4 12. In Jamaica, the frequency of declared illness does not vary greatly by economic status (see Table 1), but patterns of health care use do vary. When ill, poor children are less likely than rich children to receive medical care. Rich children, however, are taken to private doctors much more often than poor children. Overall, the use of public health care is greatest for the middle range of economic level, somewhat less for the poor and still less for the rich. Use of preventative care follows the same pattern. The tendency of rich children to go to private doctors and of the poor not to get medical care when ill provides countervailing biases in the public system. The poor do use public clinics somewhat more than the rich, so there may be some tendency for clinic data to overestimate malnutrition rates.

13. Malnourished children are much more likely to be ill than those not malnourished (see Table 1). Even though they are slightly less likely to seek care, the overall percent using care is much higher. Malnourished and normal children choose public care with equal frequency, but malnourished cht.idren are more likely to go to hospital outpatient facilities rather thav. primary clinics. Malnutrition rates based on the whole public system would therefore overstate malnutrition, those based only on the primary care network would not show much bias.

14. Because both the public and private health care systems in Jamaica are well developed, the children using the public system are not radically unrepresentative of children in the general Jamaican population. Biasas in clinic-based estimates of malnutrition rates may thus be much smaller in Jamaica than in other countries.

15. Clinic Data. The clinic data is reported through the Monthly Clinic Summary Report System (MCSR) instituted as part of the Ministry of Health's information system in 1980. The reporting system tallies the frequency of normal or low weights for age for children weighed. It reports mostly on those children who attend "child health clinics" scheduled for specific days at primary health centers. The clinics are organized to provide mainly preventive care (well-baby checks, vaccinations, and growth monitoring) but also provide curative care for sick children. If children attend "curative clinics' on a different day from the "child health clinic", it is less likely that they will be weighed or that, if weighed, that their weights will be included in the reporting system. Although a system of home visits by community health workers exists, the reporting of the weights from them is somewhat irregular. The weights of children seen at hospital outpatient clinics (about one third of public primary care for curative purposesa') are not reported through the MCSR. Private health care providers are not linked to the system. 16. Upon its institution in 1980, the Monthly Clinic Summary Report system reported all observations for a child during the quarter. This appeared to lead to double-counting of children. In 1983, therefore, the system was refined so that only the first observation of a child during the quarter was reported in the tally. The system has been well implemented with regular, timely compliance by most of the public, health clinics.

j/ From unputlished analysis of the Survey of Living Conditions, Round III, data.