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Using a cohort approach, this paper examines educational attainment in Ghana and its potential determinants considering both educational attainment in the formal education system and participation in non-formal education in the form of adult literacy programs. The results indicate an overall substitution between formal and non-formal education across the generations, with participation in adult literacy programs decreasing as the formal education system expanded its coverage across space and time in Ghana. Individuals who completed any formal education were also much less likely to participate in adult literacy programs, by about 10 percentage-points per year of formal education completed. Additionally, the generations subject to the declining education system during the 1970s were substantially disadvantaged, with the cohort that was roughly of primary school age at the time of the economic breakdown in 1983 and the first few years thereafter being the last of the disadvantaged cohorts—the “lost generations.” This is especially true for the particularly vulnerable group of individuals who never received any formal education, where the crisis cohort peaked in terms of adult literacy program participation relative to later (and earlier) cohorts, possibly in response to a decrease in the quality of the formal education system as well as increased competition from returning refugees. We perform a simple test for the declining quality of the formal education system in the 1970s and find evidence consistent with a decrease in the quality in the education system during the 1970s, followed by an increase in quality thereafter.

Highlights • Many people in developing countries defecate in the open without using a toilet. • We study a field experiment of the effects of sanitation on child height in India. • We find that the program caused children to grow taller, on average., Over a billion people worldwide defecate in the open, with important consequences for early-life health and human capital accumulation in developing countries. We report a cluster randomized controlled trial of a village sanitation intervention conducted in rural Maharashtra, India designed to identify an effect of village sanitation on average child height, an outcome of increasing importance to economists. We find an effect of approximately 0.3 height-for-age standard deviations, which is consistent with observations and hypotheses in economic and health literatures. We further exploit details of the planning and implementation of the experiment to study treatment heterogeneity and external validity.

Whether to provide services by the public or the private sector has been at the center of debates within governments and those in the international aid industry for decades. Unfortunately, this debate has often been cast in terms of absolutes with the private sector either as savior or demon. Casting the issue in this light simply can't be correct. It cannot be the case that either is appropriate for every service and with every government regardless of its capability to the exclusion of the other. In every case, policy makers need to ask "how can the government improve the well-being of citizens with the constraints and tools at hand?" Those constraints include the ability to implement and monitor policy.This paper outlines how limitations of the market can be matched to appropriate interventions by government as it actually performs, not as it is hoped to perform. This matching will, by necessity, vary with country circumstance. While pure public goods must be provided by government regardless of its weaknesses and pure private goods should generally be left to the market, most serious policies operate in between. The balance of the limitations of the sectors needs careful analysis. The welfare costs of private market failure are rarely measured and the difficulties of implementing different policies are rarely discussed let alone quantified. Policies that are sensitive to deviations from perfect implementation should be avoided in preference to those that are more robust to circumstances. Further, every policy will generate interest groups that will constrain future decisions through political pressure.Keywords: Social services delivery, governance, education, health delivery, Pakistan.JEL classification: H11, L88.1. IntroductionI am honored to have been asked to give the introductory lecture to this conference on service delivery in Pakistan. I believe that improved services in health and education, and the transfer of purchasing power to the poorest people of Pakistan are of great importance to their welfare. As a longstanding observer of Pakistan, South Asia, and the poorest countries of the world generally, this is a goal I have deeply at heart.However, I think we have become intellectually lazy in searching for the means to achieve better wellbeing. We have looked for simple solutions, usually of the variety "spend more money on things in which I (as a health, education, or social protection expert) take a particular interest." We have also become prone to wishful thinking that almost anything that is intended to improve welfare magically does so.My argument here is that the design and implementation of effective policies in these sectors requires us to face hard realities of the constraints under which governments operate. These constraints are not solely-and I would argue, not primarily-limited funds. The government is further hampered by endemic problems of governance when the stage of implementation is reached. Ignoring this fact of life has led to enormous sums of wasted money.The term "governance," too, has been used with a certain degree of laziness. This essay argues that there are concrete, if difficult, choices that specific kinds of limitations to public performance force us to make-choices that make it necessary to think strategically about the type of spending that is most important. From a more practical point of view, no government has complete control over income, health status, or education. What governments can do is facilitate improvements in all three, recognizing that their ultimate drivers are individual peoples' millions of actions.This essay seeks to put the research carried out for this conference in a context that is useful for policymakers. What do we recommend policymakers do to favorably influence these millions of actions? The answers will differ both from sector to sector and from government to government. The essay reviews, briefly, the standard approach from public economics on policymaking, focusing on resource and market behavior constraints. …

There are seventy medical care providers within walking distance of every household in Delhi. However, inequalities in health outcomes persist among the rich and poor, which might reflect...

In this paper, we report results from surveys in which enumerators made unannounced visits to primary schools and health clinics in Bangladesh, Ecuador, India, Indonesia, Peru and Uganda and recorded whether they found teachers and health workers in the facilities. Averaging across the countries, about 19 percent of teachers and 35 percent of health workers were absent. The survey focused on whether providers were present in their facilities, but since many providers who were at their facilities were not working, even these figures may present too favorable a picture. For example, in India, one-quarter of government primary school teachers were absent from school, but only about one-half of the teachers were actually teaching when enumerators arrived at the schools. We will provide background on education and health care systems in developing; analyze the high absence rates across sectors and countries; investigate the correlates, efficiency, and political economy of teacher and health worker absence; and consider implications for policy.

A high rate of absence of teachers from their posts is a serious obstacle to delivery of education in many developing countries, but hard evidence on the problem has been scarce. This study, carried out as part of a new multi-country survey project, is the first systematic investigation in Peru into the extent and causes of teachers’ absence from schools. Data from our nationally representative survey of public primary schools, based on unannounced visits and direct observation of teachers, reveals that public school teachers in Peru are absent from their posts 11 percent of the time. While this overall absence rate is low compared with those of other survey countries, the absence rates in Peru’s poorest and remotest communities are much higher—16 and 21 percent, respectively. In our multivariate analysis of the causes of public school teacher absence, we identify several important variables that are associated with increased absence: poor working conditions, such as poorer communities and infrastructure; teachers with fewer ties to the school’s community; contract teaching; and, perhaps, an absence of private competition. By contrast, proxies for more vigorous top-down and bottom-up monitoring are not associated with lower absence. These results, together with the relatively high overall public school teacher attendance rates in an environment where financial incentives for performance are weak, suggest that non-pecuniary incentives are important determinants of teacher performance.

We develop a method in which vignettes–a battery of questions for hypothetical cases–are evaluated with item response theory to measure the clinical competence of doctors. The method, which allows us to simultaneously estimate competence and validate the test instrument, is applied to a sample of medical practitioners in Delhi, India. The method gives plausible results, rationalizes different perceptions of competence in the public and private sectors and pinpoints several serious problems with health care delivery in urban India. The findings confirm, for instance, that the competence of private providers located in poorer areas of the city is significantly lower than those in richer neighborhoods. Surprisingly, similar results hold for providers in the public sector with important implications for inequalities in the availability of health care.

Vector-borne diseases especially rife in poor countries pose sectoral tax/subsidy issues. Preventions and therapies mitigate these diseases in a numerical optimization model combining dynamic epidemiology and economics. The medical distinction between prevention and therapy does not distinguish economic properties of preventions and therapies. Some interventions increase and others decrease moving to the steady state, depending: on the utility function, the targeting of interventions and the disease process. Interventions display negative own-price but indeterminate cross-price effects. Juxtaposing the social planner's with decentralized choices quantifies externalities and shows how subsidies implement the first-best. One prevention and the therapy are equally subsidized.

Twenty-five percent of teachers were absent from school, and only about half were teaching, during unannounced visits to a nationally representative sample of government primary schools in India. Absence rates varied from 15% in Maharashtra to 42% in Jharkhand, with higher rates concentrated in the poorer states. We do not find that higher pay is associated with lower absence. Older teachers, more educated teachers, and head teachers are all paid more but are also more frequently absent; contract teachers are paid much less than regular teachers but have similar absence rates; and although relative teacher salaries are higher in poorer states, absence rates are also higher. Teacher absence is more correlated with daily incentives to attend work: teachers are less likely to be absent at schools that have been inspected recently, that have better infrastructure, and that are closer to a paved road. We find little evidence that attempting to strengthen local community ties will reduce absence. Teachers from the local area have similar absence rates as teachers from outside the community. Locally controlled nonformal schools have slightly higher absence rates than schools run by the state government. The existence of a PTA is not correlated with lower absence. Private-school teachers are only slightly less likely to be absent than public-school teachers in general, but are 8 percentage points less likely to be absent than public-school teachers in the same village. (JEL: O15, I21, H41, H52)

The structure of representative agents and decentralisation of the social planner's problem provide a framework for the economics of infection and associated externalities. Optimal implementation of prevention and therapy depends on: (1) biology including whether infection is person to person or by vectors; (2) whether the infected progress to recovery and susceptibility, immunity, or death; (3) costs of interventions; (4) whether interventions target everyone, the uninfected, the infected, or contacts between the two; (5) individual behaviour leading to two types of externalities. By way of example, if people recover to be susceptible, government subsidies should equally favour prevention and therapy. The economic approach to infectious diseases is in its infancy, somewhat oddly because many economists have long had the intuition that epidemics and infectious diseases are quintessential manifestations of the principle of an externality, itself a central concept in economics (Gersovitz and Hammer, forthcoming a). Furthermore, epidemiology provides ready-made dynamic models of disease transmission and economics provides methods of valuing the costs and benefits of health interventions and methods of dynamic optimisation to guide policy. Policy toward infections is of great importance. Yet only recently have economists begun to look at these questions in a formal way. This paper has two main goals. The overarching goal is to dissect two important externalities involving infectious diseases when there are the options of both prevention and therapy, so that the relative phasing of these two types of interventions is important. To achieve this goal, we need to state the social planner's or first-best problem and to compare it to a representative agent's problem. To avoid compounding the identification of any externalities with problems of myopia, imperfect ability to insure health outcomes, or a disregard for the welfare of future generations, we make assumptions about the behaviour of the representative agent such that these problems do not arise, allowing us to focus exclusively on the externalities that we identify. These assumptions may not always be adequate approximations and a relaxation of these assumptions would lead to further considerations in the design of interventions but we do not deal with these issues in this paper. The economic literature on infectious diseases has taken as its starting point some special although important concerns. This starting point has influenced modelling strategies in ways that we believe obscures the general structure of private choice and consequent externalities in the process of disease transmission.

The assumption of rational choice helps in understanding how people respond to infectious diseases. People maximize their well- being by choosing levels of prevention and therapy subject to the constraints faced. Objectives and constraints are numerous, necessitating tradeoffs. For example, this approach predicts how people respond to changes in the risk of infection and to the availability of diagnostic tests. The combination of individual rationality with epidemiological models of infection dynamics predicts whether individual choices about infectious disease prevention and therapies produce the best possible social outcomes. If not, individuals’ choices generate rationales for government interventions to influence the levels of preventive and therapeutic activities. Optimal policy usually means accepting endemic infection, but at a level lowered by a coordinated package of interventions. Economics combined with epidemiology provides much qualitative guidance on the design of such packages, including immunization programs.

In many developing country settings, and particularly in rural areas, the implementation of anything more than very rudimentary contracts for medical care providers, including public employees, is virtually impossible. In this paper, we examine the kinds of policy levers that governments might conceivably have available to induce physicians to serve in rural areas. Using simple models of screening and spatial competition, we investigate how the government can sort between physicians with low and high opportunity costs of relocation, and how the quality of existing providers (e.g., traditional healers) might affect the government's training policies.

In an earlier article, the authors outline some reasons for the disappointingly small effects of primary health care programs and identified two weak links standing between spending and increased health care. The first was the inability to translate public expenditure on health care into real services due to inherent difficulties of monitoring and controlling the behavior of public employees. The second was the “crowding out” of private markets for health care, markets that exist predominantly at the primary health care level. This article presents an approach to public policy in health that comes directly from the literature on public economics. It identifies two characteristic market failures in health. The first is the existence of large externalities in the control of many infectious diseases that are mostly addressed by standard public health interventions. The second is the widespread breakdown of insurance markets that leave people exposed to catastrophic financial losses. Other essential considerations in setting priorities in health are the degree to which policies address poverty and inequality and the practicality of implementing policies given limited administrative capacities. Priorities based on these criteria tend to differ substantially from those commonly prescribed by the international community. In a previous article in this journal, we raise questions about the prevailing orthodoxy concerning appropriate health policy in developing countries (Filmer, Hammer, and Pritchett 2000). That article questions the strategy of promoting of primary health care (phc) for virtually all countries. It discusses the disappointing experience with this approach in some countries and concludes that it should not be universally promoted because the success of phc activities is likely to be highly context specific. That article raises doubts as to the universal applicability of the approach. This article addresses the question “What is to be done?” or, given the wide variety of circumstances in different developing countries, “How do we go about determining what is to be done?” We propose a return to first principles suggested by the standard literature of public economics.

New research on the quality of care in public and private primary care facilities has significantly enriched our understanding of how health care is delivered in low- and middle-income countries. First, this article summarizes recent advances in the measurement of quality, distinguishing between measurements of provider knowledge and provider effort. Second, it looks at the determinants of practice quality variation in low-income settings, highlighting the limited role of structural constraints such as infrastructure, the supply of materials including drugs, and provider training—the mainstay of much of global health policy today. In contrast, practice quality variation is clearly linked to provider effort, an aspect of provider behavior that can be altered through a variety of means. Third, it provides a broad economic framework to interpret the findings. We look for evidence of specific market failures in the provision of primary care and emphasize that the key difficulty is (and always was) the transaction-specific nature of medical advice. Providers can do too much or too little (or both), and the extent of either depends on the specific patient and the specific disease. We document specific ways in which it is difficult for both consumers and governments to monitor every transaction to detect potentially errant behavior.

Treatment of cultured rat oligodendroglial progenitors with either platelet-derived growth factor (PDGF) or fibroblast growth factor-2 (FGF-2) activated extracellular signal regulated kinase 2 (ERK2). Activation was transient in response to PDGF, whereas it was greater and more prolonged in response to FGF-2. ERK2 activation by PDGF was preceded by a very rapid, robust and transient tyrosine phosphorylation of the PDGF receptor. Although there was consistently more activation of ERK2 in response to FGF-2 than to PDGF, immunostaining of FGF receptors 1 (FGFR1) and 2 (FGFR2) and their tyrosine phosphorylation in progenitors was very weak, and both receptors were up-regulated during differentiation to oligodendrocytes. Tyrosine phosphorylation of the FGF receptors was maximal from 15 to 60 min of treatment and was sustained for many hours. Binding of radioiodinated FGF-2 to FGFR1 was predominant in progenitors, whereas binding to FGFR2 was predominant in oligodendrocytes. ERK2 activation by PDGF was more sensitive to inhibition of tyrosine kinases, whereas ERK2 activation by FGF-2 was relatively more sensitive to inhibitors of protein kinase C. These differences in signal transduction pathways probably contribute to the different cellular responses of oligodendroglial lineage cells to PDGF and FGF-2, respectively.

Myelin-associated glycoprotein (MAG) is expressed in periaxonal membranes of myelinating glia where it is believed to function in glia–axon interactions by binding to a component of the axolemma. Experiments involving Western blot overlay and coimmunoprecipitation demonstrated that MAG binds to a phosphorylated neuronal isoform of microtubule-associated protein 1B (MAP1B) expressed in dorsal root ganglion neurons (DRGNs) and axolemma-enriched fractions from myelinated axons of brain, but not to the isoform of MAP1B expressed by glial cells. The expression of some MAP1B as a neuronal plasma membrane glycoprotein (Tanner, S.L., R. Franzen, H. Jaffe, and R.H. Quarles. 2000. J. Neurochem. 75:553–562.), further documented here by its immunostaining without cell permeabilization, is consistent with it being a binding partner for MAG on the axonal surface. Binding sites for a MAG-Fc chimera on DRGNs colocalized with MAP1B on neuronal varicosities, and MAG and MAP1B also colocalized in the periaxonal region of myelinated axons. In addition, expression of the phosphorylated isoform of MAP1B was increased significantly when DRGNs were cocultured with MAG-transfected COS cells. The interaction of MAG with MAP1B is relevant to the known role of MAG in affecting the cytoskeletal structure and stability of myelinated axons.

Recent empirical and theoretical literature sheds light on the disappointing experience with implementation of primary health care programs in developing countries. This article focuses on the evidence showing two weak links in the chain between government spending for services to improve health and actual improvements in health status. First, institutional capacity is a vital ingredient in providing effective services. When this capacity is inadequate, health spending, even on the right services, may lead to little actual provision of services. Second, the net effect of government health services depends on the severity of market failures-the more severe the market failures, the greater the potential for government services to have an impact. Evidence suggests that market failures are the least severe for relatively inexpensive curative services, which often absorb the bulk of primary health care budgets. A companion paper, available from the authors, offers a perspective on how government funds can best be used to improve health and wellbeing in developing countries. It gives an alternative view of appropriate public health policy, one that focuses on mitigating the characteristic market failures of the sector and tailoring public health activities to the government's ability to deliver various services.

Although MAG-null mice myelinate relatively normally except for subtle structural abnormalities in the periaxonal region of myelin sheaths, they develop more severe pathological changes as they age. The purpose of this study was to further define the biochemical aspects of CNS pathology caused by an absence of MAG. Proteins associated with myelin and oligodendrocytes were quantified by densitometry of western blots in whole brain homogenates, as well as in isolated myelinated axons and myelin. Neither myelin yields, nor levels of myelin basic protein and proteolipid protein, were decreased in comparison to control levels in 14-month-old MAG-null mice. On the other hand, 2',3'-cyclic nucleotide 3'-phosphodiesterase (CNPase) and the 120 kD neural cell adhesion molecule (N-CAM) were substantially reduced in whole brain, myelinated axons, and myelin. Tubulin, Na(+)K(+)ATPase and Fyn tyrosine kinase were also reduced significantly in myelin-related fractions, but not in whole brain homogenate. The decreased levels of these proteins suggest pathological abnormalities in oligodendrocytes. Furthermore, significant reductions of CNPase and 120 kD NCAM were also present at 2 months, indicating that the oligodendroglial abnormalities begin at a relatively early age. Neither TUNEL assays nor multiplex RT-PCR for mRNAs of apoptosis-related proteins in the aging MAG-null mice provided evidence for apoptotic oligodendrocytes. These biochemical findings suggest oligodendroglial damage in MAG-null mice and support the morphological observations pointing to a progressive "dying-back oligodendrogliopathy" as a consequence of MAG deficiency.

The consultation-liaison (C-L) psychiatry services of seven university teaching hospitals in the United States, Canada, and Australia (the MICRO-CARES Consortium) used a common clinical database to examine 1039 consecutive referrals. A diagnosis of adjustment disorder (AD) was made in 125 patients (12.0%); as the sole diagnosis, in 81 (7.8%); and comorbidly with other Axis I and II diagnoses in 44 (4.2%). It had been considered as a rule-out diagnosis in a further 110 (10.6%). AD with depressed mood, anxious mood, or mixed emotions were the commonest subcategories used. AD was diagnosed comorbidly most frequently with personality disorder and organic mental disorder. Sixty-seven patients (6.4%) were assigned a V code diagnosis only. Patients with AD were referred significantly more often for problems of anxiety, coping, and depression; had less past psychiatric illness; and were rated as functioning better—all consistent with the construct of AD as a maladaptation to a psychosocial stressor. Interventions were similar to those for other Axis I and II diagnoses, in particular, the prescription of antidepressants. Patients with AD required a similar amount of clinical time and resident supervision. It is concluded that AD is an important and time-consuming diagnostic category in C-L psychiatry practice.

The author tries to derive price and rationing rules for public health facilities. He highlights the effect on these rules of different assumptions about the objectives of government (health versus welfare), the limits of available policy instruments, and the market environment in which the public system operates. One recurrent finding: policy reform must be assessed in relation to the changes it induces relative to the status quo before reform. This point may seem obvious, but it represents a distinct gap in the literature on resource allocation in health. To assess changes, the behavior of the private sector must be known in the type of care given in a system and on how this care will change in response to the policy. Substituting for a reasonably well-functioning private sector is not as valuable as providing services that the private sector cannot be expected to sustain. Research is needed to characterize market equilibrium for medical care and its response to policy measures. The author could not examine many issues - most important, those related to uncertainty and insurance. But if the research he calls for in this paper is pursued, those issues must figure prominently as major determinants in the demand for care. This need was originally identified by Arrow, and there is still a long way to go. The author's analysis is not done in terms of preventive or curative care, and he argues for assessing interventions on the basis of changes in the stated objectives of a public system. But there could well be a connection with the preventive-curative dichotomy if there were reason to believe that preventive care will systematically lose out to curative care in a market setting. Onthe basis of people's generally acknowledged undervaluation of preventive services, this may well be the case. Other prevention activities also have many public good features, with few private alternatives, and will look good when improvements over stauts quo are examined for all interventions. But all activities must be evaluated in their improvement over market provision. It is not necessary to prejudge the case for certain types of intervention.

Interventions recommended by consultation-liaison psychiatrists for inpatients they diagnosed as having DSM-III-R organic mental disorder (OMD) were studied to see to what extent specific variables distinguished the OMD patients and differentiated the subgroups of patients with OMD. Prospective data and Mini-Mental State Exam (MMSE) scores on 625 consecutive referrals at 3 general hospitals in Australia and the United States were collected by using the MICRO-CARES database system. The OMD group differed from the other patients because they were significantly more likely to have been referred for "organic brain syndrome" or "agitation," had less mood disorder and lower MMSE scores, and received more recommendations for antipsychotics and for ward-environment manipulation and fewer recommendations for psychological management. The many differences among the OMD subgroups were also consistent with their DSM constructs. A pilot exploration of the validity of the DSM-IV constructs of cognitive disorder and its subgroups performed on the redistributed data suggested that these constructs have similar usefulness.

The author applies to the health sector an approach to analyzing projects advocated in a recent paper by Devarajan, Squire, and Suthiwart-Narueput. In the health sector, a project evaluation should: 1) Establish a firm justification for public involvement. The author identifies a number of common failures in the markets for both health services and insurance but argues that this should be the starting place for economic analysis, not a reason to ignore economics; 2) Establish the counterfactual: what happens with and without the project. Project outputs should be predicted net of the reaction of consumers and providers in the private sector. This requires knowledge of the market structure (supply, demand, and equilibrium) for health services; 3) Determine the fiscal effect of the project. The issue of appropriate levels for fees should be handled jointly with project evaluation; and 4) Acknowledge the fungibility of project resources and examine the incentives facing public servants. Ministries of health may shift their own resources away from activities that are funded by project to those that are not evaluated at all. Project outputs depend on the incentives for civil servants to provide good service--a consideration rarely taken into account in project evaluations. The author concludes that much of the analysis relevant to projects should be done before project evaluation. If the issues of fungibility and incentives are given due respect, thedonors'best form of intervention may not be traditional projects at all but rather general loans with conditions related to general sector strategy and reform. For a standard project, a fair amount of information from supporting sector work is needed before evaluation. If clinical services (or anything depending on people s behavior) are part of the project, information is needed about the supply and demand for substitute services. The market structure of health care is an essential part of the background work.

Open defecation is exceptionally widespread in India, a county with puzzlingly high rates of child stunting. This paper reports a randomized controlled trial of a village-level sanitation program, implemented in one district by the government of Maharashtra. The program caused a large but plausible average increase in child height (95 percent confidence interval [0.04 to 0.61] standard deviations), which is an important marker of human capital. The results demonstrate sanitation externalities: an effect even on children in households that did not adopt latrines. Unusually, surveyors also collected data in districts where the government planned but ultimately did not conduct an experiment, permitting analysis of the importance of the set eligible for randomization.

There is an inherent tension between implementing organizations — which have specific objectives and narrow missions and mandates — and executive organizations — which provide resources to multiple implementing organizations. Ministries of finance/planning/budgeting allocate across ministries and projects/programs within ministries, development organizations allocate across sectors (and countries), foundations or philanthropies allocate across programs/grantees. Implementing organizations typically try to do the best they can with the funds they have and attract more resources, while executive organizations have to decide what and who to fund. Monitoring and Evaluation (M&E) has always been an element of the accountability of implementing organizations to their funders. There has been a recent trend towards much greater rigor in evaluations to isolate causal impacts of projects and programs and more ‘evidence-based’ approaches to accountability and budget allocations. Here we extend the basic idea of rigorous impact evaluation — the use of a valid counterfactual to make judgments about causality — to emphasize that the techniques of impact evaluation can be directly useful to implementing organizations (as opposed to impact evaluation being seen by implementing organizations as only an external threat to their funding). We introduce structured experiential learning (which we add to M&E to get MeE) which allows implementing agencies to actively and rigorously search across alternative project designs using the monitoring data that provides real-time performance information with direct feedback into the decision loops of project design and implementation. Our argument is that within-project variations in design can serve as their own counterfactual and this dramatically reduces the incremental cost of evaluation and increases the direct usefulness of evaluation to implementing agencies. The right combination of M, e, and E provides the right space for innovation and organizational capability building while at the same time providing accountability and an evidence base for funding agencies.

No current system of computerized data entry of clinical information in consultation-liaison (C-L) psychiatry has been well received or has demonstrated that it saves the consultant's time. The inability to achieve accurate, complete, systematic collection of discrete variables and data entry in the harried C-L setting is a major impediment to the advancement of the subspecialty and health services research. The hand-held Notebook computer with Windows PEN ENTRY MICROCARES capabilities has permitted one-time direct entry of data at the time of collection at the patient's bedside. Variable choice and selection enhances the completeness and accuracy of data collection. For example, ICD-9, Axis III diagnoses may be selected from a "look-up" which at the same time automatically assigns the appropriate code and diagnostic-related groups, (DRG) number. A patient narrative can be typed at the nurse's station, a chart note printed for the medical record, and the MICRO-CARES literature database perused with the printing of selected citations, abstracts, and in some cases experts' commentaries for the consultee. The consultant's documentation time is halved using the NOTEBOOK WINDOWS PEN ENTRY MICRO-CARES software, with the advantage of more accurate and complete data description than with the traditional handwritten consultation records. Consultees preferred typewritten in contrast to handwritten notes. The cost of the hardware (about $2000) is less than that of an optical scanner, and it permits report generation and archival searches at the nurses' station without returning to the C-L office for scanning. Radio frequency or ethernet download from the Notebook permits direct data transfer to th C-L office archive computer.

International discussions of public health policy strategies in developing countries have been characterized by strong and conflicting positions. Differences regarding the means of health sector improvement can often be traced to differences about the ends, that is, the goals of the health sector. Three types of health sector goals are reviewed: health status improvement, equity and poverty alleviation, and individual welfare (utility) improvement. The paper argues that all three must be considered in developing health sector reform strategies in all countries. Highly normative policy positions often can be attributed a unidimensional affiliation with one health sector goal and denial of the relevance of the others. The current global interest in using cost-effectiveness analysis to set national health priorities is assessed in light of this eclectic approach. Examples are provided of how a health sector strategy based on cost-effectiveness would give sub-optimal solutions. These examples include situations where a private health care sector exists and provides some degree of substitution for publicly provided services; significantly high income elasticities exist for health care such that higher income beneficiaries may differentially capture public subsidies; and market failures exist in insurance. It is argued that these conditions are virtually universal in developing countries. Thus, rational policy development should explicitly consider multiple goals for the health sector.

This article argues that despite high private expenditures on health in India, policy discourse reflects a constant preoccupation with the public sector. Even historically, envisioning a universal system of health care, the main focus of public health policy—like schooling policy—has been better “access” to public primary health care centers. This focus has been unduly narrow with little attention paid to understanding the behavior of health providers, or conducting a serious outcome evaluation of any of the components of the link from which health services can be availed, be they primary care centers or superspecialty hospitals. The article argues that “access” is not the binding constraint in the provision of primary health care in India. The problem is the quality of care provided both in the public and private sector. It also suggests how standard measures of “quality” can be directly counterproductive. The key focus should be on how health policy affects the quality of services and how to make this a starting point for future policy formulations.

Cultures consisting primarily of O-2A progenitor cells and immature oligodendrocytes with a few microglia and astrocytes were obtained by shaking primary cultures from neonatal rat brain after 12-14 days in vitro. Addition of 50 micrograms/ml exogenous Neu-NAc alpha 2-3Gal beta 1-4Glc beta 1-1'ceramide (GM3 ganglioside) to the cultures resulted in an increase in the number and thickness of cell processes that stained intensely for sulfatide and galactocerebroside (galC) in comparison to control cultures without added GM3. The treated cultures also contained fewer astrocytes than control cultures as revealed by immunostaining for glial fibrillary acidic protein (GFAP). Cells that immunostained for both GFAP and sulfatide/galC were very rare in control cultures but were frequently seen in the GM3-treated cultures, suggesting that these may represent cells changing their direction of differentiation away from type II astrocytes toward oligodendrocytes under the influence of GM3. These effects on the developing rat oligodendrocytes were specific for GM3 ganglioside and were not produced by adding GM1, GM2, GD3, or GD1a to the cultures. Lactosyl ceramide and neuraminyl lactose were also ineffective. When control cultures were initially plated on polylysine and incubated with [14C]galactose, GD3 was the principal labeled ganglioside. However, as the control cells differentiated over time in culture without the addition of exogenous GM3 and produced increasing amounts of myelin-related components, the incorporation of [14C]galactose into endogenous GM3 increased to become the predominant labeled ganglioside by 6 days after plating. Metabolic labeling of the GM3-treated oligodendrocytes with [14C]galactose revealed increased incorporation into galC and sulfatide in comparison to control cultures, but a decreased labeling of endogenous GM3. Similarly, incorporation of an amino acid precursor into the myelin-associated glycoprotein (MAG) was increased by GM3 treatment, but incorporation into myelin basic protein (MBP) was not affected. Although the overall effect of added GM3 was to decrease the phosphorylation of most proteins in the oligodendrocytes, including MBP, GM3 enhanced the phosphorylation of MAG. These findings indicate that GM3 ganglioside has an important role in the differentiation of cells of the O-2A lineage toward myelin production, since differentiation is associated with increased metabolic labeling of endogenous GM3 in control cultures and is enhanced by the addition of exogenous GM3.

Several investigations of interventions with psychiatric and medical comorbidity (CM) in the medical inpatient setting have been reported. These studies include psychiatric liaison screening and interventions, psychosocial screening, and standard consultation. The studies had a variety of outcome variables: 1) altered psychiatric morbidity: 2) lag time to identification of CM; 3) lag time to referring to mental health disciplines; 4) cost offset; and 5) discharge placement. Methodological and design problems confound many of the results, in particular, the lack of random control procedures. However, similarity of findings of the frequency of CM in the inpatient setting and patient response to early detection and treatment should stimulate further research into the effects of psychiatric interventions in the acute inpatient medical setting.

Between 2000 and 2002, the authors followed 1621 individuals in Delhi, India using a combination of weekly and monthly-recall health questionnaires. In 2008, they augmented these data with another 8 weeks of surveys during which households were experimentally allocated to surveys with different recall periods in the second half of the survey. This paper shows that the length of the recall period had a large impact on reported morbidity, doctor visits, time spent sick, whether at least one day of work/school was lost due to sickness, and the reported use of self-medication. The effects are more pronounced among the poor than the rich. In one example, differential recall effects across income groups reverse the sign of the gradient between doctor visits and per-capita expenditures such that the poor use health care providers more than the rich in the weekly recall surveys but less in monthly recall surveys. The authors hypothesize that illnesses -- especially among the poor -- are no longer perceived as"extraordinary events"but have become part of"normal"life. They discuss the implications of these results for health survey methodology, and the economic interpretation of sickness in poor populations.

Ideally, in devising and assessing policies to control disease, the rules and reasoning of economics should be combined with comprehensive epidemiological information to arrive at the best decisions. Simple economic concepts can be of great practical assistance to policymakers in disease control. This article describes the economic principles to be applied and the kind of information needed to make informed choices about the options for controlling malaria. In this context, the article surveys the research on the costs that malaria imposes on people and economies, discusses how to assess the costs and effects of interventions used to combat the problem, and identifies the conceptual difficulties and gaps in information that must be bridged before the marriage of the two disciplines can be effectively consummated.

An important source of failure in markets and justification for government intervention in the health sector of LDCs is imperfect information. Pharmaceutical use is one area in which widespread problems have been noted [1, 2] with substantial misuse, improper diagnosis and problems of compliance noted among both the population at large and health care providers, presumably due to a lack of information concerning appropriate use. One possible instrument vis-a-vis the regulation of pharmaceuticals in LDC's (and in developed countries as well) is the decision by public health officials to make a particular drug available over the counter (OTC) to consumers or to require a prescription from a licensed professional. The choice is one of balancing two competing risks. On the one hand, allowing self-prescription by the consumers who do not have medical training risks gross errors of diagnosis and mistaken prescriptions with possibly serious health consequences. On the other hand, requiring the intervention of a skilled professional runs the risk that the patient does not receive the appropriate, potential life saving, drug at all. With medical personnel in very short supply in many parts of the developing world, the real cost (including travel time and expense) of visiting licensed medical facilities can be prohibitively high. This paper presents a very general methodology for evaluating the tradeoff between these competing risks. The problem can be considered one of determining the value of information (in the form of a more accurate diagnosis through the intervention of a skilled professional) as a particular (and costly) mechanism for obtaining this information.(ABSTRACT TRUNCATED AT 250 WORDS)

Funding for consultation-liaison (C-L) psychiatry remains an overriding obstacle to its implementation and practice. Several methods have been described to access funds for this subspecialty of psychiatry, but none has been enacted as a policy by third party payers to reimburse adequately for the service. In addition, although the consultation portion of the effort can be reimbursed in part in some cases through fee for services, the liaison portion is dependent on the donation of psychiatry time or the largesse of the host department. The efforts at Stanford to capitalize on the findings that psychiatric and medical comorbidity results in prolonged length of hospital stay and increased health resource utilization suggest that specific DRGs would be important patient groups to screen and charge for psychiatric services. Furthermore, DRGs that are accompanied by a high frequency of psychiatric comorbidity are a “target” for an additional funding aliquot to assess and manage the patient's psychiatric status.

This paper documents the quality of medical advice in low-income countries. Our evidence on health care quality in low-income countries is drawn primarily from studies in four countries: Tanzania, India, Indonesia, and Paraguay. We provide an overview of recent work that uses two broad approaches: medical vignettes (in which medical providers are presented with hypothetical cases and their responses are compared to a checklist of essential procedures) and direct observation of the doctor–patient interaction These two approaches have proved quite informative. For example, doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000–96,000 Tanzanians each year. A public-sector doctor in India asks one (and only one) question in the average interaction: “What's wrong with you?” We present systematic evidence in this paper to show that these isolated facts represent common patterns. We find that the quality of care in low-income countries as measured by what doctors know is very low, and that the problem of low competence is compounded due to low effort—doctors provide lower standards of care for their patients than they know how to provide. We discuss how the properties and correlates of measures based on vignettes and observation may be used to evaluate policy changes. Finally, we outline the agenda in terms of further research and measurement.

Isolated adult bovine oligodendrocytes maintained in vitro for 10 days were treated for 1 day with 50 micrograms/ml of GM3 ganglioside (NeuNac alpha 2-3Gal beta 1-4Glc beta 1-1'ceramide) in serum-free culture medium. The treated oligodendrocytes had significantly longer processes with more branching than control cells in the same medium without GM3. The treatment also stimulated the release of a series of 22-100-kDa, [3H]glucosamine-labeled glycoproteins into the culture medium. Treatment of oligodendrocytes maintained in vitro for 50 days with GM3 for 1 day resulted in a thickening of the processes and the appearance of many fine branches on existing processes as well as a similar stimulation of glycoprotein release into the medium.

The major 24- and 28-kDa glycoproteins in shark PNS and CNS myelin express high levels of the adhesion-associated HNK-1/L2 carbohydrate epitope. The 28-kDa protein, but not the 24-kDa protein, cross-reacts strongly with one of two anti-bovine P0 antisera not previously tested against fish myelin proteins. Shark PNS and CNS myelin also contains smaller amounts of high-molecular-weight HNK-1-positive proteins, including a prominent broad band in the 65-85-kDa range. Although myelin-associated glycoprotein (MAG) is well known to react with HNK-1 in some mammals, monoclonal and polyclonal anti-MAG antibodies did not react with the high-molecular-weight HNK-1-positive material in shark myelin, a result suggesting that it is not a MAG-like protein. The high expression of the HNK-1/L2 epitope in glycoproteins of shark myelin, including the major P0-related ones, suggests that this adhesion-related carbohydrate structure may have had an important role in the molecular evolution of the myelinating process.

Agriculture's potential as an engine of third world growth depends, in large part, on the size of the production and consumption linkages it stimulates in rural regions. Current estimates of agricultural growth multipliers within rural regions vary widely, not only because economic structures differ across regions but also because the array of fixed-price models most commonly used embody widely differing basic assumptions. Among fixed-price models, the semi-input-output formulation projects the most plausible multipliers. But even they overstate the magnitude of growth multipliers by 10% to 25% according to the price-endogenous model developed here.

Despite their importance, the nature and context of referral patterns among mental health disciplines in the general hospital has not been sufficiently explored. This study focuses on consultation-liaison (C-L) psychiatry patterns of referral to social work services (SWS). From a structured data base of 1170 consults, it was observed that C-L referred 24% of the cases seen by psychiatry. Psychiatry was more likely to refer those who are: female (p = less than 0.05), living with others (p = less than 0.05), described as less urgent (p = less than 0.05), diagnosed with personality disorders (p = less than 0.01), under greater psychosocial stress (Axis IV) (p = less than 0.001), and evaluated as having better functional status (Axis V) (p = less than 0.001). Regression analysis revealed that four variables had the greatest impact on differentiating those C-L referred to SWS from the "others": 1) constant observation recommended (log -586, p = 0.0001); 2) type of psychiatric management (log -573, p = 0.0001); 3) Medicaid insurance (log -564, p = 0.0001); and 4) original referral for the consultation was the refusal of tests or medical treatment (log -559, p = 0.002).

Convincing evidence exists that psychosocial factors have a major impact on both outcome and costs in the medical/surgical services in general hospitals. This paper describes the Human Services Department's impact on social work and consultation-liaison psychiatry, using a data-based management system across five specialties: 1) social work; 2) consultation-liaison psychiatry; 3) supportive care (hospice); 4) home care (home health discharge planning); and 5) pastoral care, which offers opportunities for research and quality assurance monitoring. Time spent in service delivery was used to estimate the cost per hour: 1) pastoral care $96; 2) social work $36; 3) consultation-liaison psychiatry $59; 4) home care $49. Referral to social work was preferred for a range of family and discharge planning services. Consultation-liaison services were preferred for depression, paranoid behavior, and management problems. Referral overlap was noted for "coping with diagnosis" for social work and consultation-liaison psychiatry. Using a computerized data base format for documenting the referral process, work accomplished, and time spent among those services providing mental health care in the general hospital permits the observation of redundancy of services delivered and their costs.

In a previous study, a checklist and a schema for operationalized interventions have been described [1]. In this study, these operationalized interventions have been used in clinical practice in 820 cases. In 287 cases (35%), recommendations focusing on the medical treatment, other than diagnostic action (41%) and medication (68%), were provided. This emphasis on the intensity of medical treatment is an unreported finding. The further distribution of recommendations over the different intervention domains was: obtaining additional psychosocial information, 30%; psychosocial management on the ward, 61%, specifically its organization; discharge planning, 41%; and aftercare management, 24%. Recommendations infrequently used included: monitoring of cognition and behavior, referrals to occupational therapy and alcohol- and drug-related facilities, and a detailed specification of postdischarge care. Since consultee concordance with the consultant's recommendations is important to treatment outcome, this method of a systematic recording of operationalized recommendations is a first step toward enhancing the evaluation of treatment recommended and provided by consultation/liaison (C/L) psychiatrists. Moreover, these operationalized recommendations help advance the specification of protocols for psychiatric intervention studies.

Carisoprodol is a commonly used centrally acting muscle relaxant. A number of case reports have suggested that the drug may have abuse potential, presumably because it is metabolized to the anxiolytic drug, meprobamate, which is a controlled substance at the federal level. Two recent case reports described symptoms of withdrawal after the cessation of carisoprodol. We present two additional cases that support the concept of a withdrawal syndrome with this drug. Symptoms of carisoprodol withdrawal include anxiety, tremulousness, insomnia, jitteriness, muscle twitching, and hallucinations. These symptoms are most likely caused by withdrawal from the meprobamate that accumulates after large amounts of carisoprodol are ingested. Although carisoprodol is not a controlled substance at the federal level, clinicians should be aware of its significant potential for abuse.

Provide a reproducible method for culturing confluent monolayers of hfRPE cells that exhibit morphology, physiology, polarity, and protein expression patterns similar to native tissue.Human fetal eyes were dissected on arrival, and RPE cell sheets were mechanically separated from the choroid and cultured in a specifically designed medium comprised entirely of commercially available components. Physiology experiments were performed with previously described techniques. Standard techniques were used for immunohistochemistry, electron microscopy, and cytokine measurement by ELISA.Confluent monolayers of RPE cell cultures exhibited epithelial morphology and heavy pigmentation, and electron microscopy showed extensive apical membrane microvilli. The junctional complexes were identified with immunofluorescence labeling of various tight junction proteins. The mean transepithelial potential (TEP) was 2.6 +/- 0.8 mV, apical positive, and the mean transepithelial resistance (R(T)) was 501 +/- 138 Omega . cm(2) (mean +/- SD; n = 35). Addition of 100 microM adenosine triphosphate (ATP) to the apical bath increased net fluid absorption from 13.6 +/- 2.6 to 18.8 +/- 4.6 microL . cm(-2) per hour (mean +/- SD; n = 4). In other experiments, VEGF was mainly secreted into the basal bath (n = 10), whereas PEDF was mainly secreted into the apical bath (n = 10).A new cell culture procedure has been developed that produces confluent primary hfRPE cultures with morphological and physiological characteristics of the native tissue. Epithelial polarity and function of these easily reproducible primary cultures closely resemble previously studied native human fetal and bovine RPE-choroid explants.

The quality of medical care received by patients varies for two reasons: differences in doctors' competence or differences in doctors' incentives. Using medical vignettes, the authors evaluated competence for a sample of doctors in Delhi. One month later, they observed the same doctors in their practice. The authors find three patterns in the data. First, what doctors do is less than what they know they should do-doctors operate well inside their knowledge frontier. Second, competence and effort are complementary so that doctors who know more also do more. Third, the gap between what doctors do and what they know responds to incentives: doctors in the fee-for-service private sector are closer in practice to their knowledge frontier than those in the fixed-salary public sector. Under-qualified private sector doctors, even though they know less, provide better care on average than their better-qualified counterparts in the public sector. These results indicate that to improve medical services, at least for poor people, there should be greater emphasis on changing the incentives of public providers rather than increasing provider competence through training.

The authors develop a method in which vignettes-a battery of questions for hypothetical cases-are evaluated with item response theory to create a metric for doctor quality. The method allows a simultaneous estimation of quality and validation of the test instrument that can be used for further refinements. The authors apply the method to a sample of medical practitioners in Delhi, India. The method gives plausible results, rationalizes different perceptions of quality in the public and private sectors, and pinpoints several serious problems with health care delivery in urban India. The findings confirm, for instance, that the quality of private providers located in poorer areas of the city is significantly lower than those in richer neighborhoods. Surprisingly, similar results hold for providers in the public sector, with important implications for inequities in the availability of health care.

The quality of medical care is a potentially important determinant of health outcomes. Nevertheless, it remains an understudied area. The limited research that exists defines quality either on the basis of drug availability or facility characteristics, but little is known about how provider quality affects the provision of health care. Das and Hammer address this gap through a survey in Delhi with two related components. They evaluate "competence" (what providers know) through vignettes and practice (what providers do) through direct clinical observation. Overall quality as measured by the competence necessary to recognize and handle common and dangerous conditions is quite low, albeit with tremendous variation. While there is some correlation with simple observed characteristics, there is still an enormous amount of variation within such categories. Further, even when providers know what to do they often do not do it in practice. This appears to be true in both the public and private sectors though for very different, and systematic, reasons. In the public sector providers are more likely to commit errors of omission - they are less likely to exert effort compared with their private counterparts. In the private sector, providers are prone to errors of commission - they are more likely to behave according to the patient's expectations, resulting in the inappropriate use of medications, the overuse of antibiotics, and increased expenditures. This has important policy implications for our understanding of how market failures and failures of regulation in the health sector affect the poor. This paper - a product of Public Services, Development Research Group - is part of a larger effort in the group to understand the delivery of basic services by the government and private sector in low-income countries. The study was funded by the Research Support Budget under the research project "Health Care Providers and Markets in Delhi."