Case Study

Skolnikland is in Eastern Africa, with a population of 30 million people. The country has a plains region, a hill region, and a region with high mountains. It has a number of ecosystems. The plains are dry for much of the year, there is some rainforest, and the rest of the country includes both hills and mountains. There are two seasons of heavy rainfall.

The citizens come from several ethnic groups that tend to live in their own regions and speak different languages. The ethnic groups largely follow one of three different religions. The large cities are mixed ethnically. One ethnic group is economically and socially very dominant. The people from this group live in the capital and most of the large cities. The national language is the language of this dominant ethnic group.

According to World Bank criteria, Skolnikland is among the poorest countries in the world. The economy has been growing at about 4% per year on average over the last decade, but the economy had very slow economic growth in the decades prior to that. The richest 10% of the population controls 80% of the national income.

About 80% of the people live in rural areas and 20% in urban areas. The number of people living in urban areas has been growing recently at an increasing pace. Most people earn their livelihood in agriculture but there is an increasing garment manufacturing industry in the two largest cities. There are also a number of mining industries. In addition, other export industries are beginning to grow, mostly focused on the export of commodities to China.

The total fertility rate is about 4.5 but it has been declining slowly over the last two decades, from over 6. There is an almost equal number of men and women in the population. Infant mortality is about 90 per 1,000 live births. Maternal mortality is about 500 per 100,000 live births. Thirty-five percent of the children are underweight for age.

The adult literacy rate is about 40%. The educational enrollment rate, especially for girls at the primary and secondary levels, has been growing slowly, but steadily. Most recently, this rate has been growing at an increasing pace and about 75% of the girls now attend school regularly, although many of them are of very low quality.

Only about 50% of citizens have access to safe water. Only about 30% have access to sanitary disposal of human waste.

HIV prevalence is 7% of the adult population. The number of new HIV cases annually has begun to plateau. About half of the people eligible for treatment for HIV are on treatment. Malaria is rampant in the plains.

Investments in the road system have been growing at a solid pace in the last decade and the use of private automobiles has begun recently to increase more rapidly.

Skolnikland has a pluralistic health system that is made up of public and private institutions, publicly financed providers, licensed private providers, unlicensed medical practitioners, and traditional healers. There is no health insurance, except for some free services for the poor in the few publicly financed hospitals, which the better off people do not attend. The health system is not very effective or efficient and is generally of low quality. The HIV, TB, and malaria programs are not effective or efficient and they are just beginning to adopt paradigms for services that follow global best practices.

1.If you were interested in investing in maternal and child health using a results-based financing scheme, which program is the most appropriate?

A. Invest in training more skilled birth attendants in a village.

B. A plan to give the local clinic in the village a grant after the clinic demonstrates that its efforts have led after two years to lower under-5 child mortality.

C. Provide all pregnant women in the village with a full course of antenatal vitamins.

2.In Skolnikland today, approximately what proportion of the burden of disease, measured in DALYs, is likely to be Group I-related?

A. 45%

B. 35%

C. 60%

3.In Skolnikland, life expectancy fell in the 1990s, which can be attributed to:

A. Malaria

B. HIV

C. Pneumonia
4.In Skolnikland, the cost for treating severe diarrhea in young children is $18 for community-based care and $20 for clinic-based care. The cure rate for community-based care is 60%. The cure rate for clinic-based care is 90%. Which approach is the most cost-effective?

A. Community-based care

B. Clinic-based care

C. They are equally cost-effective

5.In Skolnikland, what are likely to be three of the five leading causes of death of under-5 children, besides perinatal causes?

A. TB, diarrhea, pneumonia

B. Malaria, diarrhea, measles

C. Diarrhea, malaria, pneumonia