Solange Ayache
email: solange.ayache.1@sorbonne-universite.fr

Simon Mcburney

Keywords: Simon McBurney, Theatre de Complicité, The Encounter, Donna eco-poetics, ecocriticism, environmental humanities, intermediality, interconnectedness, entanglement, compost, terran

Looking at Simon McBurney's award-winning solo performance

The Encounter (2015), this paper examines the play's contribution to environmental humanities through an ecocritical study of its combined use of state-of-the-art sound design and the age-old art of storytelling to address the link between the ecological and spiritual crises that we are facing. The Encounter relates the real story of the American photographer Loren McIntyre who lived with the Mayoruna tribe for six weeks in 1969 after getting lost in the Amazon rainforest. Relying heavily on sound design to take us deep into the jungle, the show addresses our relation to nature and technology and elicits our empathy to denounce the dictates of a globalised world ruled and threatened by neoliberal and neocolonial capitalistic ideologies. As the brainand the stagebecome the forest, The Encounter challenges the notions of distance and separation from the Other in favour of a deep sense of interconnectedness. Using Donna J. Haraway's 2016 book Staying with the Trouble: Making Kin in the Chthulucene, this paper sheds light on how The Encounter invites us to recognise the urgency of defining what it means to live together in "response-ability on a damaged earth" (Haraway 2) and how the intermedial, hybrid qualities of the play found not a "post-human" but, on the contrary, a "com-post" theatre piece (11).

in 2015. The play relies heavily on sound technology to take us deep into the jungle as it relates the real story of the American photographer Loren McIntyre among the Mayoruna tribe, with whom he lived for six weeks in 1969 after getting lost in the Amazon rainforest during an expedition to Brazil for National Geographic. Through McIntyre's experiences of disorientation, confusion, exhaustion, drug-induced hallucination, and telepathic communication, the play questions our common representations of time and space and addresses our relation to nature and technology, while eliciting our empathy to resist the dictates of a globalised world ruled and threatened by neoliberal and neocolonial capitalistic ideologies. As the brainand the stagebecome the forest, The Encounter takes us on a mind-expanding journey, challenging the notions of distance and separation from the Other in favour of a deep sense of interconnectedness, which is presented both as a fundamental ecological principle conditioning our lives on Earth and as a poetic and theatrical principle shaping the play by interweaving a multiplicity of stories, voices, and mediums to tell its story.

This paper examines McBurney's contribution to the environmental humanities and eco-theatre through an ecocritical study of the play's combined use of state-of-the-art sound design and the age-old art of storytelling to address the link between the environmental and spiritual crises that we are facing. As the play aims to evoke a visceral empathic response in the audienceand, thus, to foster changethrough a deliberate hybridisation of means, I propose to look at the play both as a theatrical experiment and as an activist enterprise using Donna J. Haraway's proposition to "stay with the trouble," as the title of her 2016 book suggests. Her work will help shed light on how The Encounter invites us to be "mortal earthlings in thick copresence" (4) and to recognise the urgency of defining what it means to live together in "response-ability on a damaged earth" (2). Haraway's work will be used to reflect on how McBurney's piece participates in offering new ways of relating to one another and of "making kin in the Chthulucene," to quote the subtitle of her book. Haraway's term for this new era is based on the idea that we, as "chthonic ones" -who are "beings of the earth, both ancient and up-to-the minute" (2) -need to create unprecedented hybrid forms of multispecies, multimodal, and transgenerational collaborations in order to survive the exterminating forces of the Anthropocene and the Capitalocene. I will argue that McBurney's play contributes to founding a theatre for the Chthulucene, with and for the chthonic ones.

To do so, this paper will first look at how The Encounter resorts to both prerecorded natural sounds and sound effects to evoke the sensational presence and overpowering threat of the jungle on the stage and uses embedded voices and audio technology to give the audience a sense of the telepathic type of communication which occurred between McIntyre and the headman of the village, Bar-nacle. We will see that the intermedial, hybrid qualities of the play contribute to making an empathic show which is not a "post-human" but, on the contrary, a "com-post" theatre piece (Haraway 11). I will then show that, by compiling, recycling, interweaving, and infusing a variety of storytelling materials, McBurney's eco-drama brings us back down to earth and to who we are, along with the protagonist -"response-able" interconnected humans as in humus, "coming together as earthly ones" (Haraway 136) in a world where thoughts, feelings, and objects communicate and interact with each other beyond the visible and ordinary boundaries of the individual self. In addition to Haraway's concepts and principles, I will introduce and combine a number of tools from the fields of literary theory, psychology, biology, and quantum theory around the interdisciplinary notion of uncertainty to propose an intricate yet consistent worldview to analyse McBurney's ecodramaturgy. Hopefully, this will provide a useful hybrid interpretive framework to reflect on the critical contours of the eco-dramatic forms that can actively contribute to making theatre for the Chthulucene today.

Intermediality and Dialogism: Staging Interconnectedness

The Encounter is adapted from a 1991 book by Romanian-American writer Petru Popescu, Amazon Beaming, which relates McIntyre's real-life experience. Popescu's writing style already plays with different voices and viewpoints, placing the narrative under the seal of hybridity in its form itself. The narration alternates between the first and the third person, as Popescu uses multiple existing sources, such as articles, letters, books, and photographs, to document McIntyre's story, while also including material from interviews with McIntyre, whose answers, recorded on tape, became the book's first-person sections. These two narrative modes found their way into McBurney's theatrical adaptation, explaining the multiplicity of voices that he performs and plays onstage, which also correspond to different layers of time and positions in space. This allows the piece to suggest that everything is interconnected and to convey the disorientating experience of McIntyre, who depended upon the Mayoruna people for his survival.

While McBurney is alone on stage, The Encounter is also performed by two sound operators in charge of live sound mixing. McBurney uses different types of audio devices, including a binaural microphone which looks like a human head with ears, to create the voices of five different characters as well as to play ambient environmental recordingsthe sounds of the jungle that he and his team went to capture during an immersive trip through the Amazon rainforest. The ■ Dear author, please proof the header on the right pages ■ ■ Encounters in the Chthulucene: Simon ■ soundscape of the play designed by Gareth Fry is thus made of those voices along with a variety of live sound effects created onstage, as well as pre-recorded material and voices played on a mobile phone, an iPod, and other speakers, using loop pedals and other off-stage sound technology to create polyphonic effects. As McBurney explains, his intent was to evoke the physical impression of the presence of what is not there or what is far from uspeople, places, actionsby triggering our sensory imagination. 1 Because it is able to capture sound just like real human ears and to provide the listener with a 3D stereo sound sensation, the binaural technology in particular allows the audience to "feel like the jungle is all around [them]" ("Simon McBurney Gets Inside Your Head" 01:24-01:27) while experiencing, with the headphones that they are asked to wear for the entire duration of the show, a feeling of separation evocative of McIntyre's isolation, mirrored and embodied on stage by McBurney's solo performance.

The impression of an internal form of sound triggered by the binaural dummy head also allows the audience members to feel like McBurney is whispering in their ear in a one-on-one conversation and thus to get a metaphorical idea of McIntyre's telepathic experience with Barnacle when he perceived the headman's silent messages "beaming" in his mind. This "strange case of apparent thought transference," as McIntyre calls it in his introduction to Popescu's book (20), is conveyed on stage through McBurney's use of embedded voices, as he alternately plays the Actor (who tells and performs the story, using both direct and indirect speech), Loren McIntyre (the protagonist), and Barnacle (whose voice is "heard as Loren McIntyre's voice reverberating in his own head" 4). Technically, McBurney's voice as McIntyre is altered live by a pitch shifter while his voice as Barnacle ("LOREN voice-over") is pre-recorded, which enables the audience to distinguish between the three voices. Thus, the words used convey two kinds of inaudible material, as the mind-to-mind dialogue between Barnacle and McIntyremade of thoughts unheard and unuttered from both endsalternates with McIntyre's metalinguistic commentswhich he makes internally to try and rationalise his experience but does not say out loud: ACTOR: He remembered how Barnacle had said that some of the Mayoruna were friends. But the headman had not spoken. Or had he? No, he hadn't spoken. Not in English and in fact, not at all. BARNACLE (LOREN voice-over): Some of us are friends. ACTOR: It felt like a message [. . .].

1 "I wanted people to feel the presence of the absent, which also happens because you start to see somebody there, although they're not there, because you hear them there, and you place them in space" (McBurney, "The Encounter Simon McBurney | Complicité" 04:15-04:30).

The beamed message faded. Maybe being so near to him explained the sensation. His mind then unconsciously adding words in English afterwards. He had an idea. He strained and applied focus, not on the words of his next thought, but on the content. Instead of thinking . . . LOREN: Hey buddy, I am a friend too, you can trust me . . . ACTOR: . . . he tried to fill himself with the feelings of that thought. Then he waited. BARNACLE (LOREN voice-over): I know. ACTOR: . . . somehow appeared in his mind. Or maybe it was just the feeling of the answer with his own words, in English, hurrying in to illustrate it. Suddenly the headman rose and held out a finished arrow. It was a gift, he took it. [. . .] There were so many things here in their pure state, why not thought, too? Why not the simplest form of human contactmind to mind. No, for goodness' sake. But then it had been ratified, because he had been given a gift. (26)(27)(28) This silent form of communication between McIntyre and Barnacle is the play's most powerful illustration of the kind of co-creative entanglements, at the intraspecies, human, level that our times command. It is an almost literal example of what Haraway calls "tentacular thinking,"2 where the illusory, limiting belief in an isolated and autonomous I falls apart and is replaced with the open experience of a moving interconnectedness between the "critters" involved. 3The stream-of-consciousness technique used to evoke McIntyre's thought processes enacts the notion of flux at the core of the play. This convergence between form and content around the notion of fluidity, which is both a thematic and structural motif in The Encounter, is a key component of its eco-poetics. The tribe's own livelihood being encroached on by deforestation, the Mayoruna, whose name, as it has been suggested, might originally mean the "river people" (Flowers), flee through the forest to go back to the source of the Amazonand back through time, too, as they believe that the source of the river is time's own beginning, time sharing with water its leaky and life-giving qualities. Thus, reaching this location would allow time to run backwards, just as using fire to burn their belongings means removing themselves from the life-destroying presenta question of survival since, as Popescu explains in his foreword to the play, "the present meant the oil prospectors who invaded their grounds and were erasing their tribal life."

As they arrive at their final destination, McIntyre understands that, just like Barnacle's mind, "from that source comes a message. It is wordless but so gigantic that it breaks all boundaries. It fills all the space outside [him], inside [him] and fuses the source and the beginning into one notion" ( 58). This provides a meaningful parallel between two forms of porosity which threaten McIntyre's sense of self: that of his mind in its encounter with the Other and that of his body in its encounter with the river. While the immediate communication that takes place between the two men shatters the generally accepted and unquestioned boundaries of individual thought and feeling that underlie the Western conception of the human mind, similarly, the river itself eventually dissolves the lines of separation between the self and the Other, the outside and the inside, time and space. The journalist's experience of his own mind as part of a wider ecosystem of transsubjective consciousness thus mirrors his immersive journey within the extremely complex and biodiverse ecosystem of the Amazon rainforest.

The hybrid, integrative narrative structure and the enunciative entanglement that characterise the play's ecology reflect, to an extreme degree, what Mikhail Bakhtin has identified as "our dialogical natures" and the "miracle" of polyphony, as Wayne C. Booth shows (xxi). Indeed, according to Bakhtin, dialogue, by nature, does not occur between "interacting monads,"4 for "neither individuals nor social entities ever constitute a monad. They are much looser, 'messier,' and more open than that. The most interesting and unfinalizable aspects of any interaction arise from the relative disorder of the participants," as Gary S. Morson and Caryl Emerson explain (50). Instead of being "wholes with clear boundaries," Bakhtin believed that "neither individuals nor any other social entities are locked within their boundaries. They are extraterritorial, partially 'located outside' themselves" (Morson and Emerson 50). In his "Toward a Reworking of the Dostoevsky Book," published as an appendix to his Problems of Dostoevsky's Poetics, Bakhtin remarks that, in front of "the expression in an artistic work of the writer's I," what is required is "not an analysis of consciousness in the form of a sole and single I, but precisely an analysis of the interactions of many consciousnesses; not many people in the light of a single consciousness, but precisely an analysis of many equally privileged and fully valid consciousnesses" (287). He posits the concept of "nonself-sufficiency," defined as "the impossibility of the existence of a single consciousness" (287), and explains: I am conscious of myself and become myself only while revealing myself for another, through another, and with the help of another. The most important acts constituting selfconsciousness are determined by a relationship toward another consciousness (toward a thou). Separation, dissociation, and enclosure within the self as the main reason for the loss of one's self. Not that which takes place within, but that which takes place on the boundary between one's own and someone else's consciousness, on the threshold. And everything internal gravitates not toward itself but is turned to the outside and dialogized, every internal experience ends up on the boundary, encounters another, and in this tension-filled encounter lies its entire essence. (287)

McBurney's play stages precisely this "tension-filled encounter" with another's consciousness, which tears apart McIntyre's self-concept. Intended for Dostoevsky, Bakhtin's words can thus be applied to the journalist: "A person has no internal sovereign territory, he is wholly and always on the boundary; looking inside himself, he looks into the eyes of another or with the eyes of another" (287). Indeed, in The Encounter, McBurney wanted to denounce the illusion of separation and create a form and use tools that would give us a sense of the relational nature of everything, including the self. In a striking echo of Bakhtin, he explains:

Our idea of distance, crucially the distance between one person and another, is also challenged. The notion of a "separate self," so precious to our contemporary notion of identity, is undermined to the point that it becomes, for McIntyre, utterly illusory. One self, one socalled individual consciousness, he discovers, is not necessarily separated from another by language, time, or distance. We are possibly interconnected in ways to which we are, mostly, blind in the modern worlda world in which, paradoxically, we are more connected by technology than at any time in history. (qtd. in In other words, although Bakhtin believed that only novels could provide a "representation [. . .] of human 'languages' or 'voices' that are not reduced into, or suppressed by, a single authoritative voice," McBurney successfully translates "the inescapably dialogical quality of human life" into theatrical form (Booth xxii). In The Encounter, the radical dissolution of the "monolithic quality" of verbal expression that Bakhtin points out in conventional drama (17) speaks of a profound paradigm shift and a necessary new understanding of reality as we are faced with unprecedented challenges. While in 1929, Bakhtin considered that "the whole concept of dramatic action, as that which resolves all dialogic oppositions, is purely monologic" and that "a true multiplicity of levels would destroy drama, because dramatic action, relying as it does upon the unity of the world, could not think those levels together or resolve them" (17), McBurney's play manages, on the contrary, to renew the dramatic form by substituting the traditional, outdated, principle of unity inherited from Aristotle with the notion of ecological interconnectedness which our times of global crises both reflect and call for. Instead of resolving oppositions, the play invites us to "stay with the trouble" and, thus, to adopt a more realistic position with major political implications as "entangled and worldly" critters (Haraway 4).

From the Sky to the Ground: Becoming a "Chthonic One"

As the communication resumes between the headman and the photographer, who just saw his camera being ripped apart by a monkey, Barnacle's messages leak deeper into McIntyre's mind, heart, and comprehension. In doing so, they explicitly reveal the threat which causes the Mayoruna to move deeper into the forest:

LOREN: Once we were alone, the communication started again. Smooth and implicit. And even though he was a few yards away, he communicated to me that: You are sad because what was in the dark should have stayed in the dark. It was so clear, I couldn't believe he hadn't spoken. Was he talking about my camera? No, how could he be? But it was so much like speaking . . . While "the dark should have stayed in the dark" -referring to the film containing McIntyre's best shots, which should have remained protected from the lightso should the white people have stayed where they belonged and left the natural resources of the Amazon untouched and the Indigenous tribes alone in the shadows of the rainforest. What Barnacle denounces in this passage is the bordercrossing and boundary-trespassing of a neocolonial narrative that is still ongoing, causing human and environmental destruction, the Indigenous peoples being the first and most direct victims of what has been called the "ecocide-genocide nexus," to emphasise the connections between "ecocide, genocide, capitalism and colonialism" (Crook et al. 300).

Despite the Mayoruna's efforts and determination, the presence of McIntyre represents the impossibility of actually erasing the present and the unavoidable obligation to "stay with the trouble" for both parties. Their improbable encounter mirrors the troubled, mixed-up reality of our intertwined ongoing collective stories as well as the new interactions between the natural elements that reconfigure the landscape of the Amazon rainforest and its disrupted ecosystem, as the Mayoruna burn all their material possessions (fire) before undertaking a journey towards the river (water) to try and counterbalance the threat of the "white people [coming] down from the sky" (air), taking McIntyre deep into the jungle (that is, down to earth). In her speculative fabulation "Terrapolis," Haraway imagines a fictional multidimensional and multispecies place which "is not the home world for the human as Homo, that ever parabolic, re-and de-tumescing, phallic self-image of the same" but for the human as "worker of and in the soil," where the "critters are beings of the mud more than the sky" (11). This is precisely the transformative journey that McIntyre, who cannot go back to his plane and eventually finds himself "reduced to just a body" (33), falling "on rotten leaves" (41), is forced to go through. Moreover, "Terrapolis" is precisely a place which "makes space for unexpected companions" (Haraway 11) and where the chthonic ones, driven over the edge of extinction, rely on and grow together from their ability to "[craft] safe enough ways to tangle with each other in conflict and collaboration" (150).

It is, therefore, particularly meaningful that the main piece of information at the core of the first exchange between McIntyre and Barnacle quoted above revolves around the notion of being friends, which is then practically enacted by the headman's gesture and material offering. Indeed, despite being another white man coming from the sky and representing a threat, McIntyre's own endangered life and uncertain becoming place him in a position of extreme vulnerability, which mirrors that of the tribe at the collective scale and reverses the power relationship at stake. It is crucial for his survival to befriend at least one member of the tribe, just as "making kin" with "companion species" (Haraway 2, 4) is necessary in order for us, human and nonhuman critters alike, to be able to overcome together the threats that we are faced with and to think "more livable politics and ecologies in the times of burning and extraction called the Anthropocene and Capitalocene" (90). In exchange for their help, McIntyre is endowed with the mission of being the Mayoruna's "authenticator" and of "proving that it is real" (56). Almost half a century later, McBurney, in turn, is asked by Lourival, the headman of another Mayoruna village, to "tell the world that [they] have survived. [. . .] But whether [they] all will survive . . . that is another matter" (McBurney "We See Only What We Want to See"). By engaging in such "risky comakings," they all play a part in one of those intricate "cosmological performances" which characterise the Chthulucene (Haraway 14).

Interestingly, it is by taking some altitude (air) again that McIntyre realises what it means to be a chthonic one (earth), and it is the motif of the ocean (water) which illustrates how this cosmological performance is orchestrated and how much more precious it is than fossil fuels (fire), thus inviting us to reflect on how the four basic elements are interrelated. The notion of interconnectedness, where borders and boundaries are transcended, and visible and invisible interactions eventually form a unique ecosystem, is explicitly revealed to him during a lucid dream:

Each sentence below is looped, overlapping with the next, creating a dreamlike effect. LOREN: One fifth of the world's fresh water is here. The river, four thousand miles long. A thousand miles to the east, the mouth. Connected. Flowing to the ocean. The Arctic. Where does it begin? ACTOR: Loren McIntyre was flying, suspended, airborne. Hovering above a vision of the jungle and mountains. Like an oversized map. It was a dream and in the dream he knew it. A vast stretch of jungle spread out beneath him and to the east, the two-hundred-mile-wide mouth of the Amazon River, and the ocean flowing all the way to the Arctic. Clouds hanging in the sky, heavy with water vapour. And the source of the Amazon was somewhere in the mountains behind him. The forest, phosphorescent as if lit from underneath. The phosphorescence was the forest's rich life forms, its treasure. The Christian conquistadors were wrong. Pizarro was wrong. Francisco de Orellana was wrong. The oil prospectors, the rubber tappers, the missionaries with their faith had all been wrong. They were all looking for something else, but in his dream McIntyre recognised instantly, although it didn't have any words. LOREN: It's the intricacy of the forest . . . that's the treasure. ACTOR: Something suffused the greenness of the jungle, all fed by a single source. Hidden somewhere in the mountains. An invisible force; all interconnected, pregnant with a captive message. ( 23) In McIntyre's dream, the source of the Amazon River is the focal point of all life, invisibly connecting everything together through the water cycle and indirectly attracting explorers, colonisers, missionaries, and prospectors from all places and times. However, while everything natural is in the right place, everything human moves for the wrong reasons. Later in the play, it is no longer McIntyre's mind which provides him with "a vision of the jungle," but the jungle which provides him with a vision of his mind. Lost in the forest, inebriated, and slightly hallucinating after drinking the juice of a wild vine, McIntyre eventually feels like "the forest becomes [his] brain and [his] brain the forest," to the point of having "the sensation of seeing [his] thoughts" (40).

From an ecodramaturgical point of view, the play's sound design and, in particular, the use of loops to create overlapping effects allow McBurney to evoke the parallelism between "the intricacy of the forest" and that of the protagonists' minds, which form but another kind of forest, itself deeply rooted in and interwoven with the story of the Amazon basin. Their thoughts and feelings interact in a transpersonal way, like the roots of trees communicating with each other below the surface, sharing vital information (such as "are you my friend or my enemy?") and helping each other survive. Extending the symbiotic model in biology to the spiritual plane, such visions converge with the enlarged, holistic view that supports what it means to be "terran," according to Haraway (101).

Sympoietic Ecodramaturgy: Compos(t)ing for the "Terran" Stage

Because "Diverse human and nonhuman players are necessary in every fiber of the tissues of the urgently needed Chthulucene story" (Haraway 55), the Chthulucene needs "sympoietic"5 art practices that both foster tentative "knottings" (97) between vulnerable and co-evolving critters and tell the stories of their co-creative encounters. Haraway writes:

We relate, know, think, world, and tell stories through and with other stories, worlds, knowledges, thinkings, yearnings. [. . .] Critters are at stake in each other in every mixing and turning of the terran compost pile. We are compost, not posthuman; we inhabit the humusities, not the humanities. [. . .] Crittershuman and notbecome-with each other, compose and decompose each other, in every scale and register of time and stuff in sympoietic tangling, in ecological evolutionary developmental earthly worlding and unworlding. (97)

Haraway derives her conception of sympoiesis largely from the work of biologist Scott F. Gilbert, whose study of the "significant interactions of animal and plants with symbiotic microorganisms that disrupt the boundaries that heretofore had characterized the biological individual" led him to refute the very notion of "biological individual" in favour of "symbionts" (Gilbert et al. 325). Particularly striking examples of this type of relationships in living systems include the way trees and fungi form partnerships known as mycorrhizas, whereby trees in forests and other ecosystems communicate and cooperate through subterranean circuits of fungi fused with their roots, and the way lichens allow two living organisms from different species to function as a single and stable unit, as the fungus and the alga that they are made of live in a symbiotic way. Gilbert et al. conclude their article by stating: "For animals, as well as plants, there have never been individuals. This new paradigm for biology asks new questions and seeks new relationships among the different living entities on Earth. We are all lichens" (336).

In addition to the "Dream" scene, The Encounter offers multiple images of interdependence and symbiotic growth, which correspond to the biological mode of existence of living organisms in the animal and plant kingdoms alike, while also echoing the spiritual mode of transmission of telepathic thoughts and feelings that McIntyre experiences in his own body and mind. As he wakes up scratching one morning, he realises that "the bugs have found [him] again, laid their eggs in the open cuts left by the thorns" (38) -just as Barnacle's thoughts found their way into his mind, opened by their shared need to communicate as a result of their life-threatening circumstances. Such unavoidable experiences, which may either serve or hinder his survival, force McIntyre to "stay with the trouble." His flesh becomes the soil where plants and animals alike leave their mark, infusing and hybridising his body as a functional element in the ecosystem where he becomes a natural and effective part. Finding himself at a crossroads between two diverging trails in the jungle, he is aware that, just like his alliance with Barnacle, "either one could lead to life or death. Death is already here. It's always here in the wilderness" (38). Forms of compost, confusion, superposition, and mongrelising between living and nonliving objects, human and nonhuman bodies, the biological and the technological, nature and culture, thus infuse the images that both feed the protagonist's visions and make the language of the play. Such is the case when McIntyre mistakes his roll of film for a "black creeper" (33), hanging from a branch after monkeys took the roll out of his camera, and this poetics of entanglement reaches a climax when he is confronted with a process of decomposition and scavenging:

I see a thick rope on the floor, a cable, and then I realise it's not a cable, but a traffic of army ants. I follow the procession away from the anthill and find . . . a watch. [. . .] I start running, along the freeway of ants and I find . . . four bodies. [. . .] They're piled on each other. A baseball cap, jaws without gums, teeth stained by tobacco. And they seem in some sort of motion, as the ants crawl over them. (39) Faced with a natural phenomenon of epic and traumatising proportions which he cannot properly recognise and identify at first, McIntyre uses his own frame of cultural references to try and make sense of what he perceives. The "tentacular" images that he uses to describe the procession of ants is evocative of and borrowed from our busy modern lifestyles and, more specifically, from the military field (the thick rope, the cable, the traffic, the army, the freeway). This scene of horror and its subjective depiction both convey the journalist's feeling of defamiliarisation and overwhelm at the appalling sight of what he realises could also happen to him and point at the dreadful consequence of the improbable and lifethreatening encounter of two worlds. But the war between the capitalist greed of the oil prospectors, heirs of a long line of colonisers in turn colonised by the living forces of nature, and the wilderness of the Amazon jungle and its human and nonhuman guardians, leads to a fecund superposition and hybridisation, both from a biological and a poetic point of view, within the rainforest ecosystem and the play's eco-poetics. This is precisely what living on the edge in the Chthulucene means: "Chthonic ones are monsters in the best sense; they demonstrate and perform the material meaningfulness of earth processes and critters. Chthonic ones are not safe" (Haraway 2). In particular, Haraway explains that:

Ants and acacias are avid for association with critters of all sorts of sizes and scales, and they are opportunistic in their approaches to living and dying [. . .]. These species in all their complexities and ongoingness both do great harm and sustain worlds, sometimes in association with human people, sometimes not. The devil is truly in the details of response-able naturecultures inhabited by accountable companion species. (125) From the cable to the colony of ants, from the watch to the human bodies, and from the baseball cap back to the ants, the monstrous associations that McIntyre witnesses and his description of them blur the boundaries between life and death, between natural and man-made objects, composing, decomposing, and recomposing the multispecies ecosystem in which they participate.

Similarly, in their mental and affective "compost pile," thoughts and feelings not only circulate between the reporter and the headman but break down and reemerge in new configurations through their interactions and reciprocated acknowledgment, allowing unprecedented forms of intertwined living and mutual care to take place in a sympoietic way between the two strangers as they become friends. And, as a story and as an enterprise, The Encounter itself is an illustration of these necessary forms of organic cooperation and interdependence, which play out at several different levels and in arborescent waysbetween the tribe and their natural surroundings, between McIntyre and Barnacle, between Popescu and McIntyre, between Complicité and the Mayoruna, between McBurney and his audience, between Western ecologists and Indigenous peoples, etc. In other words, McBurney's eco-drama founds a "theatre of compost."

The sophisticated sound arrangements co-created and orchestrated in real time by him and the sound technicians also mirror and add to these patterns of risky cooperation and ecological interdependence. In particular, McBurney's use of "loop pedals to create [both] exterior soundscapes and the interior worlds of the characters" (3) offers a complex aural experience for the audience, where intricate polyphonic effects tend to blur the boundaries between the emitting sources and their origins, the inside and the outside, the natural and the artificial, the subjective and the objective. And while the audience is invited to feel like they are in the middle of the jungle because of what they hear, what they actually see is a different story, as there is no army of ants but real cables crawling around McBurney on the stage and among the audience to connect microphones and headphones with the mixing desk.

As a result, The Encounter is not a piece of immersive theatre, but one that creates, to a certain extent, the illusion of immersiona body immersed in nature and a mind immersed in anotherby resorting to intermediality to suggest immediacy, using technology to create intimacy, and evoking proximity to address universality. By playing with multiple levels of closeness, blunting the arrow of time, and emphasising disorientation to give us a sense of familiarity, McBurney's piece and hi-tech show invite us to share McIntyre's mind-expanding journey from resistance and denial, ironically expressed in self-contradictory terms -"A thought suddenly howls, savagely. I was never part of nature. No, I'm not!! [. . .] We're human beings. We're not part of nature" (40-41) -, to more peaceful realisations and self-aware images of hybridisations with the plant and animal kingdoms: "And then a thought is planted in my mind"; "And then a thought blooms in my mind" (52); "And although I haven't taken any of the drug I feel like I'm turning into an animal" (56).

The play thus explores many kinds of monstrous "sympoietic arrangements" (Haraway 59) by creating what could be called a sympoietic ecodramaturgy. By "composting" Popescu's account of McIntyre's story and bringing the sounds of the jungle onto the stage, intermingled with voices and perspectives from different times and spaces which create the theatrical vision and experience of a multispecies, transgenerational, and transcultural ecosystem, McBurney's hybrid ecoperformance nourishes a fertile soil for eco-drama as an unstable, undefined place, which invites us to "stay with the trouble" and co-create from there. Planting seeds of awareness and care in the audience, it participates in renewing the forms and purpose of the theatre for Haraway's Terrapolis, thus providing a piece of theaterra. *** Gilbert's observations in the field of biology echo Bakhtin's remarks in the field of philosophy and literary theory: the idea of independent entities with discriminated, rigid boundaries securing and separating individual bodies and agencies from each other is no longer an operational scientific concept. Haraway explores and promotes the motif of interrelatedness in her work, turning it into a social agenda and an eco-ethical proposition. McBurney answers the call and uses it as an ecodramaturgical tool and a principle for eco-theatre-making.

Twenty years ago, in a 2002 paper entitled "Are We Really Interconnected? Ecophilosophy and Quantum Theory from a Postmodern Perspective," Serpil Oppermann already pointed out that "the global environmental crisis today compels us to review an essential principle of reality which has been insistently articulated by ecophilosophy as a comprehensive vision of the fundamental interrelatedness of all life" (51). Using deep ecologist Michael Zimmerman's definition of "the internal relatedness of all things, that is, that particular entities are but contemporary knots in an interconnected cosmic web" (qtd. in Oppermann 51), she then quotes quantum physics pioneer Niels Bohr who noted that "in our own century the immense progress of science has [. . .] given us an unsuspected lesson about our positions as observers of that nature of which we are part ourselves" (qtd. in Oppermann 56). This remark echoes oceanographer David Farmer's statement in The Encounter when he mentions the necessary "recognition that we are actually part of nature, and that the whole system is interacting" (40) -his pre-recorded words being repeated several times as McIntyre is still in denial. Indeed, the scientific experiments conducted in quantum mechanics have revealed that "we can no longer speak of the behavior of the particle independently of the process of observation," to quote Bohr's famous friend and colleague Werner Heisenberg, who explains the "observer effect" as follows:

When we speak of the picture of nature in the exact science of our age, we do not mean a picture of nature so much as a picture of our relationships with nature [. . .]. Science no longer confronts nature as an objective observer, but sees itself as an actor in this interplay between man and nature. The scientific method of analysing, explaining and classifying has become conscious of its limitations, which arise out of the fact that by its intervention science alters and refashions the object of investigation. In other words, method and object can no longer be separated. (qtd. in Smolin 93) Commenting on this principle of interconnectedness, which also highlights our co-responsibility in the determination of our reality, Oppermann adds:

The fact that this view finds its scientific validation in quantum physics points to a profound transformation in human thought and the discourses of the human sciences. The ecophilosophical view of the environment based on the interrelational, or in other words the holistic perception of reality is generally referred to as the new paradigm. (51) While Oppermann argues "for the need to assimilate the emerging new paradigm into all of the human discourses" (52), The Encounter provides a convincing example that the contemporary British stage is playing its part. By inviting its audience to empathically connect with McIntyre's story while technologically connecting with McBurney's voice, it develops a hybrid form of theaterra for the Chthulucene, reminding us of our nature as "intra-active entities-in-assemblages" (Haraway 101). Using intermediality to suggest that we are all in this hot "compost pile" together (55), it allows us to journey with the Indigenous tribe and to share, to some extent, the protagonist's mind-expanding experience of interconnectedness with his surroundings. Devising what could be called a quantum eco-poeticsor sympoieticsfor the stage, the show combines the physical presence of a single performer, voice, and body, with a sophisticated use of hi-tech devices, bringing technology and nature together in a hybridised format urging us to care, make kin, and be friends. Just like the Mayoruna see "the oil underneath the ground as the blood of the Earth" and are "concerned that if you suck out the blood, [. . .] then the earth will cease to exist" (53), The Encounter encourages us to nourish a holistic vision and experience of life and to ultimately take action to preserve our planet's multispecies ecosystem. For, as much as we can no longer ignore that "we are at stake in each other's company," as the ecological philosopher and ethnographer Thom van Dooren highlights (qtd. in Haraway 39), we also "render each other capable in actual encounters" (Haraway 126). And this compost-like intricacy of life forces -"that's the treasure," indeed (23).

Bionote

Solange Ayache is a Lecturer in English in the Faculty of Arts and Humanities of Sorbonne University, France. She teaches EFL and TESL at the Graduate School of Teaching and Education of Paris and holds a double-PhD from Sorbonne University and the University of Sheffield in English Literature. Her dissertation, entitled "In-Yer-Head" Theatre: Staging the Mind in Contemporary British Drama. Towards a Quantum Psychopoetics of the Stage, examines the dramatic modalities used by a number of British playwrights from the past two decades as they explore mental spaces and evoke post-traumatic mindscapes, psychological disorders, neuropathological conditions, and various cognitive processes. She suggests that this theatre paradoxically renews stage realism, especially when using quantum theories as metaphors to stage the characters' inner experiences or alternative perceptions of the real. Her research interests in contemporary drama and theatre are interdisciplinary and rooted in the health humanities and the environmental humanities. A member of the Sorbonne research team VALE (Anglophone Voices: Literature and Aesthetics), she has shared her work in a number of international conference papers and articles published in peer-reviewed journals.

■ Encounters in the Chthulucene: Simon ■

  [. . .]. Barnacle communicated something like: Here's the forest; if you run away right now, I'm not going to stop you. [. . .] Other white people have been here. They brought death. [. . .] He said: BARNACLE (LOREN voice-over):We have been moving around. LOREN: I tried to communicate back: have you been attacked? BARNACLE (LOREN voice-over):Yes. By white people that came down from the sky. LOREN: So where are you moving to? BARNACLE (LOREN voice-over):We're going to the beginning. LOREN: What beginning? BARNACLE (LOREN voice-over): The beginning. (34-35)

In chapter 2 of Staying with the Trouble, entitled "Tentacular Thinking," Haraway reminds us of the Latin roots of "tentacle," "which comes from tentaculum, meaning 'feeler,' and tentare, meaning 'to feel' and 'to try.'" The "chthonic ones" are the "tentacular ones": they try as they feel; they feel as they try (31).

3 The religious notion of creation found in "creature" is removed from the word critter, providing an earthlier way to refer to "microbes, plants, animals, humans and nonhumans, and sometimes even to machines"(Haraway 169n1).■ Encounters in the Chthulucene: Simon ■

Federico Pellizzi explains that monad is a word borrowed from Gottfried Wilhelm Leibniz which Bakhtin was fond of and which refers to "a single unit that constitutes a viewpoint over the world and is therefore the whole world from a certain viewpoint" (204).

Haraway defines "sympoiesis" as the art of "becoming-with and making-with a motley clutch of earth others" (137).■ Encounters in the Chthulucene: Simon ■


Khalid Habbani

Wim Groot

Izabela Jelovac

Household health-seeking behaviour in Khartoum, Sudan: The willingness to pay for public health services if these services are of good quality

Keywords: Willingness to pay, Public health services, Good quality, Contingent valuation, LRM, Sudan

Household health-seeking behaviour in Khartoum, Sudan: The willingness to pay for public health services if these services are of good quality

Introduction

Despite its recent classification as a middle-income oil importer Sudan's economy is underdeveloped. Since the late 1970s Sudan has been experiencing an economic crisis [START_REF] Abd-Elgadir | The Sudan economy in disarray: essays on the crisis[END_REF]. In addition, there have been significant cutbacks in external funding and donations.

The World Bank and the International Monetary Fund have ceased their operations in the country [2]. The poor economic conditions in Sudan have eroded the resources needed for the government to provide minimally acceptable healthcare services. As in other Sub-Saharan countries, the long-standing free of charge health services to the entire population has had negative impacts on the whole system [START_REF]Health finance in developing countries: synthesis of applied field research[END_REF]. In addition, the slow development of financial institutions and formal wage sector employment has limited the potential for health insurance to grow and has delayed the start-up of the private health sector [START_REF]Health finance in developing countries: synthesis of applied field research[END_REF].

In its quest to establish a sustainable solution for the financing of health services the government initiated the Health Insurance Act, which was approved by the National Assembly in 1995 [4]. According to the act, insurance is compulsory for all residents in the republic of Sudan. The contribution is income-related and amounts to 10% of the salary for the formal sector (4% paid by the employee and 6% paid by the employer).

Health services are provided through the public sector freely for the insured except for 25% of the drug expenses. Although the vast majority of the population (more than 80%) is not employed in the formal sector no clear plans have been devised for insurance for the informal sector [START_REF] Litvack | User fees plus quality equals improved access to health care: results of a field experiment in Cameroon[END_REF]. The informal sector is composed of the self-employed, nonemployed, the poor, etc. This sector is facing many questions concerning people's income, affordability, willingness to pay, collection of contributions and provision of health services. It will be very difficult to establish a health insurance scheme without answering these questions.

In 1992 Sudan started a new policy of Economic Liberalization. This encouraged and extended cost-recovery policies for the health sector, which imposed user charges for publicly provided healthcare services. In response to the Economic Liberalization policies the private sector expanded tremendously. A free market for health services including NGOs appeared but without private health insurance which is not yet established. One of the main factors that encouraged the private provision of health services was the perceived deterioration of the quality of services provided by the public health facilities.

In addition, the introduction of charges for the publicly provided health services made the ratio of quality/cost more favourable for the private services, as the higher user charges in the private sector are compensated by its high quality [START_REF] Babiker | The impact of liberalization policies in health: some evidence from the Sudan[END_REF].

In the years 1996 and 2000 the government decided to provide free of charge health services at emergency departments and inpatient wards. These steps were taken under the pressure of expanded poverty and the political situation. The expansion of poverty has led to deficient health services and an uninsured informal sector. Protests took place against the negative impacts of the Economic Liberalization's new policies i.e. the rapid growth of the private sector that favours the rich. This opened the debate again about these cost recovery policies and their usefulness for the Sudan. An answer to the question "Are people willing to pay for public health services if these services are of good quality?" will provide guidelines to help health planners in establishing an adequate health financing system in Sudan.

This paper aims at providing and discussing a broad study on the willingness to pay (WTP) for improving the quality of public health services in Khartoum in Sudan. The WTP is made operational by the contingent valuation method. The WTP for public health services is conditional on the improvement of the quality of health services in terms of:

(a) specialist services, (b) advanced laboratory and X-ray unit analysis, (c) availability of drugs and consumables especially for children and (d) decreased waiting time. The paper uses a logistic regression model (LRM) to examine the WTP in relation to the demographic and socio-economic characteristics of respondents. Further the paper aims to explore the differences in WTP between the respondents who already pay for the health services (group 1) and those who do not (group 2).

The paper is organized as follows: Section 2 presents a short description of the costrecovery policies in Sudan. The statistical methodology is presented in Section 3. Section 4 contains the interpretations of the results and the discussion. Section 5 concludes with policy suggestions for the healthcare system in Khartoum in Sudan.

Cost-recovery policies in Sudan

During the 1980s and early 1990s Sudan responded to a number of international health initiatives to strengthen its health system: The World Bank 1987 Agenda for Change, which advocated user fees and considered the health services as a private good; the Bamako Initiative with its community financing tool 1 ; the Harare Declaration on decentralization; and the World Development Report in 1993 with its focus on the minimum essential services package [START_REF]Implementing Health Sector Reforms in Africa: a review of eight country experiences[END_REF]. In 1992 Sudan launched new Economic Liberalization policies, which are influencing the expansion of the cost-recovery policies in public facilities and encouraging private sector growth.

Community participation in the design of the cost-recovery schemes is the main mechanism for achieving financial compatibility. In addition it helps to ensure benefit packages that are socially and culturally acceptable to the community [START_REF] Abin | Rural health insurance: available alternative to user fees, department of public health policy[END_REF]. User charges may be one way to improve the sustainability of financing public health services in Sudan. It has been used in other countries with more or less success [9] and [START_REF] Yasin | Impact of structural adjustment policies on health in developing countries: User fees, utilization and quality of health care services[END_REF].

Moreover, one study shows that people are willing to pay the higher prices of the private sector in return for good quality health services [11]. Sudan, like other developing countries, cannot allocate enough money for financing its health services but neither can the majority of the population afford to fill this gap [START_REF] Mao | Farmers' Willingness to Pay for Cooperative Medical System[END_REF]. User charges have a negative effect on equity. Fees tend to impose a barrier on the poor to use services. Some studies show the role of the nature of payment mechanisms on equity i.e. systems that employ a pure user charge are more likely to influence inequality than those with exemptions or risk sharing schemes [START_REF] Mao | Farmers' Willingness to Pay for Cooperative Medical System[END_REF]. No studies of the negative impacts of the user charge policies on equity have been held in Sudan but, as has been mentioned before, the debate on these issues was recently opened again in the Sudan.

According to Curries, cost-recovery policies are the foundation for health insurance schemes and the transition towards privatisation [START_REF] Currier | Public-Private Collaboration[END_REF]. Cost-recovery policies are expected to support the sustainability of the health financing system. They also allow the government to reallocate expenditure from curative services to public health activities that have a broader beneficiary base. Moreover, they are expected to reduce the private sector's price disadvantage relative to the government sector, and encourage the expansion of the health insurance schemes for the formal and the informal sectors [START_REF] North | Expenditure patterns and willingness to pay for health services in Belize: analysis of the 1991 Belize Family Life Survey[END_REF].

They are also expected to stop the widespread misuse of and drain on medical supplies by citizens and health workers [START_REF] Joseph | User fees in government health units in Uganda: Implementation, Impact, and scope[END_REF].

Methodology

Survey data

The data obtained in the survey were collected through interviews based on an adapted questionnaire in Arabic. The questionnaire was pre-tested and retested after correction and modifications. The survey was conducted in 2001 in Sudan by a trained team following the pre-tests. 2 The team was based in middle Khartoum, joining the Ajaweed Society research department. 3 The survey was held in Khartoum, the capital of Sudan, and covered urban, suburban and rural areas. The samples were selected by a multi-stage sampling procedure, i.e. first, a selection of the three towns of the capital Khartoum (Khartoum, Omdurman and Bahary) was made. Second, each of these towns was divided into central, peripheral and rural areas. We made a random selection of localities in the central, peripheral, and rural areas, then a random selection of neighbourhoods and finally a random selection of households for the purposes of the survey. As planned, 460 households were contacted and none of them refused to respond. For the purpose of similarity and to increase the internal consistency of the sample, 10 questionnaires were dropped. This meant that the overall respondents' rate is 100%, which suggests high evidence of reliability. The survey targets the heads of households (HH), or their nearest relation. The survey includes questions on the respondents' age, gender, tribe, origin of HH, family size, education, occupation, and place of work. The respondents were asked a set of questions on their socio-economic position that included income and expenditure. With regard to income, the respondents were asked about their monthly income and any other income. Some studies use monthly income to categorize households as poor, rich or others [START_REF] Morey | Willingness to pay and determinants of choice for improved malaria treatment in rural Nepal[END_REF]. We classified the respondents' monthly income in an ordinal manner, as shown in Table 1. The currency used in this paper is the Sudanese Pound (Ls). 4 Monthly income in developing countries is not considered as a sufficient indicator for the household's economic status. To collect additional information on their wealth, the respondents were asked whether they owned one of the following durable goods: a refrigerator, a car or a house. To examine their health condition the respondents were asked to determine the number of sickness episodes, visits to health facilities and the number of prescriptions during the last 3 months. To examine the accessibility of health services the respondents were asked how far the nearest pharmacy is from their residence. They could choose between walking distance and driving distance. In addition, a question on the choice of one pharmacy is included. The respondents were asked a set of questions regarding their payments for the health services during the last 3 months. These were: whether they had paid any amount of money for health services, and whether they had bought drugs for themselves or any members of their household.

The contingent valuation method

The contingent valuation method is frequently applied in developed countries, but not in developing ones [START_REF] Dong | Willingness to pay for community-based insurance in Burkina Faso[END_REF]. The validity and reliability of these methods are not yet well established, so the results should be interpreted with some caution [START_REF] Wouters | Quality of Health Care and its role in cost recovery with a focus on empirical findings about Willingness to Pay for Quality Improvements[END_REF]. The healthcare systems in developed countries offer a good environment for conducting these studies and results are used to increase the efficiency of healthcare delivery. In developing countries the high illiteracy rate and poor institutions do not contribute to a good environment for conducting such studies. As far as we know no similar studies have been held in Sudan. The transition towards privatisation, economic liberalization and towards building institutional facilities encouraged us to use these methods to analyse people's willingness and ability to pay (ATP) for these transformations in healthcare provision.

Uncertainty about household income, the Sudanese dislike of bargaining over prices, the well known prices of the private sector and its relation with quality together with the bias of the starting price of the bidding game method made us decide to use the take-it-orleave-it method. The prices presented in Appendix A for the two groups were constructed from the current costs of the public health services. Prices varied around the estimated cost of the improved quality facilities and are close to the private sector's prices. In developed countries, willingness to pay corresponds closely to the ability to pay, which is not the case in developing countries. Instead of asking the respondents to give a yes or no answer, we offered them four options. The aim of this was to get some insight into the differences between willingness to pay and the ability to pay. For example, the response 'I would go into debt' is a strong indicator of willingness to pay but a weak indicator of ability to pay. Table 2 shows these differences. We also aimed to overcome possible strategic behaviour biases, e.g. the response 'if I have enough money' is used to overcome the risk of respondents making a pledge they cannot keep. Because of the dichotomous nature of the responses the model chi-square was used as a reliability test. The most common test of reliability is the amount of variance explained by the variable. A significant level of less than .05 indicates that the likelihood of the observed responses -given the estimated equation -is significantly greater than their likelihood given an equation without independent variables. Results reported in Appendix B show that the contingent valuation method is reliable [START_REF] Weaver | Estimating The Willingness To Pay For Quality Of Care: Comparison Of contingent Valuation And Two-Step Health Expenditure methods[END_REF].

Table 2: Differences between WTP and ATP related to the answers in the take-it-orleave-it method

Answers

For the purpose of this paper -which investigates only the respondents' WTP -we considered the upper three options as WTP. For the analysis of ATP see [START_REF] Habbani | User fees policy in Khartoum state of Sudan: the ability to pay for the public health services and its relation with willingness to pay[END_REF]. To examine their willingness to pay for public health services, the respondents were divided into two groups according to their answers to the question 'do you receive free of charge public health services?' (more information about the group who is entitled to free of charge public health services can be found in [START_REF] Habbani | Do free of charge public health services impediment the cost recovery policies in Khartoum State of Sudan? Mimeo[END_REF]) The respondents who answered no were classified into group 1. Because they already pay for public health services, they were asked a set of questions to investigate their willingness to pay an extra amount of money if these services were of good quality. The respondents who receive free of charge public health services were classified into group 2. They were asked a set of questions to investigate their willingness to pay for public health services if these services were of good quality (Appendix A shows the contingent valuation scenario). Four aspects of health services were selected to represent good quality: (a) specialist services, (b) laboratory and X-ray unit analysis, (c) availability of drugs, especially for children and (d) decreasing waiting time. The possible answers to investigate their willingness to pay for good quality were, (1) I would not hesitate, (2) I would go into debt, (3) I would pay if I have enough money and (4) I would not pay. These options were designed to encourage the respondents' intentions rather than beliefs or attitudes. Intentions are better predictors of behaviour than attitudes [START_REF] Wouters | Quality of Health Care and its role in cost recovery with a focus on empirical findings about Willingness to Pay for Quality Improvements[END_REF]. To explain what determines the WTP for improved quality of health services, we constructed a regression model in which the dependent variable is based on the four answers as follows. For each aspect of quality considered, and for the binary nature of the dependent variable we merged the first three answers (1)-( 3). We interpreted these as signifying that the respondent is willing to pay for this aspect of quality and the dependent variable takes a value = 1. If, instead, the respondent answers (4), then we interpreted this as signifying that he/she is not willing to pay the proposed amount and the dependent variable takes the value = 0 (Fig. 1 shows the construction of the dependent variables for the two groups).

Steps in regression analysis

Models selection

The data used in this paper were taken from a multi-purpose household survey. To avoid irrelevant variables bias, some variables were eliminated as a first step in the modelbuilding strategy. Due to transportation and security constraints the survey was conducted during daylight and thus most of the respondents were females (62.9%). To solve the problem of the ratio of cases to variables a process of merging categories was done for the variables age, family size, education, occupation and the type of the disease [START_REF] Tabachnick | Using multivariate statistics[END_REF].

A necessary step in the model building strategy is the selection of variables to fit the model. A univariable selection analysis of each variable, i.e. Chi square, t-test, correlation and the ordinary least square (OLS), was done. Appendix C and Appendix D present the results of the OLS models for group 1 and group 2, respectively, as the last step of the univariable selection analysis. After completion of the univariable analysis, a selection for the multivariable analysis was carried out. Any variable with a level of statistical significance <.05 was a candidate for the multivariable model and for variables considered important for the paper. Following the fit of the multivariable model, the importance of each variable included in the model was verified by a Wald statistics examination [START_REF] Hosmer | Applied logistic regression[END_REF].

Models with only the significant variables of the OLS estimations proved to be poor models for the two groups. The direct and the stepwise procedures were used instead.

Compared to the OLS results, the full models of the direct procedure method for both groups show that some variables were eliminated and that the models do not fit better than the OLS models. In the stepwise procedure method a backward logistic regression was done and a series of additions and removals together with interactions and combination of variables resulted in eight models that have the advantage over the OLS and the full models.

Statistical method

Because of the dichotomous nature of the dependent variables a LRM was used for the statistical analysis to estimate the factors (independent variables) that influence the dependent variable willingness to pay. Appendix E presents the statistical analysis method.

Results

Descriptive results of the survey

The description of the socio-demographic variables in the sample can be found in Table 3. The frequencies in Table 3 show that more than 80% of the respondents in group 1 are willing to pay extra money for public health services if these services are of good quality.

In group 2, more than 75% is willing to pay for public health services if these services are of good quality. Table 3 also shows that almost 80% of the respondents are in highly productive middle age (31-40 years). It also shows the family size scales i.e. that Sudanese society is composed of extended families. This explains the high dependency rate (93.5%) [START_REF]Economical review[END_REF]. Primary education in Table 3 refers to illiterate, pre-school Khalwa (Quraanic School), and primary school education. Secondary education refers to secondary and higher secondary schools. University education refers to graduates and post-graduates. The relatively high percentage of university education is only found in Khartoum and big cities, as is clear if we consider that in the whole of Sudan the literacy rate is 40% for males and 15% for females [START_REF]Priorities and Strategy for a concerted United Nations Response[END_REF]. Migration to the business sector due to the economic liberalization policies explains the high percentage of the merchant category (34.4%). 5 In Table 3, 86% of the respondents have a monthly income between 100,000 and 500,000 Ls. These wages cover a small proportion of family expenses and are equal to one quarter of the family's expenditure [START_REF] Sahl | Public sector employees' poverty-coping mechanisms: the rolling of an empty ball, a case from El-Obeid[END_REF]. Monthly income is an inadequate indicator for socio-economic status in developing countries. The variables referring to other income and to car ownership are also indications of the socio-economic status of the family. The variable referring to other income in particular is an example of how families bridge the income-expenditure gap.

Questions on car and house ownership were asked to differentiate between different classes of socio-economic status, assuming that people who have a car and own a house are rich. The high percentage (70.4%) of house ownership indicates that the majority of the respondents have their own house. The variables 'have dependents' (55.6%) and 'pay tuition fees' (78.9%) together with the variable 'family size' show the burden of additional expenditure on the household's budget.

The high percentage of people who had paid for treatment during the last 3 months (86.2%) and who had bought drugs during the last 3 months (90%) show the considerable demand for and utilization of health care services. The response to questions on the number of episodes of sickness during the last 3 months (88.1%), frequency of visits to health service units for treatment during the last 3 months (86.4%), and the internal medicine diseases (49.8%) confirm this.

Logistic regression estimation

The goodness of fit assessment for the eight models is presented in Appendix E. The models provide a good fit for the data; the percentage of correct predictions is between 78% and 88%, the chi squares are significant and the McFadden R 2 are satisfactory.

Table 4 shows the LRM results for the dependent variables in group 1. For the first dependent variable for group 1, 'specialist services', the variables 'moderate income', 'high income', 'very high income', 'always paid for treatment during the last 3 months' and 'sometimes paid for treatment during the last 3 months' are statistically significant.

While the variables 'occupation' and 'bought drugs during the last 3 months' are not significant, they are still important for the significance of other variables in the model.

These results show that the odds ratio for the significant factors are more than one and this indicates that the respondents with these significant characteristics are more likely to be willing to pay for the public health services if these services were introduced by a specialist. For the second dependent variable for group 1, 'advanced lab and X-ray analysis', the variables 'low income', 'moderate income', 'high income', 'very high income', 'always paid for treatment during the last 3 months', 'sometimes paid for treatment during the last 3 months', 'sometimes bought drugs during the last 3 months' and 'own a house' are statistically significant. While the variable 'occupation' is not significant, it is still important for the significance of other variables in the model. These results show that the odds ratios for the significant factors mentioned above are 4, 4, 10, 8, 5, 6, 4, and 4, respectively (see column six in Table 3). This suggests that the respondents with these significant factors are more likely to be willing to pay for public health services assuming that the attribute of good quality in these services is an advanced lab and X-ray analysis.

For the third dependent variable for group 1, 'availability of drugs especially for children', only five factors significantly influence the probability of the household to be willing to pay for public health services. These factors are: 'moderate income', 'high income', 'very high income', 'always paid for treatment during the last 3 months', 'sometimes bought drugs during the last 3 months' and 'own a house'. These results

show that the odds ratios for the significant factors are 3, 3, 3, 4, 7 and 3, respectively (see column six in Table 3). This suggests that those with such significant variables are more likely to be willing to pay for public health services if drugs are available, especially for children.

For the fourth dependent variable for group 1, 'decreased waiting time', the variables 'merchant', 'high income', and 'always paid for treatment during the last 3 months' are statistically significant. While the variables 'frequency of visits to health services unit during the last 3 months' is not significant, it is still important for the significance of other variables in the model. These results show that the odds ratio for the HH who is a merchant is almost 4.195. This suggests that those who are merchants are over four times more likely to be willing to pay for public health services if the waiting time for these services decreases. The odds ratio for the HH who has a high income is almost 10.980.

This suggests that those who have a high income are almost eleven times more likely to be willing to pay for public health services if the waiting time for these services decreases. The odds ratio for the HH who always paid for treatment during the last 3 months is almost 3.302. This suggests that those who always paid for treatment during the last 3 months are almost three times more likely to be willing to pay for public health services if the waiting time for these services decreases.

Table 5 shows the LRM results of the dependent variables for group 2. The first dependent variable for group 2, 'specialist services', has only two factors that significantly influence the probability of the household WTP: 'family size (1-6)' and 'HH education (university)'. While the variable 'have dependents' is not significant it is still important for the significance of other variables in the model. These results show that the odds ratios of the significant factors are 6.963 and 7.099, respectively. This suggests that the respondents of the significant factors mentioned would be more likely to be willing to pay for public health services if these services were introduced by a specialist. For the second dependent variable for group 2, 'advanced lab and X-ray analysis', only the variable 'family size (7-10)' is statistically significant. While the variables 'HH education' and 'have dependents' are not significant they are still important for the significance of other variables in the model. These results show that the odds ratio for the HH who have a family size of (7-10) members is almost 8.526. This suggests that those with a family size of 7-10 members are almost nine times more likely to be willing to pay for public health services if these services include advanced lab and X-ray analysis.

In the regression with 'availability of drugs especially for children' as the dependent variable, the variables 'HH education (secondary)' and 'HH education (university)' are statistically significant. While the variable 'HH family size' is not significant, it is still important for the significance of other variables in the model. These results show that among group 2 the odds ratios of the significant factors are 6.250 and 12.170, respectively. This suggests that the respondents with such factors are more likely to be willing to pay for public health services if drugs are available, especially for children.

In the forth equation for group 2, 'decreased waiting time', only the variables 'family size

(1-6)', 'family size (7-10)' and 'episodes of sickness during the last 3 months' are statistically significant. While the variable 'HH education' is not significant, it is still important for the significance of the model. The positive odds ratios of the 'family size'

(1-6) and 'family size' [START_REF]Implementing Health Sector Reforms in Africa: a review of eight country experiences[END_REF][START_REF] Abin | Rural health insurance: available alternative to user fees, department of public health policy[END_REF](9)[START_REF] Yasin | Impact of structural adjustment policies on health in developing countries: User fees, utilization and quality of health care services[END_REF] indicate that respondents with these significant variables are more likely to be willing to pay for public health services if the waiting time for these services decreases. The negative odds ratio for the variable 'episodes of sickness during the last 3 months' indicates that the respondent with this variable is less likely to be willing to pay for public health services if the waiting time for these services decreases.

Discussion

The overall percentages of people willing to pay for good quality of public health services in group 1 and group 2 are more than 80% and 75%, respectively. This indicates a high percentage of WTP for public health services with good quality and supports the claims of health planners. These empirical findings confirm the importance of the quality of health services in motivating the demand for public health services. It appears that with improved services, a floor for reasonable fees could be set [START_REF] North | Expenditure patterns and willingness to pay for health services in Belize: analysis of the 1991 Belize Family Life Survey[END_REF]. This supports the continuity of the cost recovery polices because virtually the majority of the households are willing to pay these reasonable fees.

Our results show that the willingness to pay for each aspect of the quality of public health services (dependent variables) depends on the respondents' characteristics.Table 6 provides these main influencing characteristics for quality aspects for the two groups of respondents. For group 1, socio-economic factors are important determinants of WTP. The LRM analysis shows that the main socio-economic variables ('income', 'merchant', 'house ownership') and expenditure on health (i.e. 'always and sometimes paid for treatment during the last 3 months' and 'always and sometimes bought drugs during the last 3 months') have a significant impact on WTP behaviour. The higher a respondent's income, the greater his/her willingness to pay, and the more eager he/she is to pay for good quality public health services.

'House ownership' and 'merchant' variables are powerful indicators for the relatively high socio-economic status of a respondent in developing countries like Sudan. Although monthly income is an imperfect indicator of socio-economic status in developing countries, it can still be accepted in the presence of powerful indicators like 'merchant'.

Generally there are no prominent differences between the four aspects of quality of health with regard to the influence of socio-demographic characteristics of group 1.

Nevertheless the preference for high quality of 'lab and X-ray unit analysis' and 'availability of drugs especially for children' is expressed by respondents who have a high demand for health care and who own a house i.e. most probably older residents. This is a notable point that should help planners and designers of community participation programmes to consider the requirements of older residents, their families and their community leaders when arranging the quality they prefer. It also emphasizes that these two quality aspects of services should be considered when setting charges. Besides this, the significant effect of a low income on the demand for lab and X-ray analysis is surprising and should be considered in planning. Decreased waiting time as an aspect of quality of health care seems to be favoured by the rich population. Unless the government directs revenues to be used in the same facility it will never be able to achieve a decrease in waiting time. This is because incentives will encourage the facility to make personnel available. Not only that, the facility could then overcome the chronic problem of electricity shortages that paralyse the lab and the X-ray investigation and make the waiting time even longer. If revenues are retained within the facility, managers will be able to avoid the chronic shortages of consumables by using the private market to fill the supply gap with e.g. lab reagents, X-ray films, catheters and disposable syringes.

The high percentage of people favouring 'availability of drugs' compared to the other three aspects of quality of health services confirm that people consider the availability of drugs as the most important aspect on which to judge the quality of health services [START_REF] North | Expenditure patterns and willingness to pay for health services in Belize: analysis of the 1991 Belize Family Life Survey[END_REF], [START_REF] Joseph | User fees in government health units in Uganda: Implementation, Impact, and scope[END_REF] and [START_REF] Morey | Willingness to pay and determinants of choice for improved malaria treatment in rural Nepal[END_REF]. The appreciation for public health services that adopt cost recovery policies seems to increase if quality, as measured by the availability of drugs, also increases [START_REF]Selected topics in health reform and drug financing[END_REF]. This may be because drugs are better defined than the other quality improvements [START_REF] Weaver | Estimating The Willingness To Pay For Quality Of Care: Comparison Of contingent Valuation And Two-Step Health Expenditure methods[END_REF]. The existence of infectious diseases in developing countries has made the role of drugs in relieving the situation obvious. The establishment of an active market of pharmaceuticals in Sudan means that information is now available on drug prices and on how much of the household budget is actually spent on drugs [START_REF] Weaver | Estimating The Willingness To Pay For Quality Of Care: Comparison Of contingent Valuation And Two-Step Health Expenditure methods[END_REF].

For group 2 the variables 'family size' and 'high education' have a significant impact on respondents' WTP behaviour. Respondents from bigger families tend to be more willing to pay for good quality public health services. This may be due to the nature of infections and the anticipation by big families that they will have to spend a lot of money if they delay appropriate and quick treatment.

The results show that a more highly educated respondent is more WTP for good quality public health services [START_REF] Kevin | Household willingness to pay for azithromycin treatment for trachoma control in the United republic of Tanzania[END_REF]. The reason for this may be related to the close relationship between high levels of income and education. Higher education also implies that people have more information and are more able to evaluate and judge [START_REF] Mao | Farmers' Willingness to Pay for Cooperative Medical System[END_REF].

Both groups are willing to pay for good quality public health services. However, some differences between them appear when we look at the respondents' characteristics that influence their WTP. If we compare the two groups on their WTP for good quality public health services, we see that group 1 respondents who are used to paying for health services are more willing to pay than group 2 respondents who would be willing to pay for the first time. The high WTP by group 1 in comparison to group 2 can be seen as an indication of the satisfaction of group 1 respondents with the existing public health services. Further it indicates their belief in the assumption that if they pay an extra amount of money it will encourage improvement in the quality of the health services.

Furthermore this reflects the trust and the belief of group 1 respondents in cost recovery polices. The lower WTP of group 2 may be due to hesitation and uncertainty about these new experiences. It may also be due to the amount of money that is mentioned in the contingent valuation scenario (Appendix A). However the long history of receiving free of charge public health services is expected to be a psychological barrier and may prevent them from accepting the idea of paying for health services. The results of the LRM are consistent with the expectations for both groups. While group 1 respondents varied in their WTP due to economic factors, the group 2 respondents varied in their WTP through (high) education and (big) family size.

One of the unexpected results is the insignificant effect in the LRM of being employed.

At the time of the research the adoption of the health insurance scheme had not been completed. During the pre-test phase we recognized a bias related to the answers of the insured-employee H.H. Although they are insured employees they were not willing to admit this when answering the questionnaire. Because of this bias we have excluded any reference to the respondent being insured.

Policy suggestions and conclusions

The majority (i.e. more than 75%) of the respondents are willing to pay for public health services. These results have been obtained on the assumption that public health services are of good quality. It appears that with improved services, some reasonable floor fees could be set. This supports and encourages the continuity of cost recovery policies because the majority of the households are willing to pay a reasonable fee. Our conclusions and the policy suggestions' validity is confirmed by the situational analysis of Sudan presented in The National Strategic Plan of Sudan-The First Quarter of the Century (2003-2027) [START_REF]The National Strategic Plan of Sudan -The First Quarter of the Century[END_REF].

Charges would be appropriate if the money collected is used to improve the quality of services. Thus special attention should be paid to the policies of circulating fee revenues within the facility and of using them to improve the quality of services [START_REF] Pavlova | Appraising the financial reform in Bulgarian public health care sector: the health insurance act of 1998[END_REF].

Policymakers in Sudan should focus on those quality improvements that might ultimately reduce the financial burden on the poor. This may include improving the quality of the lab, X-ray analysis and availability of drugs [START_REF] Wouters | Quality of Health Care and its role in cost recovery with a focus on empirical findings about Willingness to Pay for Quality Improvements[END_REF].

The continuity of cost recovery policies will prepare the ground for the establishment of community-based health insurance and will help the government to contribute to the effectiveness and sustainability of the informal sector [START_REF] Preker | Effectiveness of community health financing in meeting the cost of illness[END_REF]. No doubt many more studies are needed to explore other areas important for this establishment.

Regarding the private sector these results are encouraging for the tremendous growth of this sector for two reasons. First, the high percentage of WTP for the quality of health services favours the private sector. Second, the stabilization of the health financing policy will encourage the private sector to continue growing. The coordination with the public sector should be consistent with these attempts. These results also prepare the ground for co-operation between the public and the private sectors and invite the launch of privatepublic initiatives.

More studies on WTP approaches are needed to complete the scene and to deal with the uncovered areas. For example a survey to detect the individual WTP together with the household's WTP will allow for more generalization of the findings [START_REF] Dong | Willingness to pay for community-based insurance in Burkina Faso[END_REF]. Moreover, some researchers have criticized the World Bank generalization of WTP results as ability to pay and argued that 'it tells little about ability'. So, we have to consider WTP results as heralds and potentials for ability to pay, to be confirmed by additional studies [START_REF] Yasin | Impact of structural adjustment policies on health in developing countries: User fees, utilization and quality of health care services[END_REF].

The fact that there is no golden rule in contingent valuation means that other contingent valuation methods are important to support the findings of the take-it-or-leave-it procedure and to overcome its biases. The combination of more than one contingent valuation method in one study will encourage the findings and provide more reliable results.

Finally, these results are expected to encourage the government to be more cautious about decisions in health financing. No doubt the government should pay more attention to such studies.

Fig. 1 .

 1 Fig. 1. The dependent variables construction.

Table 1 : Classification of the respondents monthly income HH monthly income (Ls) Classification

 1

	<100000	Very low income
	100000-150000	Low income
	150000-300000	Moderate income
	300000-500000	High income
	>500000	Very high income

Table 3 : Description of the dependent and the socio-demographic independent variables in the sample The dependent and the socio-demographic variables Value range Frequencies N Min Max Mean S.D.

 3

	Group 1 dependent variables
	Seen by a specialist	1 = yes	86.9	388 0	.87	.338
		0 = no	13.1
	Lab and X-ray analysis	1 = yes	85.8	388 0	.86	.349
		0 = no	14.2
	Drugs availability	1 = yes	88.1	387 0	.88	.324
		0 = no	11.9
	Reduce waiting time	1 = yes	81.7	388 0	.82	.387
		0 = no	18.3
	Group 2 dependent variables
	Seen by a specialist	1 = yes	75.8	62	0	.76	.432
		0 = no	24.2
	Lab and X-ray analysis	1 = yes	77.0	61	0	.77	.424
		0 = no	23.0
	Drugs availability	1 = yes	80.6	62	0	.81	.398
		0 = no	19.4
	Reduce waiting time	1 = yes	75.8	62	0	.76	.432
		0 = no	24.2

Table 4 : Logistic regression results for group 1 dependent variables

 4

	Group 1 dependent variables	Independent variables	B	S.E.	Significance	exp(B)
	Specialist services	Employee	-.078	.528	.882	.925
		Labour	-.034	.559	.952	.967
		Merchant	.633	.576	.271	1.884
		Jobless	-1.571	.931	.091	.208
		Low income HH (100000-150000)	.751	.487	.123	2.120
		Moderate income HH (150000-300000)	.945	.461	.041	2.572
		High income HH (300000-500000)	2.040	.696	.003	7.690
		Very high income HH (>500000)	1.592	.654	.015	4.913
		Always paid for treatment during the last 3 months	1.128	.566	.046	3.089
		Sometimes paid for treatment during the last 3 months	1.882	.759	.013	6.569

Table 5 : Logistic regression results for group 2 dependent variables

 5

	Group 2 dependent variables	Independent variables	B	S.E.	Significance	exp(B)
	Specialist services	Family size (1-6)	1.941	.942	.039	6.963
		Family size (7-10)	1.778	.955	.063	5.920
		HH education (secondary)	1.087	.804	.177	2.964
		HH education (university)	1.960	.960	.041	7.099
		Always have dependents	-.549	.994	.581	.578
		Sometimes have dependents	-1.064 1.075 .322	.345
		Constant	-.654	1.148 .569	.520
	Lab and X-ray analysis	Family size (1-6)	1.831	.945	.053	6.241
		Family size (7-10)	2.143	1.007 .033	8.526
		HH education (secondary)	1.250	.902	.166	3.491
		HH education (university)	1.263	.891	.156	3.537
		Always have dependents	-1.503 1.247 .228	.222
		Sometimes have dependents	-1.326 1.363 .331	.265
		Constant	.131	1.315 .921	1.140

Table 6 : The main characteristics influencing quality aspects for groups 1 and 2

 6

	WTP for	Main determinants
	Group 1
	Specialist services	Monthly income (either moderate, high or very high)
		Use of health services (who always or sometimes paid for treatment during the last 3
		months)