
techniques will depend on the nature of the dependent variables. For
example, where the dependent variable is dichotomous (e.g., whether the
child has been immunized or whether contraception has been used), we will
use logit or probit analysis. If the variable is qualitative with several
outcomes (e.g., type of contraceptive method used, type of health
practitioner seen), we will use multinomial logit or probit analysis. If
the dependent variable is continuous but limited, e.g., health expenditures
(which may equal zero for many families), Tobit estimation will be
employed.
Other statistical issues that may arise are the intercorrelations
of errors that can occur when there is more than one observation per family
(e.g., on the health of several members of the same family) or more than
one observation on the same person (e.g., for the two seasons).
Variance-components techniques will be used in such cases, and it may be
possible to estimate family- or individual-specific effects, which can be
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used in a second round of estimation to assess the influence of such
unobserved factors as "health endowment" (as discussed in Schultz, 1984).
METHODOLOGICAL EXPLORATIONS
In addition to analyzing the effects of public and private health
and family planning services on health and fertility outcomes, and the
price elasticity of demand for these services, this research project will
explore two methodological issues:
(1) the reliability of survey responses to retrospective questions on
fertility, mortality, and morbidity in West Africa; and
(2) the reliability and usefulness of questions on willingness to pay
(WTP) for public services.
Retrospective vs. Prospective Data
As noted above, in Sukuta and Farafenni, MRC has been collecting
monthly information prospectively on all pregnancies, births, and deaths in
the study populations. Our survey will collect retrospective data on these
same events for these same individuals. Comparison of survey responses for
these individuals with the prospective MRC data on them will allow us to
assess the biases in data collected retrospectively in such popula-
tions. The costs of collecting retrospective data are much lower; if they
are accurate, retrospective surveys provide a low-cost alternative to
costly longitudinal surveys for providing information on levels and trends
in fertility, mortality and health.12/ Or to the extent their inaccuracy
12/ For example, the MFLS data from Malaysia have been shown to be quiteaccurate in their information on fertility, infant mortality, malewages, and other socioeconomic variables in the past (Haaga, 1984;Smith, 1983). The MFLS have been used in a number of studies that haveilluminated the factors underlying trends over time in these variables(e.g., DaVanzo and Haaga, 1982; Smith, 1983; DaVanzo and Habicht,1984).
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can be shown to be a function of characteristics (education, ethnic group)
and can be modelled over time (with inaccuracy presumably increasing as one
goes backward in time), we can "correct" the retrospective information from
households not included in the MRC studies.1 3 /
Furthermore, comparison of the retrospective and prospective data
will enable us to assess the biases associated with maternal mortality in
retrospective data on pregnancies, births, and deaths (e.g., number and
outcomes of pregnancies missed in the retrospective data, types of women
missed).
In Farafenni and Sukuta MRC has also been collecting data monthly
on the morbidity of children. The questions ask about morbidity on the day
of the interview and about illnesses over the month preceding the
interview. Our survey will ask these same questions and will also test the
possibility of asking about particular serious illnesses over a longer
period, probably a year. We will compare the answers to these questions
about serious morbidity over the past year with responses to the MRC
morbidity questions for each of the previous 12 months to assess the error
associated with the longer recall period.14 /
13/ For example, if the ratio of the actual rate to reported rate ofmorbidity was shown to vary systematically with the respondent's age,education, ethnic group, or amount of time since the even occurred, thereported rates could be adjusted to reflect these reporting biases.If these factors are only related to the degree of "noise" in thereports, we can give less weight to these less accurate reports in theanalysis.
14/ It is also possible that the one-year recall may reveal illnesses notreported in the monthly reports because families were temporarilyabsent when the illness occurred. If the one-year recall data appearto be accurate, they can be used to "fill in" values missing in themonthly data due to seasonal migration.
TEXTNAME: REPAC-Jdv (R)P: 23
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Testing the Willingness to Pay Approach
In addition to estimating equations explaining utilization of
health, family planning and other related goods and services as a function
of fees, quality, distance, wage rates, unearned income, and so forth, we
will examine the effect of these same explanatory variables on respondents'
willingness to pay for services using the "contingent valuation" approach.
We will focus on willingness to pay for a village health worker and
willingness to pay for certain specifiable drugs (e.g., one treatment
regime of chloroquine). We have chosen these two items because villagers
are already paying for them in some villages, i.e., those villages where
the village health care system has been started, but not in other village.
We will explain fully to respondents the characteristics of the
hypothetical item (e.g., skills, age, sex, hours of work of hypothetical
worker; exact quantity and purpose of drug). They will then be asked
questions to elicit the amount they would be willing to pay for the item
(or in some cases, the amount they would be willing to accept to give up
the item). In the case of the village health worker, the respondent will
be given a hypothetical morbidity situation (e.g., an infant with a high
fever that has lasted three days); this will enable us to hold constant
(hypothetically) the extent of morbidity.
This contingent valuation approach is particularly useful in
areas where new projects are being planned and where imposition of some
form of user fees is necessary to their long-run financial viability. In
villages where a planned service has not existed before, the results of the
expenditure analysis examining demand for a similar but not equivalent
TEXTNAME: REPAC-Jdv (R)P: 24,
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service provide little guidance on the potential demand for the new
service. Or existing similar services may not charge any fee, or may
exhibit no variation in fees; without variation in fees, there is no basis
for estimating a fee elasticity in a cross-section.
The contingent valuation approach has been used widely as a
method to elicit preference functions for public goods such as better air
quality or wildlife preserves in developed economies (Freeman, 1979), and
recently, to estimate willingness to pay for housing services (Follain and
Jimenez, 1983) and water and health services (Birdsall and Chuhan, 1983) in
developing economies. The approach is of course particularly useful in the
case of public goods where there is no actual market and thus consumer
preferences cannot be indirectly revealed. In an analogous way it is also
potentially useful in developing countries for analyzing preferences for
certain services -- such as village health workers, water supply, and
education -- for which there is no market for one of several reasons:
(1) services have not been previously provided -- even privately; (2)
existing services are offered at such low quality or such great distance
from potential clients that the full price is close to infinite; 15/ or
(3) as suggested above, services are provided at no charge and thus without
the variation in fee required to estimate the effect of fees on demand.
There remains, however, considerable skepticism, particularly
among economists, about the validity of amounts elicited by this method,
15/ One might ask why no private market emerges. The answer may be that
there are externalities or market imperfections (poor capital
markets). In the case of lack of preventive health services in rural
areas (e.g., immunizations), the idea of "uninformed consumers"
probably also has merit.
TEXTNAME: REPAC-Jdv (R)P: 25
- 24 -
with concern focussing on several possible types of response bias. These
include hypothetic bias -- that respondents' answers will be meaningless
because the market described to them is not real; and, of greater concern,
strategic bias - that respondents will inevitably strategize rather than
tell the truth if telling the truth is more costly. For example, respon-
dents might understate their willingness-to-pay in an attempt to reduce
their own payments and thus to free-ride1 6/, or respondents might exagge-
rate their own bid, upwards or downwards, to increase the difference
between their own and the expected mean bid and thus move the sample mean
in their preferred direction. Behavior of this kind will increase the
variance of the bids and, assuming a minimum acceptable bid of zero, bias
sample mean bids in an upward direction.
Experiments and validity tests have indicated, however, that the
WTP approach, when carefully carried out in terms of the survey approach,
does yield sensible results in valuing public goods. For example, the
expected relationship between individual bids and such socioeconomic
characteristics as income has been found. The frequency of protest bids
(bids of zero or no response at all) has varied from 10 to 50 percent in
various surveys, suggesting that the effort made to explain the structure
of the contingent market is important to the quality of the WTP data.1 7!
And travel cost models and hedonic rent equations have been used in the
same samples to estimate by an alternative method implicit willingness
to pay. The two methods have generally yielded comparable results.
16/ This notion was suggested by Samuelson (1954). For a report of an
experiment indicating free-riding is a factor, but has a relatively
modest effect, see Schneider and Pommerehne (1981). Kurz (1974) also
reports results of an experiment.
17/ See Mitchell and Carson (1982) for discussion.
- 25 -
Nature of Final Products
There will be five main products from this project:
(1) The data set per se.
(2) A descriptive report on levels of expenditures and willingness topay, health status and health care utilization, fertility andcontraceptive practice, etc.
(3) Report(s) of multivariate analyses of influences on family plan-ning and fertility, and health care utilization and healthstatus, with emphasis on effects of prices and access on serviceutilization and of service utilization on health and fertilityoutcomes.
(4) Methodological papers assessing the quality of theretrospectively collected data (by comparing its implicationswith those of prospectively collected data on the samehouseholds) and the usefulness of data on willingness to pay forpublic services.
(5) A separate report on the health effects of the government'svillage-based primary health care program.
III. ORGANIZATION
PROJECT PERSONNEL
The principal investigators of this project are Nancy Birdsall
(Chief, PHNPR) and Julie DaVanzo, (Senior Economist at The Rand
Corporation). Dr. DaVanzo's curriculum vitae is attached (Appendix D).
We hope to have the active involvement of the following Gambian
government staff:
Ms. Eliza Jones, of the Ministry of Economic Planning and
Industrial Development (MEPID). Ms. Jones was released by government to
spend several weeks at the Bank helping to prepare the questionnaires. We
hope she will be able to take an active role in coordinating the project
for government, in supervising field work, and in data analysis.
Drs. Fred Oldfield, Hatib N'Jie and Philip Cowers, all of the
Department of Medical Services, Ministry of Health, The Gambia. Drs.
Oldfield, N'Jie and Gowers have all been involved in the design and
management of the still-expanding village primary health system in The
Gambia, the evaluation of which is a major objective of this research.
M.S. Jeng - Chief Demographer, Central Statistics Department, The
Gambia.
Mary Yamwa - Demographer at the Central Statistics Department who
has been working with Phil Hanlon on his MRC field studies.
FIELD WORK
The fielding of the questionnaires will be carried out by
interview staff of the government Central Statistics Department (CSD), who
will be trained for this survey.
We anticipate that each interviewer will be able to complete
interviews with an average of 1-1/2 compounds per day (allowing for time
for locating compounds and locating respondents). In Farafenni it should
be possible in about two weeks time with 15 interviewers to complete
individual and community interviews for the 100 or so non-treatment
compounds on which we have detailed monthly data, as well as additional
non-MRC compounds from outside the MRC study area. After Farafenni, we
should be able to complete interviews with an average of around 50
compounds per week and their corresponding communities. At this rate, the
entire first round of interviewing will last around five months.
We will keep this staff of interviewers for the second round
(rainy season) interviews and will reinterview a random two-thirds of
selected compounds, including those absent during the first round. We
- 27 -
should be able to complete more interviews per week in the rainy season
because (1) we will not be administering the full five-year retrospective
pregnancy and child mortality histories, but rather only updating those
events that occurred since the compound was last interviewed, and (2) most
of the community and provider data should not require updating in the
second round (e.g., distances to service points). Nevertheless we will be
careful to update the community and provider information wherever changes
have occurred or where conditions differ during the rainy season.
Furthermore, the compound and individual questionnaires will repeat the
full set of questions about morbidity and health care utilization, since
these are areas where we expect important seasonal variations.
For the physical design of the questionnaire, and for data entry
procedures, we will rely heavily on two computer programs designed by LSMS
staff for use in the LSMS Ivory Coast household and community survey. The
first program, written for an IBM/PC permits rapid reworking of the
questionnaire after pilot tests in the field (allowing a revised
questionnaire to be duplicated quickly and avoiding long printing
turnaround). The second, a data entry program, is designed to allow
entry in the field of questionnaire results directly onto disk, and has
built in consistency and editing checks. (Data collected in the Ivory
Coast has been available for processing in Washington within less than two
months after collection, compared to typical elapsed time periods of five
years, e.g. for a 1979 Ivory Coast consumption survey.)
- 28 -
TIMING OF RESEARCH TASKS
Month 1 Project begins; draft questionnaires completed by DaVanzo,Birdsall, and Jones
Months 2 and 3 Questionnaires reviewed by Gambian collaborators andpilot-tested
Questionnaires finalized and printed
Additional interviewers hired
Month 4 All interviewers trained
Month 5 Field work begins in Farafenni
Additional villages selected
Mid mo.5-mo.9 Field work in other parts of the country
Month 10- early Holiday for interviewers; debriefing and retrainingmonth 11
(beginning of
rainy season)
Remaining dry-season data punched and transmitted to Bankand Rand. (Data will be immediately checked forinconsistencies and these will be sent to The Gambia to beclarified during the second round of the survey.)
Mid mo.1I- Rainy-season interviews (on a two-thirds subsample ofmo.13 compounds)
Month 12 Analysis begins of dry-season data
Month 14 Remaining rainy-season data punched and transmitted to Bank
Month 15 Rainy- and dry-season data merged
Through Analysis of data and preparation of reportsMonth 24
TEXTNAME: REPAC-Jdv (R)P: 30.1
- 29 -
IV. B U D G E T
[To be donel
XTNAME: REPAC-Jdv (R)P: 31
- 30 -
REFERENCES
Birdsall, Nancy and P. Chuhan. 1983. "Willingnes to Pay for Health andWater in Rural Mali: Do WTP Questions Work?" In Three Studies on CostRecovery in Social Sector Projects, CPD Discussion Paper No. 1983-8,World Bank. February.
Birdsall, Nancy and P. Chuhan. 1985. "Treatment Choice for HealthProblems in Rural Mali." Draft.
Butz, W.P., and J. DaVanzo. 1978. The Malaysian Family Life Survey:Summary Report, R2351-AID, The Rand Corporation.
Butz, W.P., J.P. Habicht, and J. DaVanzo. 1984. "Environmental Factors inthe Relationship between Breastfeeding and Infant Mortality: The Roleof Sanitation and Water in Malaysia," American Journal ofEpidemiology, Vol. 119, No. 4.
DaVanzo, J. and J.G. Haaga. 1982. "Anatomy of a Fertility Decline:Peninsular Malaysia, 1950-76," Population Studies, Vol. 37.
DaVanzo, J. and J.P. Habicht. 1984. "What Accounts for the Decline inInfant Mortality in Peninsular Malaysia, 1946-75?" N-2166-WB/RF/FF,The Rand Corporation, and background paper to the 1984 WorldDevelopment Report, World Bank.
Follain, J.R. and E. Jimenez. 1983. "Estimating the Demand for HousingCharacteristics in Developing Countries", Urban DevelopmentDepartment, mimeo.
Freeman, A. Myrick. 1979. The Benefits of Environmental Improvement: Theoryand Practice (Baltimore, Md., Johns Hopkins University Press forResources for the Future).
Haaga, J.G. 1984. "The Accuracy of Retrospective Data from the MalaysianFamily Life Survey," N-2157 AID, The Rand Corporation.
Kurz, Mordecai. 1974. "Experimental Approach to the Determinants of theDemand for Public Goods". Journal of Public Economics 3, pp. 329-348.
Lamb, W.H., F.A. Foord, C.M.B. Lamb, and R.G. Whitehead. 1984. "Changesin Maternal and Child Mortality in Three Isolated Gambian Villagesover Ten Years," The Lancet, October 20, 1984.
TNAME: REPAC-Jdv (R)P: 32
- 31 -
Mitchell, Robert Cameron and Richard T. Carson. 1981. "An Experiment inDetermining Willingness to Pay for National Water QualityImprovements", (Draft report prepared for U.S.E.P.A.) June.
Mwabu, Germano. 1984. "Conditional Logit Analysis of Household Choice ofMedical Treatments in Rural Villages in Kenya", paper presented at theAfrica Studies Association Conference, Boston, December 1983.
Potter, J. 1985. "Use of Maternal Health Services in Rural Mexico," paperpresented at the meeting of the Population Association of America,Boston, March.
Samuelson, Paul. 1954. "The Pure Theory of Public Expenditure". Reviewof Economics and Statistics 36 (November), pp. 387-389.
Schneider, F. and W.W. Pommerehne. 1981. "Free Riding and CollectiveAction: An Experiment in Public Microeconomics". Quarterly Journal ofEconomics, November 4, pp.689-704.
Schultz, T.P. 1984. "Studying the Impact of Household Economic andCommunity Variables on Child Mortality," Population and DevelopmentReview, supplement of Vol. 10.
Smith, J.P. 1983. Income and Growth in Malaysia, R-2941 AID, The RandCorporation.
RESEARCH PROPOSAL
Health Care and Family Planning in The Gambia:Determinants and Consequences of Service Utilization
Mar&- 1986
Policy and Research DivisionPopulation, Health and Nutrition DepartmentWorld Bank
Nancy Birdsall, Julie DaVanzo (Consultant)
EEXTINAME: ,REPAC-Jdv (R)P: 36
SUMMARY
This proposal describes a research project in The Gambia that
will complement a population, health, and nutrition project currently being
prepared by The Gambian Government for IDA financing. The research has two
related objectives: (1) analysis of the effects of public and privatehealth and family planning services on health and fertility outcomes; and(2) analysis of the price elasticity of-demand for these services. Theresults of these andlyses will allow (1) evaluation of the effectiveness ofthe government's village-based primary health care system and recommenda-tions for improved design and targetting of the health and family planning
system; and (2) recommendations on the extent to which there is scope forincreasing fees to help finance the system without reducing utilization bythe poor.
The research will also explore two methodological issues: (i) thereliability of survey responses to retrospective questions on fertility,mortality, and morbidity in West Africa (via comparison of already-collected prospective demographic surveillance data with retrospectivesurvey responses), and (ii) the reliability of questions on willingness to
pay for public services (via comparison of survey responses to suchquestions with expenditure data). These are explained more fully below.
Analyses will be based primarily on data to be collected from arepresentative sample of individuals, compounds, and communities in The
Gambia. A typical compound might include 10 to 15 people in three house-holds, each household including a married woman and children, all relatedto each other through the compound head. Some income and expendituredecisions are at the compound level, some at the household level. Thesurvey will collect information on households' (and compounds') use of andexpenditures on health and family planning services, and on their willing-ness and ability to pay for these services. The last item will requireinformation on sources of income and on expenditures, which will fill animportant void since there has not been an income and expenditure survey inThe Gambia since 1968, and that survey took place only in the capital city,Banjul. The survey will also collect data on individual, household,compound, and community characteristics that may explain variation inutilization of services, and expenditures on them.
The research will directly support the purposes of the largerproject being prepared for IDA financing. That project will provide opera-tional support to Gambian government efforts to maintain and develop basicfamily planning, health, and nutrition services while initiating policies,including appropriate levels of user fees, to enhance the financial self-
reliance of these sectors.
The research project will complement the PHN project by providingdata on households' actual expenditures and willingness to pay for health
and family planning services, and information on how these are influenced
tima n-tshe UNICEF-rasident-representative-in The Gambia -who -is a-health,
planne-r-and spent e-y-ar worktng-ir-the-Planning Unit of the Ministry of -
IHeal_ttpr-f--eo-jotntng-UleEW; The MRC has research stations and, related
clinical services at several sites in The Gambia, A Questionnaires will be
finalized in consultation with government a'flV= staff 1eld work will
be carried out by staff of the government's Central Statistical Office and
The data will be collected in four major sampling areas: the
Farafenni area, a rural area on the north bank of The Gambia River in the
center of the country, where the MRC has been collecting demographic and
health data from households in 42 villages for the last two years; Sukuta,
a peri-urban area about 15 kilometers outside of Banjul in western Gambia,
where ?RC has recently done a census and has ongoing demographic surveil-
lance, covering about 400 households; the rural areas around the town of
Basse, in the eastern part of the country, where MRC is also doing demo-
graphic surveillance; and the urban area of Banjul/Serrekunda. In each of
,EXTNAME: REPAC-Jdv (R)V: U4
-4-
the first three of these areas, we will geographically extend the sampling
area from which a random sample of compounds and communities will be taken
beyond that covered by MRC field work, so that our complete sample will
include both MRC and non-MRC households (and communities). (The urban area
of Banjul/Serrekunda has no MRC households.) These four areas will provide
representation of all ethnic and income groups in the country. Altogether
we expect a sample of about 1000 households in about 50 different community
settings.
Funding for this research project from the Bank's Research
Support Budget will complement government,, ?4RC-and UNIeF inputs. It
accords with the Bank's research agenda calling for more project-related
research. There are several additional reasons for not relying entirely on
funds the Gambian Government will be borrowing under the project PHN
project:
o The lessons learned in The Gambia are likely to be useful to the
Bank in its work in other countries. (Hence, it is unreasonable
to expect the Gambian Government to underwrite the full costs of
the research.)
o Survey and research activities have minimum fixed costs, and
would constitute a prohibitively large component of the total PHN
project cost, given that the proposed PHN project is relatively
small.
The two subsequent sections of this proposal explain the design
(including analytic framework, survey data to be colleted, estimation
issues and methodological explorations) and organization of the proposed
work.
- 17 -
Furthermore, piggy-backing onto ongoing MRC efforts will enable
us to use the carefully trained and experienced MRC interviewers. In fact,
the MRC Farafenni staff were enthusiastic about the possibility of the
Farafenni interviewers being employed for our survey, as long as they could
.be used in the slack period for MRC work (before March 1986)-. In addition
the socioeconomic data our survey will collect will complement the rich
biomedical data MRC has collected, making it a richer dataset for their
purposes, as well as for ours.
As noted above, in each of these three areas, the sampling area
from which a random sample of households and communities will be taken will
be extended geographically beyond that covered by MRC field work, so that
our complete sample will include both MRC and non-MRC households (and
communities). In addition to sampling the urban area of Banjul/Serrekunda,
up to two additional sampling areas will be added if this is necessary in
order to achieve representation of all ethnic or income groups in the
country. Altogether we expect a sample of about 1000 households in about
50 different community settings.
We will begin the survey in the MRC areas and will hire new
interviewers from the interview staff of the government Central Statistics
Department who will gain experience by working with the experienced MRC
interviewers. These new interviewers will then perform the field work in
the non-MRC sites.
Because there are two distinct seasons in The Gambia (the rainy
season between April and September and the dry season the rest of the year)
- 18 -
and morbidity, work, and diet patterns differ markedly between the two,10/
our survey 'will consist of two rounds, one in each season. We--hepe-to
begin the first round in January 1986, to coincide with a slack period for
the MRC interviewers in Farafenni. The second round would then take place
*in July-September 1986, in the rainy season. Because the rainy season is
shorter than the dry season and because we will not be able to use the MRC
interviewers in Farafenni, we plan to interview a random two-thirds
subsample of compounds in the second round.
Respondents for the Survey of Individuals and Compounds
In the villages that have already been enumerated by MRC, we will
interview the same compounds that have provided information for the MRC
intensive prospective surveys. In each of these compound, we will select
one ever-married woman of childbearing age to be the primary female
respondent and will collect data about her pregnancies, infant deaths, and
contraceptive use over the last five years. We will also ask about her
recent morbidity and health care use and those of her children who
currently live with her, including any children that are not her own that
she is caring for. We will also interview the male in each compound who
can best provide information about compound income and expenditures. Other
compound members may be interviewed if necessary to provide complete
information.
10/ For example, the 1979 World Bank Basic Needs Report on The Gambiaemphasized that greater energy demands, low (pre-harvest) income, andrainy conditions in the wet season combine to cause nutritionalproblems, especially for pregnant and lactating women.
- 19 -
In the non-MRC villages we will select a sample of compounds to
be included in the study sample, and will follow the procedures just
described for the MRC villages.
Sources of Community and Provider Information
The data on communities (villages) and service providers will
come from four main sources:
(1) government records(2) interviews with service providers(3) interviews with groups of key village people (e.g., the village
council or village health committee)(4) observation (e.g., distances to service delivery points.'1 /
As noted above, to the extent possible, we will collect data not
only on the current status of key community variables, but also on whether
there have been important changes in the recent past. Since many of our
individual-level variables of interest will come from retrospective surveys
that cover a reference period of up to five years, it is important that the
community data refer to the same points in time. For example, the primary
health care system has spread throughout The Gambia over the last five
years; villages that now have a trained birth attendant or drugs available
in the village may not have had these services readily available several
years ago. Such variation in community characteristics over time, some of
which is probably documented in government records, should help explain
variation over time in pregnancy outcomes and infant mortality.
11/ In a geographically dispersed village or community, distance toparticular points may exhibit meaningful variation among compounds andmay need to be collected separately for subareas of the village.
- 20 -
ESTIMATION OF THE EMPIRICAL MODEL
The Analytic Framework section above has already discussed the
types of equations we will estimate: reduced-form equations for service
choice and utilization ("inputs") and for health and fertility outcomes,
as well as structural equations for the outcomes that use instrumental-
variable estimates of the endogenous inputs. The equation estimation
techniques will depend on the nature of the dependent variables. For
example, where the dependent variable is dichotomous (e.g., whether the
child has been immunized or whether contraception has been used), we will
use logit or probit analysis. If the variable is qualitative with several
outcomes (e.g., type of contraceptive method used, type of health
practitioner seen), we will use multinomial logit or probit analysis. If
the dependent variable is continuous but limited, e.g., health expenditures
(which may equal zero for many families), Tobit estimation will be
employed.
Other statistical issues that may arise are the intercorrelations
of errors that can occur when there is more than one observation per family
(e.g., on the health of several members of the same family) or more than
one observation on the same person (e.g., for the two seasons). Variance-
components techniques will be used in such cases, and it may be possible to
estimate family- or individual-specific effects, which can be used in a
second round of estimation to assess the influence of such unobserved
factors as "health endowment" (as discussed in Schultz, 1984).
- 21 -
METHODOLOGICAL EXPLORATIONS
rn addition to analyzing the effects of public and private health
and family planning services on health and fertility outcomes, and the
price elasticity of demand for these services, this research project will
explore two methodological issues:
(1) the reliability of survey responses to retrospective questions on
fertility, mortality, and morbidity in West Africa; and
(2) the reliability and usefulness of questions on willingness to pay
(WTP) for public services.
Retrospective vs. Prospective Data
As noted above, in Sukuta and Farafenni, MRC has been collecting
monthly information prospectively on all pregnancies, births, and deaths in
the study populations. Our survey will collect retrospective data on these
same events for these same individuals. Comparison of survey responses for
these individuals with the prospective MRC data on them will allow us to
assess the biases in data collected retrospectively in such popula-
tions. The costs of collecting retrospective data are much lower; if they
are accurate, retrospective surveys provide a low-cost alternative to
costly longitudinal surveys for providing information on levels and trends
in fertility, mortality and health.12/ Or to the extent their inaccuracy
can be shown to be a function of characteristics (education, ethnic group)
and can be modelled over time (with inaccuracy presumably increasing as one
12/ For example, the HFLS data from Malaysia have been shown to be quiteaccurate in their information on fertility, infant mortality, malewages, and other socioeconomic variables in the past (Haaga, 1984;Smith, 1983). The MFLS have been used in a number of studies that haveilluminated the factors underlying trends over time in these variables(e.g., DaVanzo and Haaga, 1982; Smith, 1983; DaVanzo and Habicht,1984).
- 22 -
goes backward in time), we can "correct" the retrospective information from
households not included in the MRC studies.13!
Furthermore, comparison of the retrospective and prospective data
will enable us to assess the biases associated with maternal mortality in
retrospective data on pregnancies, births, and deaths (e.g., number and
outcomes of pregnancies missed in the retrospective data, types of women
missed).
In Farafenni and Sukuta MRC has also been collecting data monthly
on the morbidity of children. The questions ask about morbidity on the day
of the interview and about illnesses over the month preceding the
interview. Our survey will ask these same questions and will also test the
possibility of asking about particular serious illnesses over a longer
period, probably a year. We will compare the answers to these questions
about serious morbidity over the past year with responses to the MRC
morbidity questions for each of the previous 12 months to assess the error
associated with the longer recall period.14!
13/ For example, if the ratio of the actual rate to reported rate ofmorbidity was shown to vary systematically with the respondent's age,education, ethnic group, or amount of time since the even occurred, thereported rates could be adjusted to reflect these reporting biases.If these factors are only related to the degree of "noise" in thereports, we can give less weight to these less accurate reports in theanalysis.
14/ It is also possible that the one-year recall may reveal illnesses notreported in the monthly reports because families were temporarilyabsent when the illness occurred. If the one-year recall data appearto be accurate, they can be used to "fill in" values missing in themonthly data due to seasonal migration.
'EXTNAME:.REPAC-Jdv (R)P: 26
- 26 -
Nature of Final Products
There will be five main products from this project:
(1) The data set per se.
(2) A descriptive report on levels of expenditures and willingness topay, health status and health care utilization, fertility andcontraceptive practice, etc.
(3) Report(s) of multivariate analyses of influences on family plan-ning and fertility, and health care utilization and healthstatus, with emphasis on effects of prices and access on serviceutilization and of service utilization on health and fertilityoutcomes.
(4) Methodological papers assessing the quality of theretrospectively collected data (by comparing its implicationswith those of prospectively collected data on the samehouseholds) and the usefulness of data on willingness to pay forpublic services.
(5) A separate report on the health effects of the government'svillage-based primary health care program.
III. ORGANIZATION
PROJECT PERSONNEL
The principal investigators of this project are Nancy Birdsall
(Chief, PHNPR) and Julie DaVanzo, (Senior Economist at The Rand
Corporation). They will design the questionnaires and oversee their
fielding, and will analyze the data. Dr. DaVanzo's curriculum vitae is
attached (Appendix D). We are seeking the collaboration f Ms. Eliza
Jones, a oii i'2 p
We hope to have the active involvement of the following Gambian
government staff:
Drs. Fred Oldfield, Hatib N'Jie and Philip Gowers, all of the
Department of Medical Services, Ministry of Health, The Gambia.
Dr.- Oldfield is the Project Coordinator for the planned PHN proje"-.
- 27 -
Drs. Oldfield, N'Jie and Gowers have all been involved in the design and
management'of the still-expanding village primary health system in The
Gambia, the evaluation of which is a major objective of this research.
M.S. Jeng - Chief Demographer, Central Statistics Department, The
Gambia.
Mary Yamwa - Demographer at the Central Statistics Department who
has been working with Phil Hanlon on his MRC field studies.
In addition we would work closely with MRC staff:
Phil Hanlon - director of the MRC Measles Study in Sukuta.
Robert Snow - head of the MRC field station in Farafenni.
FIELD WORK
The fielding of the questionnaires will be carried out by
interview staff of the government Central Statistics Department (CSD), who
will be trained for this survey.
We anticipate that each interviewer will be able to complete
interviews with an average of 1-1/2 compounds per day (allowing for time
for locating compounds and locating respondents). In Farafenni it should
be possible in about two weeks time with 15 interviewers to complete
individual and community interviews for the 100 or so non-treatment
compounds on which we have detailed monthly data, as well as additional
non-MRC compounds from outside the MRC study area. After Farafenni, we
should be able to complete interviews with an average of around 50
compounds per week and their corresponding communities. At this rate, the
entire first round of interviewing will last around five months.
'EXTYAKE: REPAC-Jdv (R)P: 29
- 28 -
We will keep this staff of interviewers for the second round
(rainy season) interviews and will reinterview a random two-thirds of
selected compounds, including those absent during the first round. We
should be able to complete more interviews per week in the rainy season
because (1) we will not be administering the full five-year retrospective
pregnancy and child mortality histories, but rather only updating those
events that occurred since the compound was last interviewed, and (2) most
of the community and provider data should not require updating in the
second round (e.g., distances to service points). Nevertheless we will be
careful to update the community and provider information wherever changes
have occurred or where conditions differ during the rainy season.
Furthermore, the compound and individual questionnaires will repeat the
full set of questions about morbidity and health care utilization, since
these are areas where we expect important seasonal variations.
For the physical design of the questionnaire, and for data entry
procedures, we will rely heavily on two computer programs designed by LSMS
staff for use in the LSMS Ivory Coast household and community survey. The
first program, written for an IBM/PC permits rapid reworking of the
questionnaire after pilot tests in the field (allowing a revised
questionnaire to be duplicated quickly and avoiding long printing
turnaround). The second, a data entry program, is designed to allow
entry in the field of questionnaire results directly onto disk, and has
built in consistency and editing checks.. (Data collected in the Ivory
Coast has been available for processing in Washington within less than two
months after collection, compared to typical elapsed time periods of five
years, e.g. for a 1979 Ivory Coast consumption survey.)
TELNAME: REPAC-Jdv (R)P: 30
- 29 -
TIMING OF RESEARCH TASKS
Month 1 Project begins; questionnaires drafted by DaVanzo,Birdsall, and Jones
Months 2 and 3 Questionnaires reviewed by Gambian collaborators and tested
Questionnaires finalized and printed
Additional interviewers hired
Month 4 All interviewers trained
Month 5 Field work begins in Farafenni
Additional villages selected
Mid mo.5-mo.9 Field work in other parts of the country
Month 10- early Holiday for interviewers; debriefing and retrainingmonth 11(beginning ofrainy season)
Remaining dry-season data punched and transmitted to Bankand Rand. (Data will be immediately checked forinconsistencies and these will be sent to The Gambia to beclarified during the second round of the survey.)
Mid mo.11- Rainy-season interviews (on a two-thirds subsample of
mo.13 compounds)
Month 12 Analysis begins of dry-season data
Month 14 Remaining rainy-season data punched and transmitted to Bank
Month 15 Rainy- and dry-season data merged
Through Analysis of data and preparation of reportsMonth 24
AGENCY FOR INTERNATIONAL DEVELOPMENTWASHINGTON, DC. 20523
December 18, 1985
Dr. Nancy BirdsallPolicy and Kesearch DivisionPopulation, iiealtn and Nutrition DepartmentWorld Bank186 H Street, N.W.Washington, D.C. 20433
Dear Nancy:
ThanK you very mucn for sending A.I.D. your research proposal"Health Care and Family Planning in the Gambia." Certainly thekey question addressed by your proposal, the impact of usercharges on consumer demand for health services, is of greatconcern to our office.
I would like to summarize some of the comments and concernsexpressed by reviewers, from within and outside of our office,who reviewed your proposal.
All reviewers felt that the objectives of your proposed researchwere very important and that the scope of your project wasambitious. Making use of ongoing survey research was a valuableapproach. However numerous issues regarding (a) the ultimateuse of the results (b) the timing of the two studies (c)methodology and (d) direct revelence to A.I.D. health financingneeds remain to be addressed.
Specifically, reviewers wished to know exactly how results ofthe Gambia specific information might be used by HPN for theirproject directly. Also, more policy revelevent informationmight be obtained if some specific innovative approaches toorganizing and financing village based service could beincorporated into the study. This is particularly true sincethe usefulness of "willingness to pay" data from surveys is ofquestionable validity. With prospective evaluation, actual userfees For services being provided could then be evaluated fortneir real effects on consumer behavior. Such a design wouldnecessarily incorporate tne actual financing options availableto project managers.
-2-
As you know, A.I.D. is particularly concerned with promotion ofselected health interventions of proven or potentialcost-effectiveness e.g. ORT, immunizations, presumptivetreatments for malaria and for acute respiratory infections. Ifthe demand for these services under a variety of user fees couldbe assessed, then this research would meet pressing informationneeds by our Agency.
I am attaching comments on your analytic framework taken fromone reviewer, obviously interested in your approach to theseissues.
While the Office of Health would not be able to support such aproposal of this size, as is, we would of course be glad toreview any further drafts you may wish to submit. As theproposal so clearly is of concern to the Gambia, I will pass iton to our Africa Bureau they may have other suggestions to makethis research of direct usefulness to their programming needs.
If you would like to discuss the points raised above, pleasecontact Dr. Zeil Rosenberg at 235-8950. We look forward tocontinuing work with you on health financing issues.
Sincerely,
Anne G. TinkerChief, Health Services DivisionOffice of Health
he Analyt ic Framnwwor,
!he model of consumpr dewand and housr ! ci Fi io mbiits attempt to ( ,j e dwma d f- aw- kr, - 1,
Ius obroad model or r e, .ns iqb wk c. o, a w an -'quIs2io.s
Qj On U roi 4 '"
as stated. it doen "k mPi 50V
u DO not qn
(a hi
maximi zing utty -V 00 moifChN 0,u n c e r t a i n t y a b o u f a 1 1 i y a d h ~ t - : M h c h p oadwressed by thu Pubf i Me ths, a e on l , i ht r eincurPorAn ur n a mocei ofrw sos o ret.children's hesinh -crnn
(4 an on p r7 1 s !p.1 1d r e t e h al H I w g a e oValue o ft 'h a - Jti, incom "ie Mito2e'ixteno s tothe modlc -wiN ift5uis that the modl nwe; 4Vpilcit hoUsehold(god cr i ncome) ltwcurlO ~' i cton in jat, . mrita ry reu irnst o t h e m o t h e r u c' n o m i c a ct dp e d u p o n g e n e al h u s e h o l d
prodUCti~ FoUnr W&AIi~ lVM hfA n ' cnomic ahtuwh t(whether dld fr i s v en wit i n thc- N at eho'P h w u li kly he is ate m i g r a n t w or k e r ,' I ai t o d nd 2 ' e xt e t t siu h t h e c h i ld r e n a r envolved in houn' prodr, i( n.
T N e s w q u e n c i o 5 i p y h C C ,
pproposal, Kimpi a tC t iniUodrop the simut a (,,, in-. niti " f- -n Gt1 in mthm d e i o f c o n s u m o ( o - i ) y a 0 O n - . A " I e 1 . M i n t h O5usehold pr-oduction , d c m ,qn "nwoo ,Lel n =
a'~~ l d~ .1 UK L
V " -il rdi o o 'EA. u
I t Iii' and 1Al' t , 11 Il , d t! ifn 1; ' C "k nH '. a i e mi i a mo el in
i ' --~ Will Ucn deriL n !a i mc-' n' ir m C i' n i' demand "Urve n
_7 dtUAM U Ml''fe h . d d, --nilL'/3
'2o mc-ptu pirF
, l-It iisI- cu C ifin
be adresed ervEs hat nned LoL " wh s i s s u e s r e a d d j 1 " a h o n t i A . ( 1 9 8 0 )
minning At U Ai t . et . ( ) Ha aM en (1984), Duan a t M o) It (- iOH tnd
1 ) W i i s t nCtuld ii, n jeti i in A rii ul'i o
ttn-ld conslidera ton bot un per'i od tit Q ur for Me.i deadtmI mie
hrzn an fo h DbofaauiW
i ( o e r w t
exp e nd it ure s -wz implict ion ofe th n i, Litl
Q)Since if5 doen not EPcmj"hatsrvios", how shoul.:
i a"h ais thQ best ooretu a' MINI, Wha
Q)What are the implicqinjnirn en oeodv ndindividual-levo Il uvho OfP a Are- these distt io mM ;qu A cli ir
;*Aw o:f [- r !I;" mpis, +w n d one r(Q' e n , a &0 0 v it
to five i ,eint providors ovo, th couina or Wo weeV, and that thesequence of such vinit- mijIt npund "pon thr type or illness and past
experiences? (See Mwahn'w(0980 ugo of snuh a moodal. )
Estimation of tin Empiasi Model
Cconiderably more actontion "ed o we dcvoted to the deve.Lopment of
an adequat set of ropirical W- is for us In U iKinc tile
theoretical models. Only ct p[i in devolp jo 4 dincuvsion of tho
empirical methods ito up wmploy.'. Khe upir ia approAch is summed up
by one sont ence st at ing that 'Ke equat ion t ianon ta Chn iquas wii idepend upon the nature of the dependent vAciIble ". Mhe subsequentexplanations of wher Ppit, probil, and IbY will be used are not asufficient discussion of the variou sttis tical implications involvedfor particular modelling choi A A n r sr different charActerizations
or tht dp-r[dint VrI L-IP. 1" 1it, it Way il. [ inappropriate to
use lowit estimaticon Milud when th~e owpendant variabin iz continuousbut limited. (bee Mooddla 01( fur a oiscusion of this.)
it is importani Wo iihe --:Limit ion ssuP4 "ad probpmi that canbe anticipated in th. TIpirial work '1<cxm it my we] b possible
to avoid some or them in advanc a nydjiiqagn the survey instrument in
the appropriate way. Some unneeded inorimtion now in the Lurvey couldbe discarded, and ''a' nCaded data could 6P idantied and included.
The proposal should rovipw, for relvance to this proposed research,the literatura ont nining th varin". 4tintica1 .omp''ati m that
Can result M 5n 4inlt If CO 6&mid 1 4 hoo. c vic'> no.gV'!iven vorirou4
assumptions about %acpnen iebl" )Ad LW Wuleion or Choicefunction (for di X:t chnoicrepecu npP i cation of the
utility iunition, 4d . Win o P di ributico (and
worreiation) of v'ii Hi errc . ' rlm c-4ih within and on oss equations.There are dii (ierpo sairical modils implipo -eppindinir i pon whether-
the decisioniL to 1McI s Guiq wediral ua and t uchi to purchaseare Sim"!t mo i W'wy P. qAti. Th u mdob di-opssedand addresed befor tip -urvey inn' '.i is -'S- n Wi t d.
Also Win purnpouna o d 10o epr In udi- C , 1ESt,,inch usted (i aia 1; 1 n I"
wil l I(ot beC bea i h- -.. !2'!, i T-l .-a n C'- Iet ii' hi 4'iIA '4L.'P K4 I ,2 : 1'! o
studtionf h t e -rp ic n a Loin aIArIaIiv,L 'I- C M I V 1 . w '' 1, LIM'- 4 i '1 4
will1 in-o t i..- iil. I'. P, LIM 11/ Vi4A iL-A A'.,i 'F . Zo "'~ a1-
equ.atins~ . W, K L ' /;r~ We. PIM W4t / i t it n'4 iC s altoIa 1 V /
treatment sptt lnqv or M-oc, der vycq o !Ampj f arQ I I :olv to ho
significant will he an imporltant detWW", Wf 0ae ppropriate
Vpeification ot t' 42, fln 1< 0n Ni P . D: ilt Q? o, rK?denirabilitv Wn 1 Iunen of i oulntini navqzo in eoeovariables Wi aC) M iouliid h t A, ; b' >. . l .49i,4 Oi nh~
CicILP function. i Multinomial -H'it 1P "IQ, ' ici / Mtisitlev will
have to be derived from wqit iply nimujlut n nce Mhy cannot be
obtained dirputly nrow the paramutpr t
s5
01o it ut be keplj in i nd th ,
ch acateri i f A t"1 aat t
q aLtyk , e ) ned f L 5c' .vI b a I ) -,Aa
rmay b e? a prou i1g1 us; tat a I t I I aj t 1 t ta
i 1 hard t o kcv vwha3L vi a I At tn kl F J I e 0
respon~af~dent a C'Ach daY. ,i
FIalr, y, a qu4 a I" " Ilt
de ri yl L ak.1t ' i riap a a(a.L rkiac1 1 .~ Ia clr j) aa tII I2 jIdeterminin Ih die I, wichhe lt
for ilealth :tatus a hO ( d i kr Cl iryi e e cI
v-'ne that nuld be al i 1to S. I a t t fie u 1Q bcasmt onI on 1hwrit I i A tu pt reem tohc J beip id
the el2thod for athivinf o , t iv" b i 'ouAt b lezari
-1Ates nt i r is
'n ldo al a _W a l w b a k: -4
eRIViCOE CCaaOAufmfptio a1C i i tr yt
REFERENCES
Akir, J., Griffi, R.., ilky. D. V nd opn I (1984). THE
DEMAND FOR PR1HRY i iTHkYHEALTH iES I T HE THIRD W LD. Totowa NJ:
Rowman and Allaiheld.
Duan, N., Nningr, H. I. Jr., Moris C. N. , and Newhous, J. P. (1984)
Chriosing Bet weenm the I..mople t Model land ti i i'e Mlt i-Part Model,
JCURNWAL 0F DU 1 INLS [- ND CL CiN0MIC T f I T I 1 C . I , No. July '1984,
pp. C83-289.
Duan, N., Hanlnlin Yi Jr., Mori '4. ani NIwhotr J. P (iI84)
H CC-mp rvi' ct a V r vF cHd(lS Ccf U1' 0 CIand for M' ca.1 Ce.
RJURNAL OF BU: INE N N,4D EC(IiIC SIi< WI 1 1 V--.1. Hpr i
JPJ13, P[J JI '(j "k
J. 'WIJ,3 pp. -1
EcOVICfic Analy'ii 5 TH I, .. . fIL U
IN TIHE HELTiH C' (1; -t xa-tu I c ' crnomc
.dda1, Li. l. E ), 4Iv1y o the Li ierat.Ir on )(?IELectivity Dias
as it PertainS ro HlthI It f1cif .tA nip . 136, eatjment
of EcOromiCS, Uvllvni 3/ty CO- f
Mwabu, German- . I A MDEL HI-FI HOUTSH iOLD CHO ICE CIMONG EI'D I CAL
1 RfTREAT MENT ALEI RURL I I 0 ('Jil NYA, il - d rtat io n, Depart fenIt
jf Economruics, 1o4ton iversi
e-wht)i uSe, J I F1 1 i'. o DemfId f I N dI.ccL (Tr 'vich : 1
RetrosIp:,ect and Pro;u-ct il J Vn lin xU A ' -erilmal, eds.HEATHECOUNI As ~ka EmmTEAmsada: NrthHrolland.
Newhuse aay CF .J Mr as a (190) UnHavinq Yo~ur
Ca&ktand aLtin i it - .s -'n'- r ih I 1b II in EI Jhiml.in t he ihimand
f9(r1 Health trvicc A 1U 01 tF V;U p
AGENCY FOR INTERNATIONAL DEVELOPMENTWASHINGTON. D C 20523
December 18, 1985
Dr. Nancy BirdsallPolicy and kesearch DivisionPopulation, Health and Nutrition DepartmentWorld bank1018 H Street, N.W.Washington, D.C. 20433
Dear Nancy:
Tnank you very much for sending A.I.D. your research proposal"Healtn Care and Family Planning in the Gambia." Certainly thekey question addressed by your proposal, the impact of usercharges on consumer demand for health services, is of greatconcern to our office.
I would like to summarize some of the comments and concernsexpressed by reviewers, from within and outside of our office,who reviewed your proposal.
.all reviewers felt that the objectives of your proposed researchwere very important and that the scope of your project wasambitious. Making use of ongoing survey research was a valuableapproach. However numerous issues regarding (a) the ultimateuse of the results (b) the timing of the two studies (c)methodology and (d) direct revelence to A.i.D. health financingneeds remain to be addressed.
Specifically, reviewers wished to know exactly how results oftce Gambia specific information might be used by HPii for theirproject directly. Also, more policy revelevent informationmight be obtained if some specific innovative approaches toorganizing and financing village based service could beincorporated into the study. This is particularly true sincethe usefulness of "willingness to pay" data from surveys is ofquestionable validity. With prospective evaluation, actual userfees for services being providedP could then be evaluated fortheir real effects on consumer behavior. Such a design wouldnecessarily incorporate the actual financing options availableto project managers.
As you know, A.I.D. is particularly concerned with promotion ofselected health interventions of proven or potentialcost-effectiveness e.g. ORT, immunizations, presumptivetreatments for malaria and for acute respiratory infections. Ifthe demand for these services under a variety of user fees couldbe assessed, then this research would meet pressing informationneeds by _ur Agency.
I am attaching comments on your analytic fra ework taken fromone reviewer, obviously interested in your approach to these
/ issues.
Wnile the Office of Health would not be able to support such aproposal of tnis size, as is, we would of course be glad toreview any further drafts you may wish to submit. As theproposal so clearly is of concern to the Gambia, I will pass iton to our Africa bureau they may have other suggestions to makethis research of direct usefulness to their programming needs.
It you would like to discuss the points raised above, pleasecontact Dr. Zeil Eosenberg at 235-8950. We look forward tocontinuing work with you on health financing issues.
Sincerely,
Anne G. TinkerChief, Health Services DivisionOffice of Health
/7
aa
/ Id A/2&
OFFICE MEMORANDUMDATE: October 1, 1985
TO: F. Stephen O'Brien, Chief Economist, WANVP
FROM: Barbara Bruns, Economist, WA2DB
EXTENSION: 74029
SUBJECT: The Gambia: Research Project on Determinants of the Demand for Healthand Family Planning Services
1. This is in reply to your memo of September 18 asking for ourDivision's assessment of the above research proposal, which has beensubmitted for RSB funding. Our Division strongly supports theproposed research and I have been involved in its preparation. Ihave followed closely the preparatory discussions with the Governmentand key agencies in The Gambia that would cooperate in executing theresearch -- the British Medical Research Council (MRC) and UNICEF --and in August I participated in a mission to The Gambia led by Ms.Birdsall during which the proposal was finalized. I have also agreedto participate in ongoing reviews of the work as it proceeds.
2. The Government and the cooperating agencies are enthusiasticabout the proposed research for the following reasons, which ourDivision fully shares. First of all, it is >bvious that the issuesaddressed are important and have direct operacional significance.Improved health status and reduced fertility are central to theenhancement of human welfare in virtually all developing countries.Key problems for policymakers in low-income countries, however, arehow to design efficient health care services and how to mobilizeadequate domestic resources to sustain the quality and expand theavailability of these services. By carefully analyzing i) theeffectiveness of different types of health and family planningservices, and ii) the willingness of households to pay for theseservices, the research can be expected to yield important insights forthe design of health care systems and cost recovery mechanisms inlow-income countries.
3. The Gambia presents a particularly good place to carry outthis research, for several reasons. The Gambia's health care system-- especially the innovative village level network -- has attractedthe attention of a number of other countries and is already being usedas a model by many of these. Recommmendations to improve the designand financial sustainability of The Gambia's system are thereforelikely to benefit these countries as well. Even more importantly,thanks to the work of the British MRC, The Gambia has a wealth ofdemographic and health surveillance data that does not exist elsewherein Africa. By taking advantage of these, the project willsignificantly reduce the costs of the research. Moreover, the highquality of the MRC data will increase the reliability of results --which is often a problem with research in African countries. The
P-1867
-2-
availability of systematically collected longitudinal data for asignificant sample population is especially important. Finally, theresearch will provide an added benefit in using these data to explorean important methodological issue, namely the consistency ofprospective surveillance data and retrospective survey responses.
4. In conclusion, we believe this proposal addresses questionsthat are fundamental to the design of health care and family planningpolicy and services in developing countries and can be efficientlycarried out in The Gambia with good prospects of producing validresults. Because the results can be expected to have significance fora potentially large number of other countries, as well as for WorldBank policy, we believe it should be funded from World Bank researchresources, rather than by drawing upon the very limited fundingavailable for the proposed Gambia Population Health and NutritionProject. In support of the project, however, this Division isprepared to contribute staff time to evaluation and dissemination ofthe research results.
cleared w/ and cc: Messrs. Landell Mills and Varoncc: Mr. Westebbe, Mmes. Birdsall, Husain, Gambia Desk
OJ
____~~~de _ _ - _ _ 1 _ _
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THE WORLD BANK/INTERNATIONAL FINANCE CORPORATION
OFFICE MEMORANDUM
Date: September 26, 1985
To: Ms. Phi Anh Plesch, VPERS
From: Nancy Birdsa \VHNPR
Extension: 61581
Subject: Research Proposal: "Health Care and Family Planning in The Gambia:Determinants and Consequences of Service Utilization"
This is in reply to your memo of August 27 asking for information fromme about our efforts to seek non-RSB financing for the above researchproject. I regret the proposal itself was not more clear on this point.
1. The budget already takes into account contributions by thegovernment, by the British Medical Research Council, and by UNICEF to theresearch. Unfortunately this is not as clear in our proposed budget as wemight have made it, as we did not explicitly cost these contributions. TheGovernment would be financing much of the costs of the survey through ourarrangement with the Central Statistics Department (CSD) of the Ministry ofPlanning. (The Ministry of Planning is the host ministry for the largerBank-supported project being proposed.) The field work for the survey wouldbe carried out by CSD field staff and supervisors in three of the foursampling areas in the first round of the survey and in all four areas in thesecond round., In the fourth area (first round), MRC field staff would dothe work, with a partial subsidy from our RSB funds. We would pay fuel andovernight expenses for all field staff. (Because of the acute shortage offoreign exchange in the country, fuel is at times extremely difficult toget, and government allocations are severely rationed. It would befoolhardy to count on access to government supplies, even if there wereearmarked funding from the research project for fuel. Similarly,supplementary overnight expense funds to support field work have beennonexistent in The Gambia for some time.) The Government and MRC would alsoprovide staff to do data entry in The Gambia. Finally, the community moduleof the survey would be managed by UNICEF staff in The Gambia. The UNICEFresident representative is a former staff member of the Health Planning Unitof the Ministry of Health, and is familiar with the overall project's goalsand with the country. UNICEF wouid be contributing about 6 weeks of histime for questionnaire design, testing and field supervision.
2. In addition, we are seeking financing from other sources. We havea tentative arrangement under which the Norwegian Ministry of DevelopmentCooperation would provide $10,000 from funds it has allocated 'for populationand health work in Africa. The amount is not large, but reflects theirview that the lessons from the research in The Gambia would have wideapplicability throughout Africa. We have also discussed with the FordFoundation the possibility that they might finance the costs of bringing aGambian to the Bank or to Rand to participate in the data analysis. TheGambian whom we have in mind is a government staff person and it has not
P-1867
2
been appropriate to pursue this idea formally while the overall managementof the larger Bank project was stiit under discussion in Government.Therefore there is no provision for this activity in the budget of theproposal submitted.
:3. There are good reasons why the research project is not receivingdirect support through the larger project under preparation for Banhsupport. ( Such support was an i dea wh i ch seemed reasonab le to me inFebruary of 19KI. But I have since, as project officer, led two projectpreparation missions, in April and AngustI of this year, to The Gambia. Witha more realistic and more clear picture of the larger project, I no longerthink so.)
cI) The totai budsitgeled amount Cor ati research and evaIuation i thelarger project is $100,000, a rel atively small amount compared to ourproposed research ()Iget '000, 000. A sma]i amount may be used to Co I towup a pre-appraisal study of col lection costs and accountability in a userfee system (expkl ia ned ie iow) . n t os t o I these Funds are to be used forepidemiological studies, e.g. on schistosomiasis, needed for planningfuture a Ilocataon oi pub i c reaith resources.
k6) The tmini is di i curt . The Pro'posed larger project wouid not,bDecome ef! Itive niaI i ilietaar -:ir . the research project shouidbeg i.n be fore !he end 0' 1J85 it is to provide any insight into user Veepo if cy, vI i -l be ta i ret j is i gi, or lam I I y p i ann i ng program des indurinrg Lne nra ot Per Iod. In Government has taxen an advance on neproposed lcan ii t he naounit of , I0)H, (100 to cover a large array of necessarypreparat on studi -s ar(- hieci urai desi gn work alone will take aboutone-t hiro oi ti if Is I i id I I oin, 1'ere is a vehic le spare parts requirementinventory, a fuel aI iocat ion st udv. des irn of heal th educat ion campa ilins, atel ecommunica1 ions ")ipment -c dv I noment oi nurse traintifgcurr icu ium, arid a managomment Siru-V. Of the $400,000, $40,000 is at locatedtor a study (1 rimuleit0 SaiZsue ''I 1g Of tI e -st s of :I i erna i veco I -ct i on, enit orcemen i tand acoul iint i riig procedures io r user fees. hi s is c-ii op ic we nad or Iina I I i -ar ideIei i tci tinfg under tie research Pro je t :however, t is s Stiudy mius;t ne r'amp i :-' I fl 1r oto piroject appraisai In decemberaf ihis v''r. is- it ,s 'nirat to a' iiscussions between the iUink and
Governmen t <ni rot t Ii es I rert 0aer '!I cire neaith financing svstem. ithere fore irotped t Cr-fr m tPU ;t ml v researeti project . ;nd suppor t ed Ihestovernment s use of imito ori I reparat ion iunds to finance externacotisu 1 iins '- ao in -0. lU I heFca rr a r t csrl hu
-ontr i but ImI sanoI) t o - c ir lr a in :4n oi (jefit lv' e out, ied In mnv
original i ieS i ro';i':rd i-rI iii littds. -cii iii *m rt w illno6managed torm ia i v -!n -r i r 1oo-------e- - " a ' d cm is cc it Oil" c 'er - rs r
ituoget
i ,q1i 10 ' - ~ h' -~ a li -
Vi rst , I do riot mi'ie wi 0 n uonict e-ri ot' Rev iew(-r 2 lot f rl tn prnoosafor rsear-rh preparatio i iines or tr i Fit vacs t o' roect ti,1appropri a t e for use of' S it- t un, Tnough tie researcn is c1oseiV tied a1he 0 irger- rroetict, 7; i Jto-t i r' t ;a t tPrital vaile wi I be Ior foa " et-a
3
and program design and for Bank policy thinking in a wide variety ofcountries. Except for very narrow research questions, this is always going
to be the case for "project-related" research. If this research project"does not fall within the normal bounds of REPAC funding" then I see little
prospect that any project-related research will. As far as I know,virtually no good project-related research has been accomplished under Bank
auspices wi thout non-project support from Bank or other donor researchfunds. It is those research funds which allow quality control, sustained
input from Bank staff, continuity of work -- and in the end a study which
is viewed by all parties as independent. These are all virtually impossiblefor a government operating agency, concerned with day-to-day Aiptementationof a larger project's activities, to provide.
Second, I must adwit to some reluctance on my own part to suggest to.Government that it allocate part of its proposed project funds to what is aBank-init iated research project in which I have a professional interest asa researcher. I believe a key to the design of the research in a way whichwill complement the larger project, and to the interest in and financialcommitment of Government to the research, is the fact that I have been
serving as project officer. However, this also puts me in a position wherea suggestion from me about use of project funds could carry more weightthan might appear appropriate. Tf the overall project being proposed werenot so tightly budgeted, and financing of any sort, especially for nonsalaryoperations, not so acutely constrained in The Gambia, an allocation fromproject funds for this research might be justified. However, given thesefactors, plus the po t entiat benefis of such research outside The Gambia,justifiably financed by the Hank rather than the country, I am not suresuch an allocat.ion would be justu'ted.
cleared with and cc: T. Husain. iHNVcc: .- r-ns, - 011
B. b I t g iAnn. WA2Mi
NB: hs
THE WORLD BANK INTERNATIONAL FINANCE CORPORATION
OFFICE MEMORANDUMDATF August 27, 1985
TO Ms. Nancy Birdsall, PHN
FROM Phi Anh Plesch, VPERS 1rI
FXrENSiON 69013
SURJE(T Research Proposal: "Health Care and Family Planning in the Gambia:Determinants and Consequences of Service Utilization"
This is to acknowledge the receipt by REPAC of the aboveproposal on August 21, 1985. The proposal will be reviewed according to
REPAC's procedures and decisions on its funding will be communicated toyou as soon as the review process is completed.
There is however an important omission in your proposal forwhich I must seek now a clarification from you, because the issue willundoubtedly be raised by REPAC when it considers your proposal forfunding. You will recall that your previous request for preparationfunds had been granted by REPAC on the condition that you would seekfinancial support from non-RSB sources for the main research project.In your memo of February 14 to Mr. Lal you had indicated your acceptanceof that condition on the basis of which therefore funds in the amount of$15,650 had been released for the research preparation. Your mainproposal however did not mention anything about co-financing nor aboutyour efforts to seek this. REPAC will surely ask many questions as towhy the following sources have not been tapped for contribution to thetotal project cost as promised:
i) The proposed IDA project on population, health and nutrition,which has an evaluation component.
ii) The Bank Regional Department: The "Guidelines for Submissionof Research Proposals" clearly specify that "in cases whenregional support of the proposed research project is cited as amajor justification, The regional department(s) concerned willbe expected to make a contribution in the form of funds orstaff time or both to the research project".
iii) PHN Department
iv) Donor agencies
I would appreciate a note from you indicating how you intend toapproach this issue in anticipation of the questions that will be raisedby REPAC on that score.
P 1866
THE WOLD irANK INT! HNATK1NAL INAND CFPHAh KAN
OFFICE MEMORANDUMF)A August 27, 1985
m Ms. Nancy Birdsall, PHN
I OM Phi Anh Plesch, VPERS
690t3
Su; J Research Proposal: "Health Care and Family Planning in the Gambia:Determinants and Consequences of Service Utilization"
This is to acknowledge the receipt by REPAC of the aboveproposal on August 21, 1985. The proposal will be reviewed according to
REPAC's procedures and decisions on its funding will be communicated toyou as soon as the review process is completed.
There is however an important omission in your proposal forwhich I must seek now a clarification from you, because the issue willundoubtedly be raised by REPAC when it considers your proposal forfunding. You will recall that your previous request for preparationfunds had been granted by REPAC on the condition that you would seekfinancial support from non-RSB sources for the main research project.In your memo of February 14 to Mr. Lal you had indicated your acceptanceof that condition on the basis of which therefore funds in the amount of$15,650 had been released for the research preparation. Your mainproposal however did not mention anything about co-financing nor aboutyour efforts to seek this. REPAC will surely ask many questions as towhy the following sources have not been tapped for contribution to thetotal project cost as promised:
i) The proposed IDA project on population, health and nutrition,which has an evaluation component.
ii) The Bank Regional Department: The "Guidelines for Submissionof Research Proposals" clearly specify that "in cases whenregional support of the proposed research project is cited as amajor justification, the regional department(s) concerned willbe expected to make a contribution in the form of funds orstaff time or both to the research project".
iii) PHN Department
iv) Donor agencies
I would appreciate a note from you indicating how you intend toapproach this issue in anticipation of the questions that will be raised
by REPAC on that score.
P 1866
September 23, 1985
Mr. Oscar HarkavyFord Foundation320 9 43rd StreetNew York, New York 10017
Dear Bud.
I enclose a copy of the research proposal on The Gambia which Ireferred to on the telephone. As I said, we are seeking financial supportfor the project to supplement the support we have requested from the WorldBank Research Support Budget. I would indeed be grateful if you could, asyou suggested, pass it on to Richard Horowitz, your representative inDakar.
The research, as the proposal makes clear, would be done in closeconjunction with a larger population, health and nutrition project theGovernment of The Gambia is proposing for World Bank support. It wouldprovide baseline information for evaluation of the outcome of the largerproject. As I mentioned, I hope we can pursue at some later point amechanism by which Ford might sponsor independent research that contributesto evaluation of projects partly financed by the World Bank.
With respect to the Gambia research project, we are especiallyinterested in any contribution Ford could make toward training of Gambiansin conjunction with the project. We would, for example, ideally bring aGambian to the Bank for an extended period to participate in the data -analysis. There are several young Government staff who would benefit fromsuch an opportunity.
I would be happy to answer any questions lir. Horowitz might haveabout the project, should he wish to telephone while he is in New York(202-676-1581).
Sincerely,
Nancy BirdsallChief
Policy & Research DivisionPopulation, fPeaith & Nutrition Department
Enclosure
INF I
MRC iARAFLNNI FETILITY
QUESTlcNAiR:.
AlESURV:EY 1UBE;. I
COMPOND ATE SEtENt
\iLLAGLY O- iRTH
EThNIC GRXOUP
1. 14ARITAL STAT'U f i CiNGLE
3, D:VORCED LIiORRK
4. WCT.CVED REMARRIED
. DIVORCED1
I) 1F 3 OR 4HOW ;N1 YEARS UJ ARRIED
(b) IF 5 ORk HOG 2 NY YEARS SINCE TELMINATIONOF UNION
31 F 2 , 3 oiV. NJME CURRE IUSEAND:
IF 5 , OR 6 Ni E (: >PARATED HUSBAND
4. AGE AT F1RST M.RRIk:
1. DOES THE SUBjECT T' :NK SHE IS 9REGNANT NC'. >'k/0L
(a) HOW YINY CHIILIREN HAF THE GCMN EVER AD_
(b) HOW MANY CI-L JN ARE NOW LIVING Al xO:E
(') HOW MANY C4IL. N ARE NOW LIVING TY RE H E
(d) ROW MANY CHILDEk CAVE SINC DI
N~
7. LiST OF PREVIUS I I __
STYLL [ N(W 0EASX B-, C MOrRTIUN AGE AT DATH
TO-i~l-OF LIV'E iL LE CHILDREN
TOTAL NUME OF LTVE FEMALE CKILDRT:-'
TOTAL NUMdR 07 AOOR! 16
- 7 STILLIRT_
____ -OT AN YEAR -F
Q, I ANSWER TQ( E K., 1 V 2, 3, OR 4,-
(a) AS THE .: ShKT MUkA BIEN AMA FUR LOOGE TKAN ! HM K PAST V,YES /No
(b) _F T
c>REASON F01 s MON-
DOE! T__U _ _0K HAL) M _ YES/N __
(b; lF 1) 8OWM M
'o AV 0 1F THY 3Y y L
C, A V E YOU SEEN Y01 P______ TH_ LAM YEAR,__
SIGNTIN OF TOE MIAK NT
130 N~ 0 h~#.V1 " ~I L'. Nt~1 W. Y1L-0X
#IqJ ASS torfy jfry
SEX: 3ATS OF IRh: tOC/ION: 3
MOTHER: SUI fEY U_ .T R 1 -51 R 4
FtTHER: 10DAD;
COMPOUND: VI LLAGT :
1. Is the mother or norma7 guA dian the respondent today? 1. YES 2. Pt 16
If not, who is the responde t? Specify ..... . .... .......... 17
2. Is the child.with the t today? 1A Y 3 2. NC ...... 18
If not, why noti 1. Visiting2. Moved away5. Ill4,, Dead5. Other. Specify ...........
If the answer to question is NO corplete 6 - l) only.If the answer to questin is NO complete 3 - 5 and 9 - 10.If the answer to both ques ions 1 and 2 rre NC stop questions here.
3, Is the child well or unwl. oday? 1. "cl, 2. inwcll, 3. Don't know 20
IP the child is unwell toda ,r record symptoms and their duration in days(maximum 30)A
Fsveri headache, hot body ............... . 21
Diarrhoea, vomiting, abdomif nin ............... 23
Coughi sneezoe cold, sore-thmat, car pain .............. 4..... 25
Cough, thest pain, difficulty in breathing ........................ 27
MaCarthy Island Division(66:11) 278(45%) 298(48%) 31(5%) 15(2%) 622
Lower Saloum 10% 1 35-" 23 3 3
Upper " 8% 1 37 40 2
Niamija 4% 11 19 2
Niani 13% 1 41 37 6 2
Sami 11% 1 304 #2 4 1
Niamina Dankun- 4% 13w- 12 - 1
NiaminA West 4% 11 18 1 -
East. 10% 1 13 23 3 3
Fulladu West 34% 4 87 94 13- 5 -
MaCarthy Island 2% 1 - - -
I' 5 1 1
North Bank Division(54:9) 1-99 100-499 500-999 1000-4999 5000+ T
120 (4 2 ) 38(13%) 19 ( 6b) 1 (04>) 285
Lower Niami 21% 2 19 32 7 5-
Upper 14% 1 17 29/ 9 1 -
Jokadu 9% 1 8 28' 3 1
Lowvr Baddibu 11% 1 8 8 4 4 -
Ce 1gal ," 1 10 7 2
u3 13 8 6
10 2,, 9 3 4- 1-1
- C
i U
\ 11
b? ?
A / ( ~~~W? L~ci(66< ~ E~~
(u K p
6 k Zf-
1'~~ 4
4 - a
K (c 7
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- I7
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A IA cso"K A: cL&*m \A~ c~ t~ t
uc k~ 2ct C xeS &":2 Co flt
\C \x Ak C QL C)& s
C 2A
C',n cj
arAt-v ;:4 e
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Record Removal Notice ____
File Title Barcode No.
National Health Project - The Gambia - Credit 1760 - P000812 - Research
30159541
Document Date Document TypeJul 5, 1985 CV / Resum6
Correspondents / Participants
Subject I TitleAnthony S. Nathe
Exception No(s).
Z 1 [ 2 j 3 0 4 L 5 L 6 L 7 0 8 0 9 L 10 A-C E] 10 D E Prerogative to Restrict
Reason for RemovalPersonal Information
Additional Comments The item(s) identified above has/have been removedin accordance with The World Bank Policy on Accessto Information. This Policy can be found on the WorldBank Access to Information website.
Withdrawn by DateSherrine M. Thompson Feb 22, 2013
