INTERNATIONAL STUDIES ON HEALTH AND ECONOMIC DEVELOPMENT Release Date: May 30, 2000 RFA: TW-01-001 Fogarty International Center World Bank National Institute on Aging National Institute of Mental Health National Institute of Dental and Craniofacial Research National Eye Institute Office of Behavioral and Social Sciences Research Letter of Intent Receipt Date: June 23, 2000 Application Receipt Date: August 29, 2000 PURPOSE This Request for Applications (RFA) solicits projects that examine the effects of health on microeconomic agents (individuals, households and enterprises) and aggregate growth (cross-country growth analysis), as well as explores how health finance and delivery systems are a source of variation in health outcomes. Studies pursued must be relevant to populations in low- and middle-income nations and should preferably be either hypothesis testing or hypothesis generating. Longer-term objectives of the program are as follows: o support socio-economic surveys with rigorous biomedical and psychosocial assessments relating to functional performance and other measures of productivity; o improve and expand the quality of psychosocial and biological epidemiological data that support studies to measure and model economic outcomes; o examine the connections between health and the social environment at the level of the individual and broader community including the effects of social capital and infant/childhood antecedents of adolescent and adult well-being; o assist in the development of a system of metrics that equips researchers, service providers and policymakers with information needed to inform policy and effectively target public health interventions; o improve the quality and availability of health and economic data including longitudinal and inter-generational data sets; o establish the relative effectiveness of different financing and delivery options at community, regional and national levels to enable international comparisons; o build institutional capacity in low- and middle-income countries to incorporate health data in the measurement and modeling of economic performance. HEALTHY PEOPLE 2010 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of Healthy People 2010, a PHS-led national activity for setting priority areas. This Request for Applications (RFA) International Studies on Health and Economic Development, is related to one or more priority areas. Potential applicants may obtain information about Healthy People 2010 at ELIGIBILITY REQUIREMENTS Applications may be submitted by domestic and foreign, for-profit and non-profit organizations, public and private, such as universities, colleges, hospitals, laboratories, units of State and local governments, and eligible agencies of the Federal government. Racial/ethnic minority individuals, women, and persons with disabilities are encouraged to apply as Principal Investigators. MECHANISM OF SUPPORT This RFA will use the National Institutes of Health (NIH) individual research grant (R01) mechanism. Responsibility for the planning and direction of the proposed project will be that of the applicant. The purpose of the RFA is to stimulate research on the complex dynamics of health and productivity in low- and middle-income nations and build a theoretical and empirical foundation for future explorations in this area. An applicant may request a project period of up to five years and a budget for direct costs of up to $400,000 per year. Because we anticipate that all budget requests will exceed $250,000, the modular grants requirements would not apply to this RFA. Applicants should budget to attend an annual networking meeting of awardees at the NIH in Bethesda, Maryland. FUNDS AVAILABLE It is expected that approximately $2 million in total costs (direct plus Facilities and Administrative (F & A) costs) per year from all supporting collaborating partners for up to five years will be available beginning in fiscal year 2001. This support is dependent upon the receipt of a sufficient number of applications of high scientific merit. Although this program is provided for in the financial plans of the FIC, awards pursuant to this RFA are contingent upon the availability of funds from FIC and collaborating partners for this purpose. The level of support for these projects may be increased if a large number of highly meritorious applications are received and if funds are available. RESEARCH OBJECTIVES Background and Significance Over one hundred years after the industrial revolution, a large portion of the world remains impoverished. In the most compelling instance, the Organization for Economic Cooperation and Development indicates that the per capita income in Africa in 1992 was equivalent to that of Western Europe in 1820, and these disparities are widening. Correlates to economic development have been studied vigorously, but only modest attention has been paid to the relationship between health or demographic status and economic development. Over the past three decades the relationship between education and poverty (e.g., measured by wage rates) has been replicated in household surveys across numerous nations and now frequently is viewed as a "causal fact." These data have influenced development policies at national and multilateral levels. However, health has never ascended to a similar footing as a predictive indicator of economic performance. The foundations are now strengthening in support of the widely observed correlation between health and prosperity. Studies linking health and economic behavior have incorporated several broad avenues of investigation: macroeconomic studies to examine the relationship between country-level growth indicators and health; microeconomic studies that explore the dynamics of health and productivity at the individual or household levels; and studies that examine the effect of alternative health policies on economic outcomes. Health and Economic Welfare Historical case studies have provided evidence that dietary improvements not only extend life spans, but significantly improve labor production rates, especially in the lowest quintile of the population. These findings have been reinforced by household surveys that positively correlate nutritional status with income and labor supply. For example, in Indonesia, males with anemia have a 20 percent lower level of productivity suggesting that improved nutrition could increase household productivity and income. Studies examining the effects of disability on earnings and labor supply in Cote d Ivoire and Ghana also indicate the negative consequences of illness for labor productivity. Moreover, there is a robust literature on the implications of education and other forms of human capital on labor market performance. Because health and education both represent household investments, it is important to understand the interdependence of these choices. Some economic studies link childhood health and nutrition to the educational attainment of mothers. However, short expected lifespans also may lead households to place a low priority on education. Careful analysis of household decision-making and the policy environment will help shed light on the independent and combined effects of such investments. There is evidence to suggest that exposure to traumatic events such as war and violence are among the leading causes of disability adjusted life years that are lost at ages 15-44 years. Victims of trauma and violence (physical and social) have been found to be disproportionate users of the health care system, and there is evidence for a connection between a history of trauma and adverse workplace outcomes such as high unemployment and low wages. At the aggregate level, studies employing cross-country analyses of economic growth have examined multiple variables to explain economic performance, such as educational levels, disease burdens, fertility rates and other demographic factors, rates of national savings and natural resource availability. Macroeconomic models incorporating health as an instrumental variable suggest that even modest gains in a population's health status may have major positive impacts on a society's productivity. For example, reductions in malaria over 1965- 1990 are associated with meaningful economic growth in cross-country regressions. The importance of the relationship of malaria and economic growth suggest the need to explore the economic impact of other significant disease burdens, such as poor reproductive health, mental health disorders and the omnipresent diarrheal and respiratory illnesses affecting populations at risk. On the other hand, increasing life expectancy is associated with population aging. Over the course of the next 25 years, the age structure of the world population will continue to shift, with older age groups comprising an increasingly larger share of the total. Over half of the world’s elderly (aged 65 and older) now live in developing nations. By 2030, this proportion is projected to increase to over 70 percent. In this context, it is important to consider the impact of population aging, and the health of the elderly, on a country’s economic performance. Rapid increases in life expectancy are likely to be associated with an increase in chronic diseases. Disabilities and diseases among the over-40 population may affect the ability to work prior to retirement and retirement behavior. Increased economic productivity also has been associated broadly with demographic characteristics of a population, especially life expectancy. For example, shifts from high to low rates of fertility and overall mortality made possible by improved health maintenance have significant effects on population growth rates and economic development. Over time, these downward shifts may expand substantially the relative share of the working-age population, a bulge that has been coined the demographic gift because it carries with it the potential for increased economic productivity. By increasing the working-age population and reducing the growth of the economically dependent population (under fifteen), indices of economic growth, including rates of national savings and investment will likely increase, thereby increasing the resources available to invest in the development of human capital among children and youth. However, at both the macro-and microeconomic levels, the precise mechanisms and direction of causality have engaged brisk debate, and remain a key conceptual and empirical challenge in studies of the relationship between human capital, especially health and economic development. The lack of understanding of these relationships has impeded the development of effective forms of intervention. Causality likely is a virtuous cycle: increased income yields increased investments in health; and improved health results in greater economic productivity. Rigorous empirical assessment of these relationships involving both hypothesis testing and hypothesis generation will therefore enable us to more accurately evaluate the impact of health interventions on society. Health and Economic Arrangements There is a corresponding need to understand how economic arrangements, including policies, influence the quality of the social environment and human development. Through empirical studies, economists have demonstrated how wealth creation and allocation may influence the health and well-being of a population. For example, research on famine and food supply has deepened understanding of social and economic arrangements during times of stress and has demonstrated the limitations of more traditional indicators of economic performance. Similarly, studies among industrialized countries have demonstrated a positive relationship between life expectancy and the degree of income equity within a society. The exploration of absolute and relative levels of income in society has significant implications for understanding the relationships among health, wealth distribution and economic growth. A key element of both empirical and theoretical investigation relates to the effects of alternative health financing and delivery policies on health and economic outcomes. Lines of investigation include: 1) resource allocation within a given system (i.e. primary, secondary, and tertiary care); 2) institutional structures, especially financing schemes such as deductibles, taxes, mandated social and private insurance, user fees, drug revolving funds and community finance and 3) health service delivery configurations. To enable comparative assessments, research is needed to establish the relative effectiveness of different financing options at the national and regional level. In tandem, research is required to define the optimal mix of public and private financing for health systems and means to establish regulations and contracts to govern these relationships. In particular, there is increasing interest in the prospect of managed market reforms in low- and middle-income nations, stimulated by widespread perceptions of public sector inefficiencies. Studies are required on the effectiveness of managed markets in promoting increased provider competition, the relative efficiency of contractual as opposed to direct management, and cost-benefit analyses, among other areas. These studies represent promising lines of investigation which converge in one summary conclusion: our conceptual understanding of the long- term influences on economic development and the formulation of effective policies relies on a deepened understanding of the determinants and consequences of public health. If governments and donors are to target effectively their investment in health as a component of development plans, expanded research is required on the dynamics of health and productivity. This includes the impact on economic growth of improved health care and upon health status resulting from various economic interventions, as well as the impact on health status due to large development projects or policies. Scientific Objectives The goal of this RFA is to solicit applications for hypothesis testing and hypothesis generating studies that will examine the complex linkages between health and economic development. Categories of study may include but are not necessarily limited to: Microeconomic studies that examine the link between health and economic growth at the levels of the individual, household and family. Examples include: o Studies to project the impact of population aging or of a particular disease or disability burden on individual or household economic activity, output and growth, or small enterprise (e.g. HIV, violence, malaria, TB, micronutrient deficiencies, mental health disorders, craniofacial disfigurement, visual impairment, chronic diseases). o Studies to expand the battery of useful physical and functional assessments that can be linked to economic indicators. Cross-sectional surveys or longitudinal panel hypothesis testing or hypothesis generating studies of macroeconomic growth. Examples include: o Surveys or natural experiments to examine the relationship between investment in human resources, particularly education and health, and labor market outcomes. This might include the addition of a health module to an ongoing socio-economic survey or incorporating economic indicators in an ongoing health survey. o Studies to determine which factors link with macroeconomic growth, as for example levels and patterns of educational attainment and performance (schooling); health status (life expectancy, mortality rates, disease prevalence or age specific biomarkers); population growth, density and age structure; personal and government savings (investment rates); physical capital stock; trade policy; quality of public institutions. o Studies of the impact of nutrition, primary care interventions, prevention services, health promotion, etc, on childhood growth and development and/or subsequent physical performance and work productivity. o Identification of indicator diseases or conditions to detect and monitor communities experiencing intense poverty; and the use of these indicators to conduct multisectoral studies of the cross-cutting effects of essential nutrition and adequate sanitation on both health and productivity. o Studies of the relationship between health and economic effects of traumatic events. Natural opportunities and experimental approaches to examine the effects of alternative health policies on health and economic outcomes. Examples include: o Research to establish the relative impact of different financing options, including national and local taxes, user fees and health insurance on health outcome. o Research to examine the impact and optimal mix of private and public funding for health systems upon health outcome. o Research on the impact of decentralization of health systems upon health outcome (defined as the transfer of functions, resources and authority to local levels of government). This might include studies on the theoretical and conceptual background to understanding decentralization, the conditions for effectiveness, the study of decentralization to hospitals and local health centers and the operation of public-sector markets. o Research on the economic impact of preventive health policies (e.g., integration of mental/physical health services with other trauma victim assistance systems). SPECIAL REQUIREMENTS This program is to generate useful scientific information and also to promote collaboration between scientists in the United States and low- and middle-income nations with shared interests in the consequences of health and health policy for economic development. In this regard, the scientific questions should determine the nature of the collaboration. To achieve this end, eligible proposals must be jointly developed and demonstrate a transnational collaboration between a U.S. investigator(s) and an investigator(s) from a low- and middle-income nation(s). In operational terms, this might take the form of 1) a co- investigator and research staff from low- and middle-income nations supported under the protocol, and 2) protocol-related material support for a host institution in a low- and middle-income nation to stage field studies. (For operational and analytic purposes, the World Bank’s main criterion for classifying economies, gross national product per capita, will be employed for this RFA. A listing of countries representing low- and middle-income economies which are eligible for this program may be found at Moreover, multidisciplinary approaches to examining the dynamics of health and productivity are especially encouraged. Advances are most likely to be achieved through collaborations among disciplines of economics, epidemiology, demography, sociology, behavioral science and basic biological disciplines. For example, collaboration among economic and biomedical and behavioral scientists may result in more refined measurements of instrumental variables, including psychosocial factors. Applicants are encouraged to collaborate with the World Bank’s Global Development Network (GDN). The GDN is a growing association of research and policy institutes whose goal is to generate, share, and apply to policy knowledge about development. To this end, GDN seeks to support capacity-building activities in developing countries. Information about GDN is available on their web site at GDN’s research network covers all regions of the developing world (see below) and may therefore be a useful source of information about potential collaborators from developing countries. The World Bank’s GDN is providing up to $250,000 which is included in the total funds available for support of the NIH program of International Studies on Health and Economic Development. A listing of the GDN regional networks follows: African Economic Research Consortium (Aerced@Form-Net.Com) Center for Economic Research and Graduate Education (Randall.Filer@Cerge.Cuni.Cz) East Asian Development Network (Chia@Merlion@ISEAS.Edu.Sg) Economic Education and Research Consortium ( Economic Research Forum ( Latin American and Caribbean Economic Association (Calvo@Econ.Umd.Edu) South Asia Network of Economics Institutes (Director@Icrier.res.In) GDN hopes to build a strong community of researchers in the developing world working on health issues. To encourage this process, GDN is planning to make the economics of healthcare in developing countries one of the key themes of its Annual Global Development Conference in 2001 or 2002 depending on the availability of sufficient research output. This will present researchers from around the world an ideal opportunity to share their findings with an important cross-section of the development community. Protection of Research Subjects Applicants should be aware that provisions for the protection of human research subjects and laboratory animals must be met in research done in both domestic and foreign institutions including obtaining any necessary single project assurances. Applicants should see Title 45 CFR, Part 46 for information concerning Department of Health and Human Services regulations for the protection of human subjects and the PHS Policy on the Humane Care and Use of Laboratory Animals. These are available from the Office for Protection from Research Risks, National Institutes of Health, 6100 Executive Boulevard, MSC 7507, Rockville, MD 20892-7507 ( INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS It is the policy of the NIH that women and members of minority groups and their sub-populations must be included in all NIH-supported biomedical and behavioral research projects involving human subjects, unless a clear and compelling rationale and justification are provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43). All investigators proposing research involving human subjects should read the "NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical Research," which was published in the Federal Register of March 28, 1994 (FR 59 14508-14513) and in the NIH Guide for Grants and Contracts, Vol. 23, No. 11, March 18, 1994, and is available on the web at: INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS It is the policy of NIH that children (i.e., individuals under the age of 21) must be included in all human subjects research, conducted or supported by the NIH, unless there are scientific and ethical reasons not to include them. This policy applies to all initial (Type 1) applications submitted for receipt dates after October 1, 1998. All investigators proposing research involving human subjects should read the "NIH Policy and Guidelines" on the Inclusion of Children as Participants in Research Involving Human Subjects that was published in the NIH Guide for Grants and Contracts, March 6, 1998, and is available at the following URL address: Investigators also may obtain copies of these policies from the program staff listed under INQUIRIES. Program staff may also provide additional relevant information concerning the policy. URLS IN NIH GRANT APPLICATIONS OR APPENDICES All applications and proposals for NIH funding must be self-contained within specified page limitations. Unless otherwise specified in an NIH solicitation, Internet addresses (URLs) should not be used to provide information necessary to the review because reviewers are under no obligation to view the Internet sites. Reviewers are cautioned that their anonymity may be compromised when they directly access an Internet site. LETTER OF INTENT Prospective applicants are asked to submit a letter of intent that includes a descriptive title of the proposed research, the name, address, and telephone number of the Principal Investigator, the identities of other key personnel and participating institutions, and the number and title of the RFA in response to which the application may be submitted. Although a letter of intent is not required, is not binding, and does not enter into the review of a subsequent application, the information that it contains allows NIH staff to estimate the potential review workload and plan the review. The letter of intent is to be sent to the program person listed under INQUIRIES by the letter of intent receipt date listed. APPLICATION PROCEDURES The research grant application from PHS 398 (rev. 4/98) is to be used in applying for these grants. These forms are available at most institutional offices of sponsored research and from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/710-0267, email: The RFA label available in the PHS 398 (rev. 4/98) application form must be affixed to the bottom of the face page of the application. Type the RFA number on the label. Failure to use this label could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2 of the face page of the application form and the YES box must be marked. The sample RFA label available at: has been modified to allow for this change. Please note this is in pdf format. Submit a signed, typewritten original of the application, including the Checklist, and five signed, photocopies, in one package to: CENTER FOR SCIENTIFIC REVIEW NATIONAL INSTITUTES OF HEALTH 6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710 BETHESDA, MD 20892-7710 BETHESDA, MD 20817 (for express/courier service) Applications must be received by August 29, 2000. If an application is received after that date, it will be returned to the applicant without review. The Center for Scientific Review (CSR) will not accept any application in response to this RFA that is essentially the same as one currently pending initial review, unless the applicant withdraws the pending application. CSR will also not accept any application that is essentially the same as one already reviewed. This does not preclude the submission of previously reviewed applications with substantial revisions. Such applications must include an introduction addressing the previous critique. REVIEW CONSIDERATIONS Upon receipt, applications will be reviewed for completeness by the CSR and responsiveness by FIC, the World Bank, NIA, NIMH, NIDCR, NEI, and OBSSR. Incomplete and/or non-responsive applications will be returned to the applicant without further consideration. Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit by an appropriate peer review group convened by the CSR in accordance with the review criteria stated below. As part of the initial merit review, all applications will receive a written critique and undergo a process in which only those applications deemed to have the highest scientific merit, generally the top half of the applications under review, will be discussed, assigned a priority score, and receive a second level review by the FIC Advisory Board. Review Criteria The goals of NIH-supported research are to advance our understanding of biological systems, improve the control of disease, and enhance health. In the written comments reviewers will be asked to discuss the following aspects of the application in order to judge the likelihood that the proposed research will have a substantial impact on the pursuit of these goals. Each of these criteria will be addressed and considered in assigning the overall score, weighting them as appropriate for each application. Note that the application does not need to be strong in all categories to be judged likely to have major scientific impact and thus deserve a high priority score. For example, an investigator may propose to carry out important work that by its nature is not innovative but is essential to move a field forward. (1) Significance: Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will be the effect of these studies on the concepts or methods that drive this field? (2) Approach: Are the conceptual framework, hypotheses, design, methods, and analyses adequately developed, well-integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative tactics? (3) Innovation: Does the project employ novel concepts, approaches or methods? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies? (4) Investigators: Are the investigators appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the Principal Investigator and other researchers (if any)? (5) Environment: Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support? (6) Research Capacity-Building: Does the proposed program contribute to the capacity of scientists and/or institutions in low- and middle- income nations to perform research related to health and economics (e.g. health outcomes and economic linkages; microeconomics of health care)? Does the proposed program contain explicit strategies or plans to strengthen this capacity through training, career development or other modes? In addition to the above criteria, in accordance with NIH policy, all applications will also be reviewed with respect to the following: o The adequacy of plans to include both genders, minorities and their subgroups, and children as appropriate for the scientific goals of the research. Plans for the recruitment and retention of subjects will also be evaluated. o The reasonableness of the proposed budget and duration in relation to the proposed research. o The adequacy of the proposed protections for human participants, particularly the risks that may be posed to groups as well as individuals, animals or the environment, to the extent they may be adversely affected by the project proposed in the application. Schedule Letter of Intent Receipt Date: June 23, 2000 Application Receipt Date: August 29, 2000 Peer Review Date: October/November 2000 Council Review: December 2000 Earliest Anticipated Start Date: December 2000 AWARD CRITERIA Award criteria that will be used to make award decisions include: o Scientific merit (as determined by peer review); o Responsiveness of the proposed project to achieve the goals of this RFA; o Balance among projects to respond to the questions included in this RFA; o Availability of funds o Programmatic priorities INQUIRIES Inquiries concerning this RFA are encouraged. The opportunity to clarify any issues or questions from potential applicants is welcome. Direct inquiries regarding programmatic issues to: Dr. Kenneth Bridbord Director Division of International Training and Research Fogarty International Center Building 31, Room B2C39 31 Center Drive, MSC 2220 Bethesda, MD 20892-2220 Telephone: (301) 496-2516 Fax: (301) 402-0779 Email: Programmatic inquiries can also be addressed to the NIH program contacts listed on the FIC web site ( for the International Studies on Health and Economic Development RFA. Frequently asked questions and responses to these inquiries will also be listed at this website. Direct inquiries regarding ISHED fiscal matters to: Ms. Susan Bettendorf Grants Management Specialist Fogarty International Center Bldg. 31, Room B2C39 31 Center Drive, MSC 2220 Bethesda, MD 20892-2220 Telephone: (301) 496-1653 FAX: (301) 402-0779 Email: Direct inquiries regarding review issues to: Dr. Robert Weller Center for Scientific Review 6701 Rockledge Drive Room 3160, MSC 7770 Bethesda, MD 20892-7770 Telephone: (301) 435-0694 FAX: (301) 480-3962 Email: AUTHORITY AND REGULATIONS Awards are made under authorization of Sections 301 and 405 and Title IV, Part A, as amended (42 USC 241, 284, and 287) of the Public Health Services Act, and administered under NIH grants policies and Federal Regulations 42 CFR 52 and 45 CFR Parts 74 and 92s. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or to Health Systems Agency review. The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people.

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