In order to develop various methods of comparable data collection on health and health system responsiveness WHO started a scientific survey study in 2000-2001. This study has used a common survey instrument in nationally representative populations with modular structure for assessing health of indviduals in various domains, health system responsiveness, household health care expenditures, and additional modules in other areas such as adult mortality and health state valuations.
The health module of the survey instrument was based on selected domains of the International Classification of Functioning, Disability and Health (ICF) and was developed after a rigorous scientific review of various existing assessment instruments. The responsiveness module has been the result of ongoing work over the last 2 years that has involved international consultations with experts and key informants and has been informed by the scientific literature and pilot studies.
Questions on household expenditure and proportionate expenditure on health have been borrowed from existing surveys. The survey instrument has been developed in multiple languages using cognitive interviews and cultural applicability tests, stringent psychometric tests for reliability (i.e. test-retest reliability to demonstrate the stability of application) and most importantly, utilizing novel psychometric techniques for cross-population comparability.
The study was carried out in 61 countries completing 71 surveys because two different modes were intentionally used for comparison purposes in 10 countries. Surveys were conducted in different modes of in- person household 90 minute interviews in 14 countries; brief face-to-face interviews in 27 countries and computerized telephone interviews in 2 countries; and postal surveys in 28 countries. All samples were selected from nationally representative sampling frames with a known probability so as to make estimates based on general population parameters.
The survey study tested novel techniques to control the reporting bias between different groups of people in different cultures or demographic groups ( i.e. differential item functioning) so as to produce comparable estimates across cultures and groups. To achieve comparability, the selfreports of individuals of their own health were calibrated against well-known performance tests (i.e. self-report vision was measured against standard Snellen's visual acuity test) or against short descriptions in vignettes that marked known anchor points of difficulty (e.g. people with different levels of mobility such as a paraplegic person or an athlete who runs 4 km each day) so as to adjust the responses for comparability . The same method was also used for self-reports of individuals assessing responsiveness of their health systems where vignettes on different responsiveness domains describing different levels of responsiveness were used to calibrate the individual responses.
This data are useful in their own right to standardize indicators for different domains of health (such as cognition, mobility, self care, affect, usual activities, pain, social participation, etc.) but also provide a better measurement basis for assessing health of the populations in a comparable manner. The data from the surveys can be fed into composite measures such as "Healthy Life Expectancy" and improve the empirical data input for health information systems in different regions of the world. Data from the surveys were also useful to improve the measurement of the responsiveness of different health systems to the legitimate expectations of the population.
Kind of Data
Sample survey data [ssd]
Multi Country Study Survey (MCSS)
Producers and sponsors
Authoring entity/Primary investigators
World Health Organization (WHO)
International Research Associates
The metropolitan, urban and rural population and all .administrative regional units. as defined in Official Europe Union Statistics (NUTS 2) covered proportionately the respective population aged 18 and above. The country was divided into an appropriate number of areas, grouping NUTS regions at whatever level appropriately. The NUTS covered in Ireland were the following; Connaught/Ulster, Dublin, Munster, Rest of Leinster.
The basic sample design was a multi-stage, random probability sample. 30 sampling points were drawn with probability proportional to population size, for a total coverage of the country. The sampling points were drawn after stratification by NUTS 2 region and by degree of urbanisation. They represented the whole territory of the country surveyed and are selected proportionally to the distribution of the population in terms of metropolitan, urban and rural areas. In each of the selected sampling points, one address was drawn at random. This starting address forms the first address of a cluster of a maximum of 20 addresses. The remainder of the cluster was selected as every Nth address by standard random route procedure from the initial address. In theory, there is no maximum number of addresses issued per country. Procedures for random household selection and random respondent selection are independent of the interviewer.s decision and controlled by the institute responsible. They should be as identical as possible from to country, full functional equivalence being a must.
At every address up to 4 recalls were made to attempt to achieve an interview with the selected respondent. There was only one interview per household. The final sample size is 711 completed interviews.
Dates of Data Collection (YYYY/MM/DD)
Mode of data collection
At each site the data was coded by investigators to indicate the respondent status and the selection of the modules for each respondent within the survey design. After the interview was edited by the supervisor and considered adequate it was entered locally.
Data Entry Program
A data entry program was developed in WHO specifically for the survey study and provided to the sites. It was developed using a database program called the I-Shell (short for Interview Shell), a tool designed for easy development of computerized questionnaires and data entry (34). This program allows for easy data cleaning and processing.
The data entry program checked for inconsistencies and validated the entries in each field by checking for valid response categories and range checks. For example, the program didn’t accept an age greater than 120. For almost all of the variables there existed a range or a list of possible values that the program checked for.
In addition, the data was entered twice to capture other data entry errors. The data entry program was able to warn the user whenever a value that did not match the first entry was entered at the second data entry. In this case the program asked the user to resolve the conflict by choosing either the 1st or the 2nd data entry value to be able to continue. After the second data entry was completed successfully, the data entry program placed a mark in the database in order to enable the checking of whether this process had been completed for each and every case.
The data entry program was capable of exporting the data that was entered into one compressed database file which could be easily sent to WHO using email attachments or a file transfer program onto a secure server no matter how many cases were in the file.
The sites were allowed the use of as many computers and as many data entry personnel as they wanted. Each computer used for this purpose produced one file and they were merged once they were delivered to WHO with the help of other programs that were built for automating the process. The sites sent the data periodically as they collected it enabling the checking procedures and preliminary analyses in the early stages of the data collection.
Data quality checks
Once the data was received it was analyzed for missing information, invalid responses and representativeness. Inconsistencies were also noted and reported back to sites.
Data Cleaning and Feedback
After receipt of cleaned data from sites, another program was run to check for missing information, incorrect information (e.g. wrong use of center codes), duplicated data, etc. The output of this program was fed back to sites regularly. Mainly, this consisted of cases with duplicate IDs, duplicate cases (where the data for two respondents with different IDs were identical), wrong country codes, missing age, sex, education and some other important variables.
Use of the dataset must be acknowledged using a citation which would include:
- the Identification of the Primary Investigator
- the title of the survey (including country, acronym and year of implementation)
- the survey reference number
- the source and date of download
Disclaimer and copyrights
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.
Multi-Country Studies, Measurement and Health Information Systems