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PolicyResearch

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WORKING

PAPERS

Populatilon, Health, and Nutrition

Population andHuman Resources Department TheWorld Bank November 1992 WPS1046

Public Disclosure Authorized

Public Disclosure Authorized

World Bank Project-Financed Researchon Population, Health,and Nutrition

J. PriceGittinger and CarolBradford

Public Disclosure Authorized

Mostpopulation,health,and nutritionprojects providefinance for research.Personalities- of both borrowersand Bank staff - make a differencein the qualityof research. Supervision and peer group review also make a difference, and more bestpracticesworkshopsare in order.

PolicyReah WongPapcudminatthefmndings ofwinpn ndM numgetheehan8cofide amongBankstaffand asldbexinciead dopeuuic&Thaspapw,& dbytuxbythReRab hAdvisoyStaff.cynamc thsnfescauthwusrcfl a 1ythdrvwsandsbohdbtWad ndcitodaoconigly.Thefindings, intutadons,andconc1usoaetheauthomeown. Theyshould
act be aunbud to the Wodd B o , its Baud of Dims, its managmemat,or any of its mamber couantri

r_ Policy R orh
Poualn, Health,andNutrition WPS 1046

-

Thispaper-aproductofthe HealthandNutritionDivis-n, PopulationandHumanResourcesDepartment is partof a largereffortin the departmentto dissemLa&te Bank-funded population,health,and nutrition research.Copiesof thepaperareavailablefreefromtheWorldBank, 1818H StreetNW, Washington, DC 20433. PleasecontactOtilia Nadora,room S6-065,extension31091(November1992, 16 pages). researchcomponenton time and of good quality. For quality researchto be completed,it is importantthat those responsiblefor supervision attacha high priorityto researcheven if it is not a large part of the project in terms of budget.
* Researchthat leads to a project outcomesuch as researchneededto justify releaseof fundsor for a follow-onproject - is morelikely to be undertakenand completedthan is research with a moregeneral objective.

This report on WorldBank project-financed researchon population,health, and nutrition (PuN) iLbased on a reviewof 109staff appraisal reports for projectsfinarnced in fiscal 1980-91 and on selectedinterviewswith task managers. The report looks at only the simplestdimensions of project-financed researchand examines researchoutcomesof only a few projects. Amongconclusionstentativelyreached:
* More than 90 percentof PHN projectsfrom fiscal 1980-91financedresearch. * Bank experiencewith project-financed

researchin the PHN sectorhas beenextremely variable:quite successfulin some countriesand almosta total failure in others. Evenso, some strikingsuccessesjustify continuedefforts to incorporateresearchinto projects and to encourage use of that researchto improveboth national PHN policy and follow-onBank-financed projects. * Personalitiesmake a difference,both among borrowersand withinthe Bank. Oftensuccesses are associatedwith a particularpersonwithinthe govemmentor the Bank who has taken a continuingpersonalinterest in encouragingresearch. * Supervisionis crucialto good results. Supervisionmust be frequentenoughto keepthe

in countrieswhere the institutionalcapabilI ity exists, using a nationalinstitutionto review researchproposalsand to administerresearch grantscan be quite effective.Experienceindicates that some sort of peer-groupreview oroducesbetter research.
* There is probably room for more bestpracticesworkshopswhere PHN staff can exchangeexperiencesaboutsuccessfuldesign and supervisionof project-financed research components.But usuallyit will be necessaryto retainexperiencedconsultantsto help design substantialresearchcomponents.
* More systematic collectionand dissemination of project-financed researchis justified, giventhe considerableamountsof moneyand effortdevotedto it.

ThePolicyResearchWorkingPaperSeriesdisseminates thefmdings of workunderway im theBank.Anobjectiveof theseries is to get these findingsout quickly,even if presentationsare less than fully polished.The findings, interpretations, and conclusions in thesepapersdo notnecessarilyrepresentofficialBank policy. Producedby thePolicy ResearchDissemination Center

Health. Price Gittinger and Carol Bradford . and Nutrition by J.World Bank Project-Financed Research on Population.

........................... 4 4 10 11 13 ...... Annex Projects Reviewed........................ .......... ........................................................................................ 1 1 Total Value of Project-Financed Research ............ Project-Financed Reseach EBperlence .... Other Sector Project-Flnanced Rescarh .... Conmnon Theme and Condusions .......Table of Contents Proportion of Projects wlth Research Categories of Research Financed ..................

.. and researchneededto prepare information. revision in the light of fuller investigation.-------. .managerial (including operational research). The World Bank encouragesPHN research Word Bnkenow gebaseuPoNresech to tostrengthen to strengthen the kcnowledge base upon Which to design cost-effective investments in population. & r"i54 .. There were no operations in the Europe and Central Asia region during the period reviewed. health. ... Bank-wideand in 20 A_ "t . 14 in the Middle East and North Africa region. .) The projects represent essentiallyall Bank financingin the PHN sector during the period under review.-.. _ 0 .. In tbis note. andcommunication (IEC)programs. _ .. Projectswere reviewedand tabulatedBankwide and on a regional basis (Table 1). This note is an initial.rkeyis tabulatedin the MiddleEast and North Africa region... four of the five regions covered. and 19 in the Latin America and Caribbean region. Health... The categorieswere medical. financial.oo 9_ . the research proposed in the SAR was dassified by one of six categoriesor else was noted as uncategorized(see box). 15 in the South Asia region. _ . WFigure 1. Tu... and to evaluate program and project performance as a basis for improvingfuture design... ... . Categories of Research Financed For every project reviewed. the conclusions reached must be consideredtentativeand subjectto . so 0 40 . human resources (including studiesrelatingto personnelpractices). .._ Proportion of ProjectswithResearch Virtually every project in the PHN sector during the period reviewed containedsome provision for research (Figure 1). 13 in the East Asia and Pacific region. to strengthenthe analytical capacity of borrowing governments to undertake policy-related PHN research. . . It is based on a review of 109 staff appraisal reports (SARs) for projects fLiancedin fiscal years 1980 through 1991 and selected interviews with task managers....exploratory survey. Hence. The projects reviewedinclude47 in the Africa region..World Bank Project-Financed Research on Population. the proportionof projectswhich includeda research componentwas over 90 percent.. .. o A .. and Nutrition This note reports on World Bank project-financed research on population. --. Proportion of projects with research componentsby region and Bank-wide.. and nutrition (PHN)..education. in MENA 80 percent of the projects includeda research component... ..... health. . and nutrition. demographic/ epidemiological.. (A list of the projects reviewed is given in the Annex. It looks only at the simplestdimensionsof projectfinancedresearchand examinesresearchoutcomes of only a few projects. tooprt.

morethan one in five LACprojectsdid so. Whilethere are regionaldifferences in the frequency in whichcategories are included in projects. DEMOGRAPHICGTPIDEMIOLOGICAL. managerial studies werethemostfrequent category encountered. Res to determine numbers of personnelneededor to assess the skills of individuals providing careor otherservices. Researchfor EECmaterialsand programs rangedfrom 7 percentin MENAto 40 percentin SouthAsia. Studies assessingadministrative issues. earchcarriedout HUMANRESOURCES. It is interesting to note that financial studiesin the Africaregion frequentlyrevolved aroundcost recovery.including training of personnel. Includesstudieson cost-recovery and healthinsurance.the most common research component was a managerial studyor operational research.censusts. Researchwas taken to mean special studiesof some sort. and it may be insignificant. it was assumedthat everyprojectwouldhavea management informationsystem. AND COMMUNICATION(IEC). The reasonfor the variation is not clear.Includes assessments of additionaltraining needed or how existing skillsmightbe improved. FINANCIAL. Studies prepareIECmaterials wereincluded in 16percent of theprojectsreviewed. INFORMATlON. Demographic/epidemiological or financial researchwere the secondand third most common. studiesof medicalinsurancewere concentrated in Asia. However. In every region except MENA. etc.2- FHNResearch Project-Financed Frequencyof Categories Research Categories Researchproposedin the 109 SARs reviewed for this note was categorized in one of six categories or else notedas uncategorized. Researchon programcosts or means of financinghealth care or nutrition interventions. The next most commoncategories of research were demographic/epidemiological included in 48 percentof all projectsandfinancial studiesincluded in 47 percentof all projectsreviewed. Cov- ers surveys. includingoperational research and means to increase program efficiency. RegionalDifferences cal studies. wasincludneeded to ed in 30 percentof theprojects. it proveddifficult to separate outtheresearch needed to prepare IECmaterials fromthe workof preparingthe materials themselves. Research on informa- tion neededfor IEC programs.medical trials.) In some 13 percentof the projectsthere was a medical researchcomponent. Researchturning on human resources issues.a topicwhichwas of great concern to healthadmniistrators and governments during the decadeof the 1980s. they are not strikingand p:obablyare not significant. MEDICAL.so MISintended primarily as a management tool duringprojectimplementationwas not included. On the other hand.clini- Bank-wide. MANAGERLi.studiesdone withlarge groupsto determine the effectof a program. etc.EDUCAI7ON.Whileno projectin MENAincluded medical research. Includes biological research. . (Preparation of the IEC materials themselves wasnotcounted as research. Includes epidemiology. Includes stand-alone evaluations of projects or programs. Seventy-two percent of all projects reviewed included oneor anotherkindof managerial research.but notpreparationof the materials themselves. either as part of project impleir :tationor for a broaderpurpose.

Project-FinancedPHN Research Table 1...... _.. 21 percentof the SARsincluded some explicit provision for research intended to facilitate preparation of a follow-on project percent... sions of adjustment. it was knowledge.. in East Asia and Pacific 23 percent... in MENA 7 percent... Projectswith Research Components by Region and Category. t MC te. Book-l Figure 2. and commonto find provisionfor family planning (Figure2).attitude. ... O MA. and practice (KAP)research.. ... Includes Turkey... in South Asia 20 percent.... search). Proportion of projects with follow-on project research componentsby region and Bank-wide. 100Pat . especially the extent of malnutrition (classified as demographic/epidemiologicalre.. Structural adjustment loans with PHN activities oftenincludedresearchto look at the socialdimens ......... At . . .... Nutrition projects. Population projects also included research on Bank-wide....... . In populationprojects..distribution.. generally included nutrition-related o research.... not surprisingly... or formulation figured in several projects.. FY'80-FY'91 (Percent)East Asiaand Pacific 15 54 31 54 38 8 Research Category Medical Demographic/ Epidemiological Human Resources Managerial Financial IEC a. Africa 13 43 28 74 55 17 South Asia 13 47 47 93 27 40 MENA' 0 60 20 53 40 7 LAC 21 47 32 74 53 5 Bankwide 13 48 30 72 47 16 Other 7ypes of Research Researchfor Follow-OnProjects The rangeof research proposed in the SARs reviewed was extremely broad.... Researchintodrug prescriptionpractices.... The importanceof malaria in the Amau zon basin led to inclusion of entomologicalre20 search in the Brazil AmazonBasin Malaria Control Project... The proportionin Africa was 28 maternamortality andon contraceptive use (classified as demographic/epidemiological research). even within the tabulatedcategories..

Since Bank projectin the areas of financedresearchis dominantly or fimanagement. Even the documentation oftendo notreportthe Reports ProjectCompletion unlessit wasa veryimportant outcome of research of the project. after the World Health the largest externalfinancierof Organization. The proportion proto supportfollow-on with researchintended by these understated considerably jectsis probably likelythatmanySARsmight tabulations. The SARsoftendo not project-financed for reincludeexplicitlythe amountenvisioned search.andnutrition projects. If these estimates would make the Bank. demography/epidemiology.andassuming Taking an approxito make andIDA funds. Project-Financed Research Experience are presentedto Eight countryexperiences of projectthe effectiveness insight into provide research.or on the order of $2 million. health. Bangladesh Populationand The Bank-ledBangladesh includgrouping13financiers Health Consortium. . SARs. project-financed leadingsourceof externalfinancefor thesekinds of research.In the late 1980s. If the amountfor healthand other PHN researchis betweenone and two percentof this.It seems be written in the expectationthat all research of a to the preparation wouldcontribute included projectandthat it wouldbe unnecessary follow-on to mentionit explicitly.a range of regions. researchis probablythe nance.largest.in 1988only 3 percent of this was for areaswhichmightincludepolicyresearch.mostcomplex. of follow-on supportpreparation Total Value of Project-Financed Research The sourcesof data for this note do not of permitmore than a very roughapproximation the total amountof Bankand IDA fundsusedfor research.whether is not knownon thebasisof the actually expended used in this study. many SARs generalpopulafor strengthening madeprovision planningandthat would tion. are stateinformation were the fundsenvisioned mentsof intent.it is not spenton researchis included clear to what extentloan funds will financethe fromthe entirely or if it willbe financed research to the project.it is possible mation. and both successfuland unsuccessful effortsto promoteresearch. In a largenumber of the cases where it is possibleto identifythe for between amountspenton research.or some US$4 millionto US$8 are valid. of course. Total SAR proposedlending for the in this studywas aboutUS$4. accordingto the WHO Officeof Research Promotionand Development. Frecomponent or contentious to be aboutthe amount quently wheninformation in an SAR. was instrumentalin workingout the Fourth Populationand Health in fiscalyear 1991. of the amountof mind. health and other PHN researchin Third World countries.the WHObudgetfor $60 millionto $70 researchwas runningbetween million annually. Further. that wouldcome to betweenUS$46millionand US$92million. to Bank it applies thisrange. instead research is often includedwith other items such as trainingor the management system. Theywere selectedto give a financed range of differentkinds of projects. The Consortium themost andperhaps lived. contribution government in theselimitations whilekeeping However. plusthree executing ingIDAandthe Government United Nations agencies. Almostall of theprojectcomponents and healthelementsof the Five-Year population is probablythe longestPlan.-4of projects in LAC 16 percent.it accounts one and two percent of the total project costs.6 projectsincluded PHNResearch Project-Financed billion. a gross approximation fundsdevotedto PHN researchfrom Bankloans and IDA creditsis attempted. The Fourth Projectapproved part of the Project is a crucial and significant Plan whichextendsfrom 1990 FourthFive-Year are to 1995. However. it millionannually.

and has influenced thinking about malaria control strategiesworld-wide. for example. Preparation of the Third Project was not nearly so consultative in nature as was the Fourth Project. a research component was included in the project.SUCAM. There was a three-day workshop in May 1990 in conjunction with the World Health Assemblywhere donor representatives and senior governmentofficialsdiscussedthe directions and activities to be included in the Governmentof Bangladesh'sFive-YearPlan. thus. This process of extensive consultationwas greatly facilitatedby the availabilityof a set of 24 extensivestudies on various aspectsof the population and health sector that had been includedin the Third Population and Family Health Project approved in fiscal year 1986. and it was recognizedat the time that in many areas information needed for jointly planningand settingpriorities was incompleteor unavailable.sponsoreda "Malaria Days" conferencein Brazil. US$2. Finally. more effective. the 24 studieswere carried out either directly by the ExternalEvaluation Unit of the Planning CommissionOater the Population Developmentand Evaluation Unit) or on contracts supervisedby the Unit. a . Preparation of the Fourth Population and Health Project was marked by an extensive series of workshopswhere the issuesand priorities were debated. Brazil: Malaria Control -5 - Project-financedresearch in Brazil has had a substantial impact in changing malaria control 'irograms. a three-day high level seminar for senior officials from the Bangladesh Planning Commission. However. the semiautonomousorganizationresponsiblefor planning and implementingcontrol programs for all the endemicdiseases in Brazil. which proved to be highly successful. The"Malaria Days" conferencewas also one of the first steps in the preparationof the followon Amazon Basin Malaria Control Project. yet another three-day workshop brought together donors and government officials to agree on the broad-brush outline of the major approaches and priorities for the five-year implementationperiod of the Fourth Project. Thesestudies were critical backgrounddocumentsfor the various workshopsthrough which the approachesand priorities of the Fourth Population and Health Project were agreed upon.Project-FinancedPHN Research successful exampleof donor coordinationand cofinancing in the history of Bank operations. Representativesof donor agencies met in a workshop to coordinatetheir views about issues and priorities." As the project was implemented. Ministry of Health and Family Welfare. Another three-day seminar permitted field-level staff to articulate their views about issues and priorities. By 1987. At Bank urging. During implementationof the Third Project. and Ministry of Finance. researchers from all over the country presented the results of their research. When preparation began for the Northwest Region Integrated DevelopmentProgram Project financed in fiscal year 1982.8 million of the $37. The results of this research made it possible to adapt and adjust the SUCAM anti-malarial campaigns to be more specific to particular areas and.7 was allocated for "research and evaluation. There was. the division chief concernedhad visited research institutesin Brazil and wasconvincedmore operational research conducted by these institutions of the anti-malaria couldimprovethe effectiveness campaigns implementedby SUCAM. For three days. a sizeable body of research on malaria had been financed by project funds. using predominantlyproject funds.usingproject funds. commissioned research at local institutions. there was limited interest among Governmentagencies in including provision for research in the project. has provided a substantial input to a follow-on project. The collected papers were later published in a volume which presents one of the more comprehensive views of malaria control operationsever undertaken. SUCAM.

It also illustrates importanceof carefil project design and close draws extensively supervision. 64 research under the project.41 percentof the loan funds had been hadrepercussions to 20 studies.but manyresearchprojects received have simplybeen left uncompleted. and closed on an additional efforts extended Previous malariacommunity. whichfurthercomplicated by sion-making.000.the projectwas to be administered the GovernmentPlanning Institute (IPEA) or anotherresearchinstitution.000.a new administrator success of the Brazilianproject in using opin the Miniserationalresearch to shape effectivelocal pro. were not well debilitiesof the two institutions fined.A outhavingdirect administrative was workedout by whichthe Miniscompromise relationship try wouldenter into a "consultative" for the Project withIPEA. research rolesandresponsitherespective suchexperience. From the start implementation recentlyprogresshas been made in fundingrein June 1984to loan signing FromBoardapproval searchproposals.Therewasa growing study. 1989 with the cancellationof to 'eradicate' malariawere being recognized that US$279. Six The research financedby the Northwest year beforeeffectiveness scheduled beforetheprojectwasoriginally ProgramProject months Development RegionIntegrated far beyondBrazil. sixmonths.andit wasanother tookapproximately in January 1986. CIPLAN. The NationalHealthPolicyStudiesProject part of the SecondHealth in Brazil. onlyone completed The wouldbe needed.in chargeof scienceand technology grams made it a model closelyobservedby the try. discussed. It was decidedto makea separateUS$2 as grantsto researchinstitutions.Changes of researchinstitutesin Brazilhave millionloan for the project. He felt that policy researchwas important and that the loan funds should be utilized to community. and coordination problems persisted design the project. international as December 31. reports for 23 studies have been problems can be Many implementation attributedto thg fact that the Ministryis not a with norhad it any experience researchinstitution. As originally try.) by the Bank.Duringnegotiations. organization of the grantprogram.but woulditselfbe responsible The AmazonBasinMalariaControl of the proposed to be administered contractingand administration fundsfor research alsocontains in the studies. The compromise throughout to study proposals of evaluating the role jointly with the assigned The project was appraised withinthe Minisgroup. IPEAdidhave Although administration.is oneof the Projectapproved few Bankprojectsin anysectoraimedexclusively the at fundingpolicy research. Sao Paulo Basic HealthProjectapprovedat the a coordinating and delayeddecisame time in fiscal year 1984. For the follow-on operationalresearchstudies were commissioned funds. strategies andthat different wasput Early in 1989.At closing. facility withprojectpreparation Brazil: HealdtPolicy Studies this writing.but actualdisbursements basedon committed ing patternof malariacontrolstrategies US$270.but slowedimplementation was slow. The emerg. 10 US$150million. international supportthe research. withtheloancommitmnent aboutassuming hension responsibility. (This discussion Reporton the from a draft Project Completion project.a stand-alone in fiscalyear 1984. . The project was only totalled in the thinking influenced substantially theresearch two years. it wouldbe necessaryto shift to malariacontrol.the Bankhad received appreciation unrealistic. As of projectswere identified US$198millionprojectfor whichthe Bank lent project.to close. As a result.-6 - PHN Research Project-Financed appreof Healthexpressed the Ministry however.

Bankhandlingof the project couldhavebeenbetterandmighthavecontributed TheBankcould to moreeffective implementation. In retrospect.it has in the eyes of the Bank becomequite successful for the project. in a forthcoming researchcomponent Cidna In China.has now retainedas a consultant become a full partner. the Centerfor HealthStatistics systemandis nowhas an effectivedatacollection well positionedto do effective operationalresearch. Since and a high inflation politicalchanges werenot indexedand the earlyresearchcontracts by the there were long delays in disbursement Ministry.withthe are lessons of this project in mind. it wasslowerin reaching although appreciate Initially. along with the Finnish Ministryof Public Healthand the Academyfor PreventiveMedicine. noneof whichwasparticularly Medifor Preventive as the Academy reorganized cineso that it can awarddoctoraldegrees.the Centerdid notsufficiently system nor for a health information the need for better statistics upon whichto do researchanalyunder a newhead.the National Center for Preventive Medicine. smokingbehavior. A very interestingoutcomeof the Bank credit was the broad rangeof researchwhichhas withprojectfundsnotenvisioned beenundertaken by thestrong in the SAR. and renamed sis. effective The ResearchCenter for Health Planning and Statisticshas also become quite successful. and in greaterdetail. The studyis tracing cholesterollevels. in its supervision and have been more consistent wasperformed at different follow-up. continue to be so at present.Supervision withdifferstaffmembers timesby four different missionswere and supervision ing backgrounds. As a result.and studiesin morethan 300 scholarly has completed such areasas operational researchon the Chinese health system. Revitalized it andInformation. vector and parasite control.and the Sichuan Institute of Chinese MateriaMedica.initially in the research. a highstandard. often chargedwith other activitiesso that they time to the prowere unableto devotesufficient ject. and treatment regimes. Thiswasmadepossible of the SDR againstthe dollar which appreciation for sumsbecoming available resulted in substantial research. The Communicable DiseaseCentersin the UnitedStates. the Bank should to be the administering moreoften. publishesseveraljournalsof high standard. The study thus combines countrywith researchworkersfrom a developing risingratesof strokeandheart disease. -7 Medicine Center for Preventive TheNational of five existinginstitutes.the ResearchCenter for Health Planningand Statistics. and more forcefulin persuading government of the meritsof the originaldesign. withproject-financed experience The first PHN lendingoperationin China was the Rural Health and Medical Educatirnwas to supportthree Project.theBankhashad a verysuccessfil research. was an amalgamation Now distinguished. One researchactivitybeing additional projectin Tianjin financedis a community-based whichhas institutedthe world's largestchronic diseasecontrolexperiment. have discussed viewed exactlywhat sorts of studiesthe Ministry The Bankshould as helpful to policyformulation. designof have been more carefulin institutional the the project. of Healthwas Onceit wasagreedthatthe Ministry body. Health policy studies were importantfor and Brazilat the time theprojectwas formulated.the industrialized country with the highest incidenceof . It has developed staffresponsible one of the best reportingsystemson causesof death and morbidity in the developingworld. discussions a majorpolicy witha viewto including proceeding loan. and heart attackand strokemanagement. many researchers abandoned their projectsfor lackof funds.PHNResearch Project-Financed affectedby The projectwas also adversely rate. One component research institutions.

Partly because the mid-term evaluationfindingswere not readyuntil 1986.-8 - Project-FinancedPHN Research stroke and heart disease (Finland). Of key draws heavily on the Project CompletionReport interest will be the information the study yields for the project. on the design of the second project. stand-alone disposal its (Second Project Medicine Health and Preventive and some 40 to 60 such studies projects research ChinaHealth Project)approvedin fiscal year 1986 financed research into alternative insurance were authorized. The fact that the standalone research component was not a very significant part of the total project may have meant that to continue will research Project-financed influence Chinese health policy.design and limited usefulness. The IntegratedRegional Health Develop.000 people have been identifiedand will closed at the end of March 1989.and an industri. the ment Project approved in fiscal year 1989 has fact that the PMU had great freedom in commisfunded research to determine if school-based sioningresearch and so could act rapidly and with programs influencesmokingbehavior amongpar.great flexibigityalso contributedto poor research ents. More (rhe credit became effective in August 1980 and than 500. Other Chineseprojects have also resultedin The ProjectManagementUnit (PMU)had at successfil project-financed research. were not acted upon by project managementuntil Finally. in India was an innovativeand hi'ghlysuccessful Yet another study made possible with the project. monitored over a twenty-yearperiod. The project as designed included provision sincenearly all the existk g studiesof smokingand mortality have been carried out in industrialized for a baseline survey and formal mid-term and countries and may have limited applicabilityin a final evaluations.) about the link between smoking and mortality.g regime to be extended on a wide scale is one developedwith project-financedresearch from the stroke and heart disease (the United States). The study Is tracing the effects of different regimes of treating stroke on The Tamil NaduIntegratedNutritionProject mortalityand recovery time.more formal research committee with qualified mental curriculum. It indicatesthat a ated with smoking were the basis for an experi. For example.Nadu Nutrition Project approved in fiscal year ation from researchers in the United Kingdom. In retrospect. the results of both the mid-term and final evaluationsdid have a significantimpact Finland. been a better mechanism. established with the additional project funds is being carried out in Beijing in cooperationwith India-Tami Nadu Oxford University. linkinghealth practicesand cause of death. fiscal year 1984Rural Health and Medical EducaAnother successful health research effort tion Project.they developingcountry. Most were judged by Bank staff schemeswhich has influencedChineserural health to be of poor quality and had only a limited impact policy. It showed that large-scale. communityadditionalprojectfunds is the world's largest study level interventionsin the social sectors can work.on the redesign of the project. the project has financed part of an work began on the design of the Second Tamil ongoingstudy of adult-onsetdiabetes with cooper. 1990. France.The result of the program was members which could review proposals for relean immediatesharp drop in smoking among the vance and methodologicalsoundness would have parents of the childrentaking part in the program. This section be. and the United States. Italy.asis and tuberculosiscontrol. a Bank staff couldnot devote sufficient supervision fiscal year 1992Bank loan focuseson schistosomi- . Cartoon books aboutthe health risks associ. However. The TB treatment alized country which has succeeded in reduciz. The Rural fundsto commissionsmall.

includedfunds to establisha cooperation withthe WorldBank andthe World Population StudiesCenter at ImoStateUniversity. The project provides researchprojects. in fiscal year 1989.2millionfor 36 studieswassignedbetween majorsub-sectorreport.mostlyby younger researchers pointed. in fiscal year 1991. Fnancingand Utilization. and workis proceeding. Mgerla Theprojectalsosupportsextension to otherstates of researchworkat the University CollegeHospiNigeria is another country where Bank tal of the University ofIbadan. HealthOrganization. The hospitalwas experience withproject-financed research hasbeen the first WorldHealthOrganization collaborating quitesuccessful.anda research program isbeingprepared. a director ap. Theyshowed largedropsin undernu. FederalRepublicof Nge- The project builds upon the successful implementation of a grantmade in 1988to PIDS by the International Health Policy Program (IHPP). is intendedto supportboth ria-Health Care Cost. The first PHN lending operationof the 1980sin Nigeriawas the SokotoHealthProject approved in fiscalyear 1985. not previouslyworkingon healthpolicy.andOyo states. A contract for was used extensively by Bank staff to preparea US$1. the Departmentof Health (DOH) and the Philippine Institutefor Development Studies(PIDS)in mid-1991.some in researchamongthe Bankstaffresponsible. has provisionto support studies.Project-Financed PHNResearch -9- time to improve the qualityof the stand-alone policyandmedical research. In part this is due to the avail.and whichbecameeffectivein resultsin policyformulation and to preparenew March 1992. which have been widely disseminatedand carefully The National Population Project.researchcenterfor humanreproduction in Africa.4 millionearmarked for studies. NigerianInstitutefor Social and EconomicResearch through a Technical Committeewhich includes representatives of the majorusergroups.alsoapproved in officials interested to fosterresearchandto use the fiscal year 1991. The projectincludPhilippines ed US$1. The moneywasusedto preparefollow-on projectsand The Philippine HealthDevelopment Project for majorhealthcarefinancing studiesin Sokoto. projects. The surveyworkin Ogun policy research component. studieswere alreadyunderwayto supportanticipatedrequests for grantsfromthe Fund. The resultsof the researchand the sub-sectorreport are being used as a basis for the First Referral Hospital Projectanda nutrition projectnow underpreparation.That grant resultedin six The Centerhas been established. feature is that the Fund is administered by the thesestudieswerenot fundedby theproject. . whichappeared in October1991.the researchsupported by the Pew Charitable Trusts Imo Health and PopulationProjectapprovedin and the CarnegieCorporation of New York.approved reviewed by the DOH. approved in fiscalyear 1989includes a significant Ogun. In part.including It should be notedthat a distinguished group the socio-cultural andeconomic supports for large of evaluation studieshave been publishedabout families and the determinantsof fertility and thisproject. However. it is dueto a continuing interest Even beforethe projectbecameeffective. An interesting tritionand mortalityamongchildren.substantial studies.contraceptive use in Nigeria. for a US$4millionPopulation Research Fundto financeresearchinto a rangeof topics. ability of able Nigerianresearchersand senior TheHealthSystem FundProject. a program to encouragehealth policy A secondlendingoperationin Nigeria.

Yetconditions havebeensuchthat asof this datevirtuallyno researchhas been undertaken.10For the Bank-financed research.. and disseminatedata pertinentto the healthcare financing systemand the healthsystemin general. Zaire Finally. containedbetween them provision for some US$1.financialresourcebase and institutions. Fromthis emerged the specificstudies to be supervised by PIDS.theexperience inZairedemonstrates once againthat the Bank can be of only limited effectiveness in situations wherethe overall political and ecenomicenvironment is adverse.as the country experiences outlined here have demonstrated. In addition. A secondary data inventory and primarydata collection are part of the projectactivities.quite successfulin some countries andalmosta totalfailurein others. Supervision must be frequentenoughto keepthe research component on time and of goodquality. Bank-financed research would collect. and planning models for the health care financing system. Project-Financed PHNResearch Common Themes and Conclusions The information on whichthis noteis based can only support preliminary conclusions about project-financed research.a particularperson withinthegovernment or withintheBank has taken a personal and continuing interestin encouraging research. Quiteoftenwhen there has been a successful experience. both amongborrowersand withinthe Bank. .The primarydatacollection is aimedat gathering baselinedatawhichare not collectedby governmentor private statistical agencies. * Personalitiesmake a difference. in cooperation withthe University of the Philippines Schoolof Economics and PIDS.5 million for research.These successes certainly justify continued effortsto incorporate researchinto projects and to encourageuse of that researchboth to improveoverallnational PHNpolicyandfollow-on Bank-financed projects. generate. both approved in fiscal year 1991. Even so. the healthcarefinancing environment. Monitoring andconsultation activitiesare built into the projectimplementationand several local and national level workshops are plannedfollowing a patterndevelopedunder the earlierIHPPprogram. severalgeneralizations whichcanbe made: * Bankexperience withproject-financed researchin the PHN sectorhas beenextremely variable. It is importantif good qualityresearchis to be completed that thoseresponsible for supervision attacha highpriorityto researcheven if it is not a large part of the project in money terms. A ProjectSteering Committeechairedby a DOHunder-secretary has been established.the DOH. The data base is expected to be maintainedaftercompletion of the projectby the DOH with USAIDassistance. however. There are. 0 Supervision is crucial to good results. developed terms of reference for baseline studies to be conducted in relation to the design of a corepolicy reform package for the health care financing system. 0 Research that leadsto a projectoutcome -such asthat neededtojustifyreleaseof fundsor for a follow-on project-is more likely to be undertakenand completed than is research with a more general objective. The Social Sector Project and the National AIDS Control Program AssistanceProject. some strikingsuccesses can be noted. The topicschosenfor the research studiesincludebeneficiaryand providerprofile andbehavior.

Experience peer-group reviewresultsinbetterquality research. . However. manyplanned studiesare not completed. They recommended free-standing educational research projectsin larger countries.2 percent of the loans and creditsof these 116projectswas allocated to research.but of the number of studiesincluded fromtalkingto taskmanagthegeneralimpression ers is that in the PHN sector. both suggestionswhichwouldbe applicable to thePHNsector. an outcomenot muchdifferentfrom the PHN resultsreportedin this note. it would appearmore appropriate to assureaccessto suitableconsulting servicesfor the designof research components rather than to undertakea training enoughto teach operational programsubstantial staff how to designresearchcomponents. Examination of the SARs in the PHN sectordid closeto sucha preciseestimate not yieldanything in projects. The authorsfound that 2. * There probablyis room for more "best practices"workshopswherePHN staff can exchange experiences aboutsuccessof projectful design and supervision financed research components. in most cases it will probablybe necesconsultants to sary to retainexperienced reassist with the designof substantial searchcomponents. Other Sector Project-Financed Research Two other recent studies of World Bank project-financed research havebeenpublished. 1982-89 by Marlaine E.no PHNprojectreviewed for this note was a free-standing research project.only 184 (or 42 percent) and of theseonly 84 were availwerecompleted able through Regional Information Centers. and that project completion reports containa bibliography of the studiescompleted under a project.giventhe considerable to of moneyand effortwhichis devoted it.an outcome for the PHN sector. collection and dissemi. Lockheedand Alastair G. nor have interviewswith task managersfounda substantial measureof support for free-standing PHN research projects. one eachin the education and agriculture sectors.11 by this study not demonstrated 1989. One would be hard pressedto collecta completeset of reports for those PHN studieswhichwere completed. To facilitatethis. The authors reviewed 146 Bank educationprojects inidated between fiscalyear 1982andfiscalyear 1989. Finally. the authors recommend muchmore attentionbe paid to dissemination of research reportswithintheBankand within the borrowingcountry. they recthat the Bankdevelopa programto train ommend withappropriate operational staffto designstudios methodologies andwhichwoulddevelop domestic researchcapacity. They found.that researchas a percentage of total loan commitment declinedsharplyfrom 1982to ." ingeducational that more attenThe authorsrecommended of tion be paid to the designand implementation research componentsin educationprojects. In the PHN sector. The authorsof the educationstudy were particularly criticalof the fact that only 5.Exceptfor theBrazil HealthPolicyStudiesProjectthat waspart of the SecondHealthProject.PHNResearch Project-Financed capawherethe institutional * In countries institution to bilityexists. Rodd. 116 includedresearchcomponents.6 percent of the to do withassesscompleted studies"hadanything outcomes.More systematic research is nation of project-financed amounts justified. however.too.un indicatessomesort of tive. Education The education studyis WorldBankLending for Education Research. a feel valid whichmanywouldprobably conclusion for PHN projects. Of these.usinga national andto adminreviewresearchproposals be quite effecister researchgrants c. Of the 436 plannedstudies the authors identified.

" Pritchard hada number ofrecommendations. and providing adequate trainingand education opportunities. (7) developing publicawareness programs to broaden publicsupportfor agricultural research. (8)reassessment jects withresearchcomponents. He recommended: (1) continued emphasis on developmentof strong national To increasethe chancesof successin agricultural research projects and components.(10) an evaluation of the contributions of consuljects.(6) definingstaffingneeds. and (9) exploring alternative meansof providing operating fundsfor research. staffto increase skillsin supervision andappraisal of researchprojects. Additional supportfor agricultural agriculturalresearch projects and components." However.(3) developing national agriculturalresearch plans. extension-research linkages. (4) trainingfor Bank Years 1981through 1987by Anthony J.and Consultative Groupfor International Research and (11)a reviewof the conceptsand procedures for otherinternational institutions. agriculturestaff have a tendencyto be much more directlyinvolvedin the establishment of research institutionsand programs and in supervising researchactivities. (7) development of Bank lent for 21 free-standing researchprojects Bank policy regardingsupportof biotechnology and 209 agricultural and rural development pro. Pritchardfound that free-standing research projectswere generallysuccessful 'in institutionbuilding and in financingproductiveresearch programs. manyof whichwouldbe inappropriate if applied in the PHNsectorgiventhedifferent emphasis and scale.(8) providing incentives for researchworkersto assure retentionof high calibrestaff.the successof research programs. (4) supporting regional research initiatives.The totalcostof of the Bank'sinfluenceon researchprogramsat theagricultural research elements in Bank-financed the international agricultural researchcentersto agricultural projects was $2. and grants to the tant expertsin agricultural researchprojects. J. From 1981through1987.. PriceGittinger CarolBradford Agriculture . 16 policy-based loans.(2) an examination on a regional basisfor thelackof effectiveness of The othermajorrecentlypublished studyof researchcomponents. (6)analysis researchin agriculture is muchgreaterthan it is in of therelationship between component sizeandthe the PHN sector. Because of differencesin the history of agricultural lendingand PHN lendingwithinthe Bank andbecausefree-standing researchprojects are morecommonin the agriculture sector. (5)allocating project funds for contractand collaborative research. Pritchard.(5) expansion of the timeThe extent of Bank lending to support frameof agricultural research projects.12 - Project-FinancedPHN Research agricultural researchsystems. (3) evaluation of the effecproject-financed researchis Lending by the World tivenessof policy-based lendingin the developBankfor AgriculturalResearch-A Review of the mentof agriculturalresearch.research for developing countries. researchwas provided through 12 education pro.(2) adaptive and applied research needsfor the complete farmingsystem.1 billion-25 to 50 ensureefficient use of resources.butsome of whichwouldsoundfamiliar to PHN staff."problems in implementing research componentsin agriculturaland rural development projectswere sometimes severeand thelimitedsuccess of thesecomponents is a cause for concern. (9) developing a timesthe amountof project-financed researchin methodology to determinecosts and benefitsof PHNprojects.identifying requirementsfor support staff. Pritchard suggestedincreasedattentionto: (1) administrative and proceduralproblems during projectstart-up.

Populationand Rural Water Supply Health and Nutrition Health SokotoHealth Imo Health and Population EssentialDrugs Health SystemFund NationalPopulation Family Health First Population Fiscal Year 1989 1984 1985 1988 1990 1990 1984 1986 1988 1987 1990 1986 1991 1988 1987 1982 1988 1990 1985 1990 1991 1983 1987 1991 1984 1991 1989 1986 1985 1989 1990 1991 1991 1986 1991 .5 8.6 11.0 5.0 19.3 7.4 42.5 26.5 4.6 14.1 29.0 15.6 28.7 4.2 23.3 22.8 85.9 74.5 13.0 3.5 93.6 27.5 12.0 21.7 43.5 29.5 16.7 26.8 11.9 20.0 26.0 12.6 14.4 22.0 36.8 15.6 7.8 19.2 35.Health and Nutrition Integratd Rural Health and Family Planning Third Population Fourth Population Health and Population Second Popation.0 18.4 2.3 17.6 68.0 34.0 27.0 28. Projects Reviewed Total Amount of Project (USS million) 32.1 94.1 Amount of Loan/ Credit (US$ million) 8.6 61.1 42.1 16.7 26.6 Region/ Country AFRICA Benin Botswana Burkina Faso Burundi Cameroon Chad Comoros C6te d'Ivoire Ethiopia Gambia Gambia Ghana Ghana Guinea Guinea-Bissau Kenya Kenya Kenya Lesotho Lesotho Madagascar Malawi Malawi Malawi Mali Mali Mozambique Niger Nigeria Nigeria Nigeria Nigeria Nigeria Rwanda Rwanda Project Health ServicesDevelopment Family Health Health ServicesDevelopment Populationand Health Social Dimensionsof Adjustment Social Development Action Health and Population Health and Demographic Family Health National Health Development Womenin Development Health and EducationRehabilitation Second Health and Population Health ServicesDevelopment Population.1 70. Healdth and Nutrition Sector Credit Health Development Second Health.3 53.0 78.8 22.1 31.3 41.8 34.7 24.0 26.0 27.9 3.0 27.2 33.Project-Financed PHN Research -13 - Annex.5 10.0 55.0 6.7 85. Health and Nutrition Health Sector Improvement Health SecondFamily Health Population.4 61.

0 57.0 51.7 37.0 8.6 116.6 54.0 35.0 39.4 65..5 28.0 30.5 89.0 21.0 27.4 93.9 182.0 80.9 57.4 113.0 46.0 India Fifth(Bombay andMadras) Population .7 65.8 177.4 96.0 70.0 72.6 14.9 37.0 EAST ASIA AND PACIFIC China Rural Health and MedicalEducation China Rural Health and PreventiveMedicine China Integrated RegionalHealth Development Indonesia Third Populadon Indonesia Provincial Health Indonesia Indonesia Indonesia Indonesia Indonesia Korea Korea Philippines Fourth Population Second Health (ManpowerDevelopment) SecondNutrition and Community Health Third Health Fifth Populadon Population Health Technology Health Development Third Populaton and Family Health Fourth Populationand Health SecondPopulation 1985 198S 1986 1989 1991 1980 1991 1989 94.2 108.4 81.8 5.0 25.0 32.0 52.0 78.4 20.5 37.3 47.0 5.5 103.1 SOUTH ASIA Bangladesh Bangladesh India 1986 1991 1980 213.0 70.1 30.4 43.0 85.0 10.4 Region/ Country Senegal Senegal Sierra Leone Tanzania Togo Uganda Uganda Zaire Zaire Zambia Zimbabwe Zimbabwe Project Rural Health Human ResourcesDavelopment Health and Popuation Sector Support Health and Nutrition Populationand Health Sector Adjustment First Health Social Costs of Adjustment NationalAIDS Control Program Assistance Social Sector Social Recovery Family Health SecondFamily Health Fiscal Year 1983 1991 1986 1990 1991 1988 1990 1989 1991 1991 1987 1991 1984 1986 1989 1980 1983 Amount of Loan/ Credit (USS million) 15.0 180.0 52.14 - Project-FinancedPHN Research Total Amount of Project (US$ million) 16.4 123.0 60.4 46.7 70.0 52.5 104.5 148.0 35.0 33.9 322.8 601.0 lidia Ildia India TamilNaduNutrition ThirdPopulation Fourth Population 1980 1984 1986 1988 66.2 42.

0 26.0 13.6 129.0 45.0 267.4 104.4 85.0 123.7 572.1 59.2 62.8 106.0 30.1 157.5 59.0 17.4 7.6 149.2 35.7 95.6 19.0 20.5 57.0 13.2 MIDDLE EASTANDNORTHAFRICA Algeria PilotPublicHealth Egypt SocialFund Jordan Primay HealthCare Morocco HealthDevelopment Morocco HealthSectorInvestment Oman Health Tunisia Healthand Population Tunisia Poplation and FamilyHealth Tunisia Hospital Resctudring and Supply Turkey Health Yemen ArabRepublic Health Yemen PDR HealthDevelopment Yemen PDR Second HealthDevelopment Yemen HealthSectorDevelopment Yemen Emergency Recovery LATINAMERICA ANDCARIBBEAN Bolivia Integrated Health Development Bolivia SocialInvestment Fund Brazil Northwest RegionIntegrated Development ProgramFirstPhaseHealth Brazil Second Health Brazil Northeast BasicHealthServices Brazil Northeast Endemic DiseaseControl Brazil Amazon BasinMlarda Control Brazil ondNortheast BasicHealthServices Colombia HealthServices Integration Colombia Community ChildCareandNutrition El Salvador SocialSector Rehabilitation Haiti First Health .6 4.6 63.5 38.7 15.0 75.7 124.0 28.7 218.3 12.5 7.5 15.15 Amount of Loan/ Credit (US$million) Region/ Country India India India India Pakistan Pakistan Sri Lanka Sri Lrank Project Sixth(National FamilyWelfare Training and Systems Development) Population Seventh Population Second TamilNaduNutrtion Integrated ChildDevelopment Services Population FamilyHealth Healthand FamilyPlanning PovertyAlleviation Fiscal Year 1989 1990 1990 1991 1983 1991 1988 1991 1991 1991 1985 1985 1990 1987 1981 1991 1991 1989 1983 1983 1989 1990 1991 1990 1990 1982 1984 1986 1988 1989 1990 1986 1990 1991 1990 182.6 86.0 150.0 40.5 109.5 16.0 18.0 33.Project-FinancedPHN Research Total Amount of Project (US$million) .0 10.2 49.6 33.6 118.9 10.5 28.6 171.0 198.0 13.9 21.5 47.0 30.0 36.5 24.0 57.6 95.5 26.5 146.0 26.5 139.3 30.0 141.0 140.0 610.5 28.0 10.

8 55.9 100.6 60.- 16 - Project-Financed PHN Research Region/ Country Haiti Honduras Jamaica Jamaica Mexico Peu Project Economicand Social Fund Social InvestmentFund Populationand Health Social Sectors Development Basic Health Care Primary Health Care Fiscal Year 1991 1991 1987 1990 1991 1983 Total Amount of Project (US$ million) 23.5 10.4 67.0 33.5 Amount of Loan/ Credit (USS million) 11.5 Venezuela Social Development 1991 320.0 30.0 12.0 .0 249.0 180.3 20.

Krupnick Robert Bacon Eduard Bos MyT. 1992-93 Edition AlanJ. Gustafson 33714 M. Peter Neary WPS1023 TariffIndex Theory James E. Pender 37851 0. T. Pitayatonakarn 37664 L.Deacon An Analysis of Alternative Policies WPS1030 Measuring the Effects of Urban Transportation Policies on the Environment: A Survey of Models WPS1031 Measuring the Possibilities of Interfuel Substitution WPS1032 EastAsiaand Pacific Region.Policy Research Working Paper Series Title WPS1 019 HowEffective areDirected Credk Policies in the United States? A Literature Survey WPS1020 Another Lookat Population and andGlobal Warming WPS1021 Measuring Welfare Changes from Commodity PriceStabilization in Small OpenEconomies Author AnitaM. Schwarz Date November 1992 Contact for paper M. Anderson November 1992 November 1992 November 1992 WPS1024 An Exact Approach for Evaluating WillMartin theBenefits fromTechnological JulianM. T. Gustafson 33714 D.Alston Change WPS1025 Openness andEconomic KaziM. HarryAnthony Patrinos November 1992 George Psacharopoulos November 1992 November 1992 WPS1029 Controlling Tropical Deforestation: Robert T.Sanchez 33731 D. Ballantyne 38004 Nancy Birdsall Jonathan R. South AsiaRegion Population Projections.McNelis Adjustment in ChileandNewZealand Klaus Schmidt-Hebbel WPS1027 Lessons fromBankPrivatization InMexico WPS1028 Socioeconomic andEthnic Determinants of Grade Repetition in Bolivia andGuatemala Guillermo Bames November 1992 November 1992 November 1992 A.Vu Anr. Longo 39244 P. Anderson Policy J.Matin Performance in Sub-Saharan Africa: Evidence fromTime-Series CrossCountry Analysis WPS1026 Financial Liberalization and PaulD. Rothschild 37460 D. Nadora 31091.Raggambi 37664 S. Marahon 31450 W. Pender 37851 P. Pender 37851 P.Coleman ChrisJones November 1992 November 1992 WPS1022 A NewApproach to Evaluating Trade James E.Sanchez 33731 M.Levin November 1992 November 1992 .

Bertrand Judith E. Elbadawi of Expatriate WPS1038 Determinants Rocha Robertde Rezende Remitancesin NorthAfrica and Europe WPS1039 Education. Vu EduardBos Ann Levin Date 1992 November David H. Ballantyne 37947 Jaimede Meb Dhar Sumana November 1992 MoniNag November 1992 0. Scott 034 RevisingFinancialSectorPolicy WPS1 in TransitionalSocialistEconomies: Will UniversalBanksProveViable? WPS1035How ImportProtectionAffects the Philippines'Motor VehicleIndustry WPS1 036 OutputDeclinein Hungaryand and Polandin 1990-91:Structural Changeand AggregateShocks Wendy E. and Nutrition J.Policy Research Working Paper Series Contact for paper 0. Fertiliy. Maraiion 31450 PHREE 33680 D. Brown 1992 November Stijn Claessens Country WPS1043 DerivingDeveloping Capacityfrom the Market GeorgePennacchi Repayment Pricesof SovereignDebt Cost Functionsfor WPS1044 HospRtal Developing Countries AdamWagstaff Howard Barnum 1992 November November1992 0. Nadora 31091 Title WPS1033Latin Americaand the Caribbean Region (andNorthernAmerica) PopulationProjections.Extemaliies. Ballantyne 37947 0. Nadora 31091 0. Nadora 31091 Subbarao 045 SocialGainsfrom FemaleEducation: Kalanidhi WPS1 LauraRaney Study A Cross-National WPS1046 World BankProject-Financed Health. Nadora 31091 R. Cristobal 33640 November 1992 Workers' IbrahimA. Takacs November1992 K. PriceGittinger Carol Bradford November 1992 1992 November . del Cid 35195 SimonCommander FabrizioCoricelli November 1992 Ana-Maria Arrlagada WPS1037 VocationalSecondarySchooling. Researchon Population. Nadora 31091 M. Vo 33722 Jane T. Growth and Economic in WPS1040 Lessonsof Trade Liberalization in Latin Americafor Economies Transition WPS1041Family PlanningSuccessStoriesin Bangladeshand India WPS1042 FamilyPlanningSuccessin Two Citiesin Zaire MartinWeale November1992 A. Waelti 37664 November1992 D. Choice.1992-93 Edition Author My T. Abundo 36820 0.and Earnings AdrianZiderman Occupational in Brazil 1992 November C.

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