SAGA Progress Report

SAGA
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SAGA Progress Report
October, 2003

II. RESEARCH
C. Madagascar

1. Activities over the past 12 months

Our work on designing and planning the research agenda in Madagascar began this past year with discussions of the broader SAGA program with the Centre d’Etudes Economique (CEE)’s and USAID Mission. Those meetings initially focused on CEE’s capacity, and the Mission’s new strategy set to take effect October 1, 2003.

In terms of the major research themes to be pursued in Madagascar, health is one of the major foci of our expanding program. In that area, we have two areas of interest that are mutually reinforcing and intertwined. The first is our work on HIV/AIDS. Consistent with the Mission’s interest in this area, we have been undertaking an analysis of existing data with Malgashe counterparts to examine HIV-AIDS knowledge and behaviors in the context of a country that currently has low HIV prevalence but is considered vulnerable to a rapid increase in incidence and prevalence.

The study, using data from the last (1997) Demographic and Health Survey conducted in Madagascar, estimates the individual, household, and community-level determinants of AIDS prevention knowledge, condom use, and related outcomes for women of childbearing age. The DHS is extremely valuable in that it includes a module on AIDS knowledge and thus allows us to address these questions. It is, however, less comprehensive than standard household surveys. To partially address this shortcoming, we have been able to supplement the DHS with the nationwide commune census conducted in 2001, which collected information on a number of aspects of local health, schooling, and other infrastructure that are likely to influence AIDS knowledge and behavior. In the months ahead, we anticipate working with the 2003 DHS to augment this study in order to assess how the levels of knowledge and behaviors have evolved over the past six years, and to explain the determinants of these changes.

The second major area of the health work relates to the SAGA themes of empowerment and institutions. Specifically, we have been working with the Institut National de la Statistique (INSTAT) and the Ministry of Health, with funding from and in collaboration with the World Bank, to conduct surveys of health facilities and their users. There are several main objectives to this project. First, informal accounts during the political and economic crisis of 2002 indicated that the crisis was having severe effects on the health sector and on the health of many segments of the population. We seek to investigate more systematically the effects of the political crisis, as well as the impacts of the end of the crisis and the new government’s decision to temporarily suspend cost recovery on the utilization of public as well as private health services. Has demand for health services begun to recover, and in particular has it done so for the poorest groups? Second, the research seeks to understand the impacts of the crisis and subsequent elimination of cost recovery on the supply side as well—in particular, on the quality of services provided in public health centers. Third, the study has a more general but equally important aim: to provide a clear and comprehensive picture of the functioning of the Malagashe public health sector some seven years into the policy of health sector decentralization, making use of detailed facility data.

The surveys were designed to be complementary to the 2002 household survey conducted by INSTAT. Households in 80 communities surveyed in the earlier effort were re-interviewed to obtain more detailed information on health care choices as well as assessments of recent changes in service quality, in particular since the removal of PFU (the cost recovery policy or la participation financiere des usagers). Since the numbers in household surveys using a given facility in standard reference periods tend to be small, a similar questionnaire was administered to users of health facilities in these communities. Finally, a detailed health facility questionnaire, designed with the help of Malagashe medical professionals, was administered in the same localities. The uniquely detailed facility survey provides information on personnel, availability of supplies and medicines, referral and treatment practices, organization and management, and changes that have occurred since the crisis and the elimination of PFU. It also collected financial information that can be used to study budget tracking and will gather data on oversight (e.g., visits from inspectors) and relations with local authorities.

The surveys were fielded together in the spring and summer of 2003, and the data have recently been entered by INSTAT. Joint analysis by INSTAT, Cornell, and the World Bank is scheduled to start in November, 2003.

In the context of the education theme, we are engaged in finalizing a research program with INSTAT and the Ministry of Education to provide a clearer picture for policy-makers of the determinants of primary and lower secondary schooling outcomes. This work is also designed to be comparable in research methods to a similar study being undertaken in Senegal.

The education system in Madagascar is characterized by resource inefficiencies and misallocations in the composition of public spending across educational levels. The quality of schooling from elementary to higher education is low, as are gross enrollment rates both at the primary and secondary levels, even when compared with the averages for Sub-Saharan Africa. In addition to low initial enrollment, grade repetition and dropping out of primary school before completion are serious problems in Madagascar. Consequently, few children proceed to lower secondary school. This problem also reflects the small number of lower secondary schools in the country and the significant distances many children would have to travel to attend them. Further, the lack of access to secondary schools may be inhibiting primary, not just secondary, enrollments. Parents often see the value of primary education in terms of gaining entrance to higher levels of schooling and the concomitant earnings and occupational benefits that result. If they expect to be rationed out of secondary school either through restrictions on places or through distance, they may choose not to enroll or keep their children in primary school.

For those who do make it to secondary school, repetition continues to be a problem. Finally, girls are at a particular disadvantage. Across all grades, repetition and dropout rates are systematically higher for girls than for boys. Clearly, the ability of the country to increase its human capital, which is essential for development, has been seriously weakened. Our research is therefore focused on understanding the factors at different levels—household, school, and community—that affect education outcomes in Madagascar, particularly for primary and lower secondary schools. More specifically, the research has multiple objectives, reflecting (as well as determining) the broad nature of the data that will be available for the analysis. The objectives pertain to three main subject areas: (1) determinants of school enrollment and grade attainment, (2) determinants of learning, both academic (as measured by student test scores) and non-academic (acquisition of life skills), and (3) development of empirical methodologies that are applicable and appropriate to the Malgashe context. In addition, the research will examine related factors such as entry into the workforce after school, children’s time allocation, and schooling differences among siblings and between boys and girls, and migration and health and their relationships to education.

In addition to the work on health and education themes described above, CEE has an interest in urban poverty dynamics and urban labor markets. We therefore continue to explore with them the use of the 2001-2003 EPM (Enquête Permanente auprès des Ménages) survey to explore household-level poverty dynamics at a national level with INSTAT and the link between asset holdings, livelihood strategies, and welfare dynamics to explore poverty traps and vulnerability. In addition, we have encouraged them to use and build on BASIS FOFIFA (Center for National Agricultural Research) data to explore linkage between agricultural production and marketing and natural resource management patterns at household level (e.g., soil and welfare dynamics), to determine why some people do not make the jump out of poverty and what can be done to help them climb out of poverty?

Similarly, based on the confluence of Mission interest and the thematic areas of SAGA, we would are beginning to both link the poverty dynamics work with the PRSP team, as well as blend those areas of analysis with our poverty traps and rural vulnerability work. Among the issues that the Mission would like to see tackled are what are the high value agricultural products that could help stimulate sustainable agricultural intensification here? Similarly, there is an interest in looking at how rural household portfolios can be adapted to stabilize and increase well-being. The PRSP and Ministry of Agriculture are key audiences here.

2. Institutional linkages/collaborators:

In terms of institutional arrangements, CEE, Madagascar’s SISERA institution is within the Department of Economics at the Université d’Antananarivo, and thus closely linked to the university. It previously worked under EAGER with Harvard on a variety of macroeconomic and financial sector topics. The scale of CEE is quite limited. In addition, much of CEE’s major research interests are somewhat outside the core research themes of SAGA. Specifically, CEE is proposing to SISERA research on (i) privatization in the financial sector and its effects, (ii) mining sector policy and growth, (iii) urban poverty and development, and a few other topics under development. Nonetheless, there is shared concern about ensuring integration of research design and results reporting into policy discussions. We have therefore pursued, in consultation with CEE, a strategy where our major direct partners in the research activities themselves will be INSTAT, Ministry of Education, FOFIFA and the Ministry of Health. CEE will play a coordinating role and also and organizational role in starting a policy research forum with these various institutions, designed to promote greater integration of research findings into the policy-making process. In addition, given that the key researchers from INSTAT, FOFIFA, and the Ministries have formal academic appointments in the Department of Economics at the Université d’Antananarivo, CEE’s home, this approach will hopefully serve to strengthen CEE’s institutional competency as well. Further, by funding CEE to coordinate research dissemination and policy dialogue, we will hopefully increase their visibility and integrate them more into research networks, especially those with strong extramural collaboration (e.g., INSTAT-FOFIFA-Cornell).

3. Planned Activities

The next six months of activity will focus on the completion of the initial paper on HIV/AIDS, the analysis of the second Demographic Health Survey data with a focus on changes in HIV/AIDS knowledge and risk behaviors, the analysis of the health facilities and user survey data and related report preparation, the design and conduct of the education survey, and the further definition of the work that will focus on risk, vulnerability, and poverty dynamics. In addition, we will begin planning a workshop on the health research in the spring of 2004. A second workshop that will focus on the results of the education work is planned for the fall of 2004. We are also discussing the timing of a third, larger conference that will integrate results from all aspects of the SAGA agenda, possibly in beginning of 2005.

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