economic analysis of health projects
TRANSCRIPT
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ERD Technical N ote No. 6
Economic Analysis of Health Projects:A Case Study in Cambodia
Erik Bloomand
Peter Choynowski
M ay 2003
Er ik Bloom is an Economist in the Social Sectors Division, M ekong Department while PeterChoynowski is an Economist in the Economic Analysis and Operations Support Division,
Economics Research Depar tment, Asian Development Bank. The authors wish to thank I nduBhushan, David Dole, James Knowles, and Xianbin Yao for useful comments.
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Asian Development Bank
P.O. Box 789
0980 Manila
Philippines
2003 by Asian Development Bank
May 2003
ISSN 1655-5236
The views expressed in this paper are those of the author(s)
and do not necessarily reflect the views or policies of the
Asian Development Bank.
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Foreword
The ERD Technical Note Series deals with conceptual, analytical or method-ological issues relating to project/program economic analysis or statistical analysis.Papers in the Series are meant to enhance analytical rigor and quality in project/program preparation and economic evaluation, and improve statistical data and de-velopment indicators. ERD Technical Notes are prepared mainly, but not exclusively,by staff of the Economics and Research Department, their consultants, or resourcepersons primarily for internal use, but may be made available to interested externalparties.
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Table of Contents
Abstract vii
I . I ntroduction 1
I I . The Project and its Rationale 2
I I I . Economic Analysis 3
A. Least Cost Analysis 3
B. Calculation of the Economic I nternal Rate of Return 4
C. Preliminary Assessment of the I ncidence of Benefits 9
I V. Financial Sustainability of the H ealth Sector and P roject 10
A. Fiscal Sustainability 10
B. Project Sustainability 13
V. Conclusions 13
References 14
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Abstract
The economic analysis of health projects has not received the attention thatprojects in other sectors have received primarily because of perceived difficulties inquantifying economic benefits. However, there is a misconception that economic analysisis a simple calculation of an economic internal rate of return. Rather, it envelops abroader range of issues that includes the rationale for the project, cost effectiveness,demand for the project output, economic viability, sustainability, and equity consider-ations. The purpose of this technical note is to present an example of an approach tothe economic analysis of a health project that may be used as a guide for future
projects. It is based on an actual health project approved by the Asian DevelopmentBank for Cambodia that will be implemented over the period 2003-2006.
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I . INTRODUCTION
Health and physical well being are essential to the formation and maintenance of humancapital and are key components for economic growth and sustained poverty reduction. However, main-taining health is not free and requires significant public and private investment. Since resources arescarce, developing countries like Cambodia have to ensure that the right investment decisions aremade from an economic point of view. I nterventions in health, as wel l as other sectors, should be asefficient as possible, maximizing benefits and minimizing costs. Careful consideration must also begiven regarding which parts of the population will be the ultimate beneficiaries of the investments. Theeconomic analysis of projects has an important role to play in making these decisions.
An economic analysis is an important part of the planning process and the ultimate implemen-tation of a project. The process normally begins with ideas for projects that emerge from an assessment
of the sector. The sector assessment establishes the rationale for the project and suggests alternativesolutions to the identified problems. Thus, the next step in an economic analysis is to identify the leastcost alternative from this set of technically feasible projects. When the least cost option is identified, itis then subjected to a full benefit-cost analysis to calculate economic internal rates of return and netpresent values for comparison with other projects in the health and other sectors. The benefit-costanalysis is key to the efficient allocation of scarce public investment resources across all sectors.
There is usually no guarantee that the economic benefits of health projects will be realizedover the life of the project. Therefore, a financial analysis of the health project is also required toensure that the project contributes to the financial soundness of the implementing agency and that theproject will continue to operate satisfactorily over its life. For revenue-generating projects, financialinternal rates of return are usually calculated and the financial statements of the implementing agencyare analyzed.
However, many kinds of projects including those in the health sector supply public goods thatare financed by the government from its budget. The project is often not revenue-generating and theimplementing agency is likely not organized along commercial principles. Therefore, an analysis ofpublic expenditures is critical for determining the sustainability of the project in terms of its role in thehealth sector, in the overall budget process, and in terms of current and future priorities. The analysisof public expenditures should therefore comprise the following principal features. The analysis shouldpresent the trends in the level of total public expenditures and share of the budget over time. Thesenumbers may be presented in per capita terms for comparison with other countries in the region. Thisis followed by an analysis to describe the resource allocation within the health sector across majorexpenditure categories. With a good understanding of current public resources allocated to the healthsector, the analysis proceeds to forecast how budget allocations to the sector are likely to change in thefuture based on past trends, government priorities, and perceptions of government officials.
This technical note presents an example of how an economic analysis may be undertaken fora health project incorporating the above principles, consistent with the method outlined in the Hand-book for the Economic Analysis of Health Sector Projects(ADB 2 000) . I t is based on the CambodiaHealth Sector Support P roject (L oan 19 40 -CAM [SF]) , approved by the Asian Development Bank(ADB) on 21 November 2002 (referred to hereafter as the Project) . The technical note discusses the
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rationale for the Project, reviews its economic contribution to the health system, and investigates theoverall sustainability of the health sector and the effect of the Project on beneficiaries and the Govern-ment of Cambodias long-term fiscal position.
I I . THE PROJECT AND ITS RATIONALE
There is a strong economic rationale for investing in health, especially for expanding primaryand basic secondary health care to areas where it is almost nonexistent. Cambodias health indicatorsare among the worst in the Asian and Pacific region. Average life expectancy at birth is estimated atonly 56.4 years. I nfant mortality is estimated to be 95 per 1 ,000 per live births, while the mortal ity rateunder the age of 5 is 124 and the maternal mortality rate is 437 per 100,000 live births (CambodiaDemographic and Health Survey 2000). Rates of malnutrition are the second highest in Southeast Asiawith an estimated 56 percent of children under 5 affected by chronic malnutrit ion. Moreover, progressin improving these health indicators has been slow and, in some cases, for example infant and childmortality, the rates appear to have increased in the 1990s.
Health care is often characterized by asymmetrical information with respect to medical in-terventions. This is especially true in Cambodia, where education levels of patients are low and peopleoften do not know about even basic health practices, such as emergency obstetric care and childhealth. I n many areas, private, unregulated health services are the primary source of health care. Thelack of regulation and consumer information often puts the health of patients at risk and drives up thecost of health care. Publicly provided health services can help bridge the gap and provide informationabout good health practices and alternatives in health care.
Credit markets are weak in Cambodia and health insurance is virtually nonexistent. A healthcrisis in a household can lead to a household financial crisis and, for the 80 percent of the populationthat lives near or below the poverty line in Cambodia, the threat of such a crisis is ever present. Thus,a formal and transparent fee system for health care reduces uncertainty of health care expendituresand protects the poor from the burden of health care costs. At present, virtually no protection exists forthe poor but, with a formal system, it is possible to establish fee exemptions and social protection fundsand, eventually, insurance schemes to protect households in the event of an unexpected health crisis.
A lack of trained health care providers is a key constraint to improving the health careworkers performance and providing services to the poor. M any public rural facili ties have staf f short -ages that limit access to general and specialized health services. Remote health centers are seriouslyunderstaffed in midwifery and reproductive health services. A large proportion of health providers lacknecessary curative and preventative skills to provide effective health care. The lack of trained healthcare providers is compounded by the poor capacity to effectively plan, manage, and finance the healthsector. As a result, poor Cambodians have largely not benefited from available health services.
I nvestment in primary health care in the remote areas of a developing country has a positiveimpact not only on poverty but also on health equity. According to Sen ( 20 02 ) , health equity is a central
feature of fairness and justice in social arrangements. I t is not concerned only with health in isola-tion in terms of the distribution of health or the distribution of health care. Fairness and justice insocial arrangements also include consideration for economic allocations and the role of health inhuman life and freedom. The provinces where the Project will be implemented are among the poorestin the country and generally have worse health and nonmonetary indicators of poverty than the na-tional average.
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To address these issues, the Health Sector Support Projects objective is to improve health,especially of women, children and the poor in targeted regions of Cambodia. Specifically, the Projectaims to:
(i ) develop affordable, quality, basic curative, and preventative health services forthe population, especially for women, the poor, and the disadvantaged;
( ii) increase the utilization of health services, especially by women and the poor;( iii ) control and mitigate the effects of infectious epidemics and of malnutri tion with
emphasis on the poor and disadvantaged; and( iv) increase the institutional capacity to plan, finance and manage the health sector
in line with the Health Sector Strategic Plan 2003-2007.
The Projects scope consists of three components:
(i ) buildings and civil works, medical and auxiliary equipment, training of health
service providers, contracting of services to nongovernmental organizations,and supplies and drugs;
( ii) support programs addressing public health priorit ies such as the control andprevention of communicable diseases and safe motherhood, immunization andnutrition programs; and
( iii ) strengthen institutional capacity in management, planning and evaluation atthe national, provincial and district levels.
I n the contracting of services to nongovernmental organizations, two approaches are avail-able. Under the contracting-out model, the contractor has full responsibility for the delivery of speci-fied services, directly employing staff, and has full management authority and accountability for theachievement of specific targets. The contractor has full control over resource allocation and disburse-ment. Under the contracting-in model, contractors provide only management support to the civil ser-
vice health staff, with recurrent operating costs provided by the government through normal channels.Contractors have full control over allocation and disbursement of the budget supplement, but areobliged to follow government rules and regulations with respect to the government-supplied resources.Contractors have management authority over staff but do not directly employ them.
I I I . ECONOMIC ANALYSIS
A. Least Cost Analysis
Quantitative economic analysis normally begins with comparing costs in relation to healthimpacts from different project alternatives. The general procedure requires specifying alternativeincremental project impacts (the difference between a health outcome with and without a particularproject) and comparing this with incremental costs, both streams appropriately discounted. I n the casewhere incremental project impact is the same for all project alternatives, only incremental costs need
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to be considered. Box 1 provides a general framework for undertaking a least cost analysis of a healthproject.
The least cost analysis of the Project was based on the results of a pilot project in five districtsin Cambodia (see Keller and Schwartz 2001 ). 1 The pilot project engaged several nongovernmentalorganizations to manage the local health system using two dif ferent management modelscontract-ing-out and contracting-in. Other areas under the pilot project were served in the usual government-
provision approach. These three approaches to providing health care services are the range of possiblealternative interventions that could be employed. The impact of the contracting approaches was subse-quently evaluated by comparing these approaches with the government provision model. I t was foundthat the contracting approach was the most cost effective and that significant improvement in healthcare services in the contracting areas over the government provided ones was achievable. Thus, thiswas the basis for using the contracting approach in providing primary health care in the districtscovered by the Project.
B. Calculation of the Economic Internal Rate of Return
1. Economic Benefit Assumptions
The Project supports the Cambodian health systems efforts to improve the health status of thepopulation. Some of the economic benefits of the Project are quantifiable in economic terms and may
Box 1: Steps for a Health Sector Least Cost Analysis
Step 1: Identif ication of the Objective of the Intervention Establish clearly and in detail the objective of the intervention Identify the scope of the intervention in general terms
Step 2: Collection and Preparation of Cost Data Identif y the range possible interventions to achieve the given objective Obtain financial cost data from reliable sources on all inputs for each mutually exclusive,
technically feasible project alternative Disaggregate t he cost data in terms of t radable and nontradable goods or services, and taxes
and duties Derive economic costs of project alternatives in constant prices from the financial cost data
through appropriate shadow pricing
Step 3: The Least Cost Analysis
Determine the social cost of capital in real terms Using the social cost of capital, discount the stream of economic costs over the life of the
project alternatives to arrive at net present values Calculate the equalizing discount rate of the two lowest cost alternatives Determine the least cost alternative and make recommendations
1 The pilot projects were financed by an earlier ADB project in the country, Loan 144 7-CAM (S F) : Basic Heal th Servicesapproved on 20 June 1996 for $20 million.
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be broadly divided into two categories: resource cost savings and productivity gains. Resource costsavings consist of a reduction in out-of-pocket expenses for health care as a result of reforms in healthfinancing. Productivity gains are the result of less time lost to illness that would have otherwise beenutilized in some economic activity. Productivity gains are also realized when less time is spent for thecare of sick family members, as well as better learning outcomes of children who will eventually join
the labor force. Numerous studies have shown that improvements in health have a significant effect onthe populations productivity (for example, Dasgupta 1993, and Strauss and Thomas 1995). This is truefor people working, both within and outside the home, and studying. There have been few studies donein Cambodia on the relationship between health status and productivity. Therefore, this analysis doesnot attempt to quantify all economic gains and only provides conservative estimates based on benefitstreams that can be quantified.
Table 1 provides the assumptions used in the calculation of the economic rate of return underalternate scenarios based on the evaluation of the pilot project referred to above. Details of themeasurement of the economic benefits and costs that form the basis of these assumptions may be foundin Keller and Schwartz (2001) and Bhushan, Keller, and Schwartz (2002).
BASEBASEBASEBASEBASE LOWLOWLOWLOWLOW FEWERFEWERFEWERFEWERFEWER LESSLESSLESSLESSLESS
CASECASECASECASECASE PPPPPARTICIPARTICIPARTICIPARTICIPARTICIPAAAAATIONTIONTIONTIONTION SICK DAYSSICK DAYSSICK DAYSSICK DAYSSICK DAYS OUT-OF-POCKETOUT-OF-POCKETOUT-OF-POCKETOUT-OF-POCKETOUT-OF-POCKETI NI NI NI NI N THE PRTHE PRTHE PRTHE PRTHE PROJECTOJECTOJECTOJECTOJECT REDUCEDREDUCEDREDUCEDREDUCEDREDUCED EXPENSES SAVEDEXPENSES SAVEDEXPENSES SAVEDEXPENSES SAVEDEXPENSES SAVED
Reduction of per capita $6 $6 $6 $6out-of-pocket expendituresin contracted areas
Reduction of per capita $4 $4 $4 $0out-of-pocket expendituresin noncontracted areas
Reduction of per capita 2.3 days 2.3 days 1.2 days 2.3 daysdays lost due to illnessin contracted areas
Reduction of per capita 0.8 days 0.8 days 0.4 days 0.8 daysdays lost due to illnessin noncontracted areas
Population benefiting 20% 15% 20% 20%from the Project in year 3
Population benefiting 40% 30% 40% 40%from the Project in year 4
Population benefiting 60% 45% 60% 60%from the Project in year 5
Population benefiting 80% 60% 80% 80%from the Project in year 6+
Maintenance cost per dollar $0.15 $0.15 $0.15 $0.15of investment
Economic value of time $0.75 $0.75 $0.75 $0.75(daily)
Table 1: Economic Benefit and Cost Assumptionsunder Alternate Scenarios
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The evaluation shows that supporting the health care system will lead to a decrease in out-of-pocket expenditures for health services along with improvements in health status. This is not unex-pected given the current dependence on pharmaceutical products that are often wrongly prescribed
and misused, and the high use of low quality unregulated health services. As a result, spending onhealth care is inefficient because of a lack of information, provider accountability, and a disorganizedhealth system. For areas that have been participating in the contracting pilot project, the positiveeffect was more pronounced. The base case assumes that out-of-pocket spending on health care isreduced from $22 per year to $16 per year in contracting districts (a savings of $6 per person per year)and to $18 per year in noncontracting districts (a savings of $4 per person per year). Given the lowlevel of income in Cambodia, this represents significant savings for many households.
Time is valued at $0.75 per day based on prevail ing wages. This value of t ime is assumed to beconstant for the entire population, whether they work outside the home, study, or work at home. This isconsistent with the practice of valuing the life of people who do not contribute financially to thehousehold. I t al so ref lects the contribution that the nonworking population makes to householdwelfare and is based on the premise that work in the home is a substitute for work outside the home atthe prevailing wage.
I mproving the health status of the population will lead to fewer days lost due to i llness andfewer days needed to take care of ill relatives than without the health interventions introduced by theProject. The base case assumes that in contracting districts, an average of 2.3 days per year will begained per capita due to more efficient treatment and better availabili ty of services. I n other districts,the gain is assumed to be only 0.8 days per person-year. At the prevailing wage of $0.75 per day, themonetary value of the productivity gain is $1.73 and $0.60 per person-year, respectively.
As the Project begins operations, there will be relatively few new beneficiaries. However, withtime, the number of people who benefit from the project will increase. The Cambodian health system isorganized around districts that are designed to give relatively equal access to the population, based ondistance and population density. The Project is also targeted in areas where the formal health systemis not functioning. Thus, investments will be well placed to ensure broad access.
The base case assumes that in the first two years of the Project, there are no new beneficiaries.I n the third year, 20 percent of the target population benefits from the project, increasing to 40 percentin the fourth year, 60 percent in the fifth year, and 80 percent in all subsequent years. These estimatesreflect the time required for the investment from the Project to reach the local level. Evidence fromthe contracting evaluation suggests that contracting starts to have a positive effect on the health systemwithin six months and therefore these assumptions are conservative.
2. Economic Cost Assumptions
The P roject will require additional resources to cover operat ing and maintenance costs. I t isassumed that for each dollar spent on investment, an additional $0.15 per year is spent on maintenance
and providing basic supplies to new facilities. Recurrent costs associated with the purchase of newdrugs and supplies are also included. Training leads to an increase in wages and subsequently tohigher recurrent costs. Thus, salaries are assumed to increase by 15 percent. Contracting is essentiallya recurrent cost and it is assumed that the cost will remain constant in real terms after the Project iscompleted. The cost of administration of the Project, including the M inistry of Healths cost in admin-istering the loan, the cost of consultants, and monitoring and evaluation of the Project are also in-cluded as components of the recurrent cost.
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Public funds used for investment come at a premium because of the distortionary effects of thetaxes needed to collect them. Estimates in the literature indicate losses are on the order of 30 to 50percent in industrial countries and even greater for developing countries (Hammer 1997). Publicinvestment will not induce distortionary tax ef fects if the investment is financed through borrowing andthe project output is priced to achieve full cost recovery. However, such is not the case with the Project.
Although the capital investment is financed through borrowing, project output will be heavily subsi-dized and full cost recovery is not planned. Therefore, debt servicing will be financed through incre-mental taxation and this taxation will introduce incremental distortions at some future date. Recurrentcosts will also be financed through incremental taxation. The economic cost of the distort ionary ef fectsof the taxes is not included in the economic analysis because of the lack of data to quantify it. However,the economic cost is likely not substantial because borrowings to finance the Project are concessionalwith a grace period of 8 years. Thus, any distortionary effects that may occur are heavily discountedand should not have a significant impact on the economic analysis.
3. The Economic Internal Rate of Return
I n cases where the economic benefits of a health project may be identified and valued, it ispossible to subject the project to a full cost-benefit analysis in which the values of health benefits arecompared wi th project costs. Three cri teria are commonly used to aggregate and compare benefits andcosts: (i) economic benefit-cost ratio, (ii) economic net present value, and (iii) economic internal rateof return ( EI RR) . I t has been the standard practice for ADB to use the E I RR criterion because not al linvestment opportunities are evaluated together and compared in terms of economic net present value.Thus, EI RR ensures that at least the project creates net benefits in excess of a discount rate represent-ing the next best al ternative project in the economy. An acceptable project will have an EI RR abovethe critical discount rate of 12 percent in real terms. Box 2 provides a general framework for calculat-ing the EI RR of a health project.
Box 2: Steps for a Benefit-Cost Analysis of a Health Sector Project
Step 1: Collection and Preparation of Benefit and Cost Data Determine the appropriate price numeraire for the benefit-cost analysis. Normally, the
domestic price is used as numeraire if most benefits and costs are nontradables Identify and value economic benefits of t he project in terms of resource costs savings,
productivity gains, and any other quantifiable benefits that are expected to be realized overthe life of the project
Identify and value economic costs. These economic costs are the same economic costs ofthe preferred project alternative used in the least cost analysis
Step 2: Calculation of the Economic I nternal Rate of Return Calculate the net economic benefits for each year Calculate the economic internal rate of return from the net economic benefit stream
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Table 2 shows the estimated cost and benefit streams for the Project for 20 years, the expectedlife of the Project. Costs and benefits exclude taxes and duties and are valued in constant 2002 dollarterms. Local currency costs and benefits are converted using the average 2002 exchange rate. Borderprice is the numeraire because of the limited use of the local currency, especially in the rural areas.The standard conversion factor applied to nontradables is 0.95 . The net present value calculat ion
discounts the cost and benefit streams at 12 percent in real terms.
YEARYEARYEARYEARYEAR ECONOMI C COSTSECONOMI C COSTSECONOMI C COSTSECONOMI C COSTSECONOMI C COSTS ECONOMI C BENEFI TSECONOMIC BENEFITSECONOMIC BENEFITSECONOMIC BENEFITSECONOMI C BENEFI TS NETNE TNE TNE TNE TCapitalCapitalCapitalCapitalCapital ContractingContractingContractingContractingContracting I ncrementalI ncrementalI ncrementalI ncrementalI ncremental I ncrementalI ncrementalI ncrementalI ncrementalI ncremental CostCostCostCostCost ECONOMI CECONOMI CECONOMI CECONOMI CECONOMI C
CostCostCostCostCost CostsCostsCostsCostsCosts RecurrentRecurrentRecurrentRecurrentRecurrent BenefitsBenefitsBenefitsBenefitsBenefits SavingsSavingsSavingsSavingsSavings BENEFITSBENEFITSBENEFITSBENEFITSBENEFITSCostsCostsCostsCostsCosts
2002 1,572,911 4,076,000 179,341 (5,828,252)
2003 4,036,807 1,493,000 830,210 (6,360,017)
2004 5,891,602 2,089,000 2,015,146 882,000 3,000,000 (6,113,748)
2005 2,640,315 2,049,000 2,748,172 1,764,000 6,000,000 326,513
2006 655,366 1,849,000 2,470,817 2,646,000 9,000,000 6,670,817
2007 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2008 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2009 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2010 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2011 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2012 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2013 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2014 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2015 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2016 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2017 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2018 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2019 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2020 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
2021 2,383,000 2,470,800 3,528,000 12,000,000 10,674,200
Economic Internal Rate of Return = 30.5%Economic Internal Rate of Return = 30.5%Economic Internal Rate of Return = 30.5%Economic Internal Rate of Return = 30.5%Economic Internal Rate of Return = 30.5%
Net Present Value (at a 12% discount rate) = $30.6 millionNet Present Value (at a 12% discount rate) = $30.6 millionNet Present Value (at a 12% discount rate) = $30.6 millionNet Present Value (at a 12% discount rate) = $30.6 millionNet Present Value (at a 12% discount rate) = $30.6 million
Table 2: Estimated Costs and Benefits of the Project
($ million in 2002 constant prices)
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The major benefits from the Project are in terms of out-of-pocket savings, as health financeimproves and more resources are channeled through the formal system. Even with these relativelyconservative assumptions, the Project yields a real economic rate of return of 30.5 percent. The rate ofreturn is likely higher as healthier workers are able to work more productively and earn a higherwage.
Table 3 presents the results of the alternative scenarios to test the sensitivity of the Project toless optimistic assumptions. The Low Participation scenario assumes that the uptake of the Project isslower than expected. The Fewer Sick Days Saved scenario assumes that the Project does not reducethe number of days lost due to sickness. The L ess Cost Savings scenario assumes that the Project isnot as successful in reducing out-of-pocket expenses. Table 1 provides the details of those alternativescenarios.
Even with the most pessimistic assumption, the Project has a positive rate of return of about 13
percent. Reducing the number of sick days saved has little effect on the overall rates of return, reflect-ing the low value of time. Of course, as health and economic conditions improve, the value of time willincrease. M ore important to the overall economic viability of the Project is the cost savings associatedwith reforming health finance in Cambodia and improving efficiency in the health sector. This under-lines the importance of the Projects commitment to health sector reform and improving delivery tocomplement the traditional Project focus of providing supply and infrastructure.
The Project is part of the larger health sector reform process, as guided by the Health SectorStrategic Plan, 2002-2007. At this stage, it is not possible to economically assess the Strategic Planbecause of the large number of components that have not yet been identified and a number of activitieswhose impacts are difficult to measure ( for example, sectorwide monitoring and evaluation) . The WorldBank undertook an economic analysis of its component in the health sector and found an overalleconomic internal rate of return of 29 percent, which is consistent with the Projects rate of return.
C. Preliminary Assessment of the Incidence of Benefits
A key question regarding the economics of a project, especially one that provides publicgoods such as some health services, is who benefits from the project. On a general level, this questionmay be answered by assessing the projects impact on the health of people in the targeted region and
SCENARIOSCENARIOSCENARIOSCENARIOSCENARIO ECONOMI C I NTERNALECONOMIC INTERNALECONOMI C I NTERNALECONOMIC INTERNALECONOMIC INTERNAL NE TNE TNE TNE TNE TRATE OF RETURNRATE OF RETURNRATE OF RETURNRATE OF RETURNRATE OF RETURN PRESENT VALUEPRESENT VALUEPRESENT VALUEPRESENT VALUEPRESENT VALUE
Base Case 30.5% $30.6 million
Low Participation in the Project 20.1% $12.0 million
Fewer Sick Days Saved 26.1% $22.3 million
Less Cost Savings 13.4% $1.9 million
Table 3: Sensitivity Analysis($ million in 2002 constant prices)
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subsequently estimating the proportion of the project benefits that accrue to the different beneficiarygroups. ADBs priorities for health sector projects are the poor, women, and indigenous peoples, ac-cording to the Handbook for the Economic Analysis of Health Sector Projects(ADB 2000) . The degreeof detail in the assessment of benefit incidence will normally vary considerably, depending on theamount of resources available for surveying and data compilat ion and analysis. In cases where a
detailed analysis is not possible, simpler indicators may be used, such as the number of people withina target group that are served by the project. This was the approach used in the analysis of theincidence of benefits from the Project. A more detailed analysis of the incidence of benefits was notpossible because of the limited amount of data on beneficiaries in the project area.
The approach utilized began with an assessment of poverty in the provinces where the projectfacilities were to be constructed. Data on the poor and near-poor was obtained from the sourcespublished by the World Food Program. I t was assumed that the number of people served by the projectfacilities varied proportionally with the amount of investment and that the composition of the benefi-ciaries by income level would be similar to that at the provincial level. Since the project facilities wereto serve a significant proportion of the population of each province, this assumption was deemedreasonable. Based on these assumptions and data, the distribution of project benefits was estimated.
I t was found that the Project covered more than 5 mill ion people (about 40 percent of the totalpopulation of Cambodia). The poor made up 36 percent of the project area population and the near-poor made up about another 40 percent. Thus, about three-quarters of the project areas populationwas poor or near-poor. The Project was designed to direct a disproportionate amount of the benefits tothe poor segment population and it is estimated that these people would capture at least 47 percent ofthe project benefits. Since health problems are normally considered one of the main causes of poverty,the Project would also reduce the number of people falling into poverty.
I t was estimated that about 92 percent of the beneficiaries (4 .2 million people) will come fromthe rural areas. By strengthening safe-motherhood services, improving antenatal care, and providingemergency obstetric facilities, the Project is expected to improve access to quality health service for2.5 million women, or about half of the women in the project area. The Project is also expected to havea major impact on improving the health status of ethnic minorities in the provinces of M ondol Kiri andRatt anak Kiri, which are among the poorest in the country, through measures that bridge linguistic and
cultural gaps.
IV. FINANCIAL SUSTAINABILITYOF THE HEALTH SECTOR AND PROJECT
A. Fiscal Sustainability
The sustainability of the health care system is a serious concern for the government. Cambodiais still in the process of reconstructing its economy and its health care system and, as a result, the
amount of resources available for all sectors (including health) is quite limited. Although the healthneeds of the country are great, any investment in the health system must be sustainable, in the long run,with domestic resources. I t is estimated that a basic package of publicly provided services costs be-tween $12 (World Development Report 1993) to $24 ( M acroeconomics and Health Report 20 01 ) .
Cambodia is unusual among Asian countries with a large share of spending on health, cur-rently accounting for an estimated 12 percent of the GDP. Of this, the largest percentage comes from
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household expenditures at 83 percent. The governments contribution to total health care is estimatedat be 5 percent and development partners for the remaining 12 percent of the total. The governmentseffort is severely limited by its narrow revenue base, currently accounting for around 12 percent ofGDP.
While the private sector is an important source of health care services in Cambodia, moststudies suggest that the countrys overreliance on the private sector has serious negative consequenceson efficiency because of a lack of supervision and regulation. The private sector relies heavily on theprescription of drugs that are often not appropriate and often of poor quality. I n addition to concernsabout the efficiency of private health care, there are serious equity issues associated with high privatecosts and a weak social safety net associated with private health care. Health interventions that havea strong public good component generally require government support.2
The health sector is largely dependent on international support and patients for financing.Patients often have limited information about their health care options and the government can playan important role in providing health services that are low-cost and effective. A large proportion ofinternational resources goes to capacity building and capital expenditures which, while important, donot directly contribute to providing basic health care.
The Government of Cambodia currently does not have the resources to sustain the healthsector on its own. With a budget between $2 to $3 per capita, government spending is well below therecommended targets for health spending. Given Cambodias low income and small revenue base, thecountry will have to depend on international assistance for several more years. Nevertheless, Cambo-dia will have to develop an exit strategy to ensure that the health sector will function when interna-tional support eventually is reduced. I t wi ll also have to develop a strategy to better target privatehealth care spending.
The Government of Cambodia allows user fees to be charged, the level of which are officiallygoverned by the health financing charter. The charter establishes national fees for services and autho-rizes that 99 percent of the revenues generated from the fees remain with the health service provider(health center or hospital) to provide incentives to health workers to improve the quality of services.The remaining one percent is transferred to the provincial government. I n practice, user fees are
normally charged, but many health workers also collect unauthorized fees to supplement their rela-tively small official salaries. In distr icts where nongovernmental organizations are contracted to man-age health services, local health care providers have more flexibility and autonomy in the collection ofuser fees. In some cases, for example, tuberculosis treatment, there is no fee charged because thegovernment subsidizes the entire cost.
Currently, primary health care is funded by the government budget, user fees, and donors.Figure 1 estimates the total contribution from all three sources based on a number assumptions aboutthe size and direction of these financing sources. The assumptions are as follows.
(i) The economy will grow at a moderate rate of 5.5 percent and the populationwill grow at the current rate of about 1.7 percent. The projected economicgrowth rate is below the current t rend but is consistent with the long-term growthrate of the country.
( ii) The proportion of the economy accounted for by government expenditure willgrow moderately to about 18.7 percent of GDP in 2015. The health sector will
2 This includes both pure public goods (for example, vector control and disease monitoring) and goods with high publicexternalities (for example, vaccination coverage and control of tuberculosis).
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account for 10 percent of total government spending. Some of this expenditurewill be for administrative costs and for higher-level services.
( iii ) Donor financing will drop off sharply over the period 2001 to 201 5. Given thatdonors primarily finance capital spending and capacity building, only part ofdonor financing will support basic primary health care.
( iv) Currently, household spending for health is relatively inefficient because of alack of information and alternatives. Over time, households will learn to betterallocate their resources for basic primary health care.
On the basis of these assumptions, Cambodia should be able to meet the basic primary healthcare target of $12 per capita by 2010, relying almost entirely on domestic resources. These assump-tions are conservative and the country may be able to reach this target earlier. Cambodia alreadyspends substantially more than $12 per capita on health care, largely through household financing oflow-quality private services. Were this spending better utilized, Cambodia would already be aboveinternational guidelines for basic health care. With the long-term increase in education and withimprovements in the health care system, it is possible that household spending will have a morepositive impact on health.
Donor Contribution Government ContributionUser Fees
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Year
Spendingonprimaryhealth
$24
$12
$-
Figure 1: Estimated Spendingon Basic Primary Health Care
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B. Project Sustainability
One of the goals of the Project is to increase the efficiency of health care spending while atthe same time increasing the affordability of health care. By focusing on health system managementand development, the Project generates user fees more efficiently, contributing to the sustainability ofthe Project by providing additional resources to finance recurrent and other costs. Consumers currentlyspend enough to ensure that the health system has sufficient resources to provide basic health servicesfor al l. I mproving the efficiency of consumer health care spending wil l also increase the sustainabilityof the health sector and contribute to Cambodias long-term development.
The financial impact of the Project on governments health spending will be felt in severalareas. Contracting of health services requires at some point that the government either take over thecontract (putting the contract on its own budget) or replace the contract service with its own publiclyorganized services. The construction of new civil works and the provision of equipment will requireadditional spending on maintenance. While these costs are modest, they will require a commitment onthe part of the government to ensure that the benefits of the investment are not lost.
The Project is part of a larger health sector reform program with the World Bank and DFI D
also providing funding for specific components. The ADB/DF I D component of the P roject wil l introduceabout $4.2 million per year in incremental recurrent costs. On the basis that this amount is 1/3 of thetotal incremental recurrent costs, the total additional resources needed for financing recurrent costs in2008 will be $12.6 million per year. The overall budgetary allocation to the health sector in Figure 1shows that the government should expect an increase of its health sector budget from $43 million in2003 to $68 million in 2008. This increase of $25 million will be more than sufficient to cover com-pletely the additional costs introduced by the Project. Although future ADB assistance is likely neces-sary for the health sector, following current trends Cambodia is in a good position to ensure thesustainability of the Project.
IV. CONCLUSIONSThis technical note demonstrates how an economic analysis of a health project may be under-
taken. The analysis began with establishing a sound rationale for the proposed project, then confirmedthe cost effectiveness of the approach taken to achieve the objectives of the project. Cost effectivenesswas based on a least cost analysis in which all feasible alternatives were examined. The least costalternative was further examined in terms of the returns it was expected to generate with respect tothe economic resources invested. This step involved the identification and valuation of economic ben-efits that the proposed project is expected to create. Economic benefits are usually resource costsavings and productivity gains, but there may be other positive externalities that could be valued andincluded in the analysis as well . The estimated EI RR was estimated in excess of 30 percent.
The economic benefits that health projects are expected to generate will be realized only ifthe project is sustainable over its lifetime. The key issues regarding sustainability are the institutionaland financial capacity of the government to ensure that staff has the skills and training to operate,maintain, and administer the Project, and that financial resources are available to fund the recurrentcosts that will be incurred in the future. The project design is a key factor that will prevent institutionalshortcomings from impeding the operation of the project facilities. The contracting of services to
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Jere R. Behrman, Anil B. Deolalikar, and Lee-
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No. 24 Financia l Opening under the WTO Agreement in
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Arsenio M. Balisacan, Ernesto M. Pernia,
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No. 26 Causes of the 1997 Asian Financia l Cr is i s: What
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Juzhong Zhuang and J. Malcolm DowlingOctober 2002
No. 27 Digital Divide: Determinants and Policies with
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M. G. Quibria, Shamsun N. Ahmed, Ted
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October 2002
No. 28 Regional Cooperat ion in Asia: Long-term Progress,
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Arvind Panagariya, November 2001
N o. 3 U nequal Bene fi ts of Gr ow th i n Vie t Nam
Indu Bhushan, Erik Bloom, a n d Nguyen Minh
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No. 4 Is Volat i li ty Buil t into Todays World Economy?
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Arsenio M. Balisacan and Ernesto M. Pernia,
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Christopher Edmonds and Jean-Pierre Verbiest,
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E. M. Pernia and P. F. QuisingOctober 2002
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N o. 12 D ange r s of D efl at ion
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February 2002
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July 2002
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No. 2 Development I ssues for the Developing East
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Seiji Naya and Graham Abbott, April 1982
No. 3 Aid, Savings, and Growth in the Asian Region
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N o. 4 D evel opm en t -or ien t ed Fo re ign I nvest m en t
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N o. 9 Sm all and Medium -Sca le Manufact u r ing
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Mathias Bruch and Ulrich Hiemenz,
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No. 10 A Note on the Third Ministerial Meeting of GATT
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Seiji Naya, March 1983
No. 13 The Future Prospect s for the Developing
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Seiji Naya, March 1983
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Wisarn Pupphavesa, June 1983
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J.M. Dowling, E. Go, and C.N. Castillo,
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J.M. Dowling, H.Y. Kim, Y.K. Wang,
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No. 19 Rela t ive External Debt Si tua t ion of Asian
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William James and Teresita Ramirez, July 1983
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Pradumna B. Rana and J. Malcolm Dowling,
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S eiji Naya, Decem ber 1983
No. 23 Changing Trade Pat terns and Pol icy Issues :
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Seiji Naya and Ulrich Hiemenz, February 1984
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Seiji Naya, February 1984
No. 25 A Study on the External Debt Indica tors
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Jungsoo Lee and Clarita Barretto,
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No. 26 Al ternat ives to Ins t itu t ional Credit Programs
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Jennifer Sour, March 1984
No. 27 Economic Scene in Asia and I ts Special Features
Kedar N. Kohli, November 1984
No. 28 The Effect of Terms of Trade Changes on the
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Jungsoo Lee and Lutgarda Labios, January 1985
No. 29 Cause and Effect in the Wor ld Sugar Market :
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Yoshihiro Iwasaki, February 1985
No. 30 Sources of Balance of Payments Problem
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Pradumna Rana, February 1985
No. 31 Indias Manufactured Exports: An Analysis
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Ifzal Ali, February 1985
No. 32 Meet ing Bas ic Human Needs in Asian
Developing Countries
Jungsoo Lee and Emma Banaria, March 1985
No. 33 The Impact of Fore ign Capita l Inflow
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Evelyn Go, May 1985
No. 34 The Climate for Energy Development
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V.V. Desai, April 1986
No. 35 Impact of Appreciat ion of the Yen on
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No. 36 Smuggling and Domestic Economic Policies
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A.H.M.N. Chowdh ury, October 1986
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Ifzal Ali, November 1986
No. 38 Review of the Theory of Neoclassical Polit ical
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M.G. Quibria , December 1986
No. 39 Factors Influencing the Choice of Location:
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E.M. Pernia and A.N. Herrin, February 1987
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N o. 1 I n te rn a tion a l Re se rve s:
Factors Determining Needs and Adequacy
Evelyn Go, May 1981
No. 2 Domest ic Savings in Selected Developing
Asian Countries
Basil Moore, assisted by
A.H.M. Nuruddin Chowdhury, September 1981
No. 3 Changes in Consumpt ion, Impor t s and Expor t s
of Oil Since 1973: A Preliminary Survey of
the Developing Member Countries
of the Asian Development Bank
Dal Hyun Kim and Graham Abbott,
September 1981
No. 4 By-Passed Areas , Regional Inequal it i es ,
and Development Policies in Selected
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William James, October 1981
No. 5 Asian Agr icul ture and Economic Development
William James, March 1982
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A.H.M. Nuruddin Chowdhury a n d
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Developing Asian Countries: Issues and
EC ONOMIC STAFF P AP ER S (ES)
Perspectives for the Coming Decade
Ulrich Hiemenz, March 1982
No. 8 Pet rodol lar Recycl ing 1973-1980.
Part 1: Regional Adjustments and
the World Economy
Burnham Campbell, April 1982
No. 9 Developing Asia : The Impor tance
of Domestic Policies
Economics Office Staff under the direction
of Seiji Naya, May 1982
No. 10 Financia l Development and Household
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Wan-Soon Kim, July 1982
No. 11 Industr ial Development: Role of Special ized
Financial Institutions
Kedar N. Kohli, August 1982
No. 12 Pet rodol lar Recycl ing 1973-1980.
Part II : Debt Problems and an Evaluation
of Suggested Remedies
Burnham Campbell, September 1982
No. 13 Credit Rat ioning, Rura l Savings , and Financia l
Policy in Developing Countries
William James, September 1982
No. 14 Small and Medium-Scale Manufactur ing
No. 42 Shi ft ing Revealed Compara t ive Advantage:
Experiences of Asian and Pacific Developing
Countries
P.B. Rana, November 1988
No. 43 Agr icul tura l Pr ice Pol icy in Asia :
Issues and Areas of Reforms
I. Ali, November 1988
No. 44 Service Trade and Asian Developing Economies
M.G. Quibria, October 1989
No. 45 A Review of the Economic Analysis of Power
Projects in Asia and Identification of Areas
of Improvement I. Ali, November 1989
No. 46 Growth Perspect ive and Challenges for Asia :
Areas for Policy Review and Research
I. Ali, November 1989
No. 47 An Approach to Es t imat ing the Pover ty
Alleviation Impact of an Agricultural Project
I. Ali, January 1990
No. 48 Economic Growth Performance of Indonesia,
the Philippines, and Thailand:
The Human Resource Dimension
E.M. Pernia, January 1990
No. 49 Foreign Exchange and Fiscal Impact of a Project :
A Methodological Framework for Estimation
I. Ali, February 1990
No. 50 Public Inves tment Cr i ter ia : Financia l
and Economic Internal Rates of Return
I. Ali, April 1990No. 51 Evaluat ion of Water Supply Project s :
An Economic Framework
Arlene M. Tadle, June 1990
No. 52 Interrelat ionship Between Shadow Prices, Project
Investment, and Policy Reforms:
An Analytical Framework
I. Ali, November 1990
No. 53 Issues in Assessing the Impact of Project
and Sector Adjustment Lending
I. Ali, Decem ber 1990
No. 54 Some Aspects of Urbaniza t ion
and the Environment in Southeast Asia
Ernesto M. Pernia, January 1991
No. 55 Financia l Sector and Economic
Development: A Survey
Ju ngsoo Lee, Septem ber 1991
No. 56 A Framework for J us t ify ing Bank-Ass is ted
Education Projects in Asia: A Review
of the Socioeconomic Analysis
and Identification of Areas of Improvement
Etienne Van De Walle, February 1992
No. 57 Medium-term Growth-Stabil iza t ion
Relationship in Asian Developing Countries
and Some Policy Considerations
Yun-Hwan Kim, February 1993No. 58 Urbaniza t ion, Popula t ion Dis t r ibut ion,
and Economic Development in Asia
Ernesto M. Pernia, February 1993
No. 59 The Need for Fi sca l Consol ida t ion in Nepal:
The Results of a Simulation
Filippo di Mauro and Ronald Antonio Butiong,
July 1993
No. 60 A Computable Genera l Equil ibr ium Model
of Nepal
Timothy Buehrer and Filippo di Mauro,
October 1993
No. 61 The Role of Government in Export Expansion
in the Republic of Korea: A Revisit
Yun-Hwan Kim, February 1994
No. 62 Rural Reforms, St ructura l Change,
and Agricultural Growth in
the Peoples Republic of China Bo Lin, August 1994
No. 63 Incentives and Regulat ion for Pollut ion Abatement
with an Application to Waste Water Treatment
Sudipto Mundle, U. Shankar,
and Shekhar Mehta, October 1995
No. 64 Saving Transi t ions in Southeast Asia
Frank Harrigan, February 1996
No. 65 Tota l Factor Product ivi ty Growth in Eas t Asia :
A Critical Survey
Jesus Felipe, September 1997
No. 66 Fore ign Direct Inves tment in Pakis tan:
Policy Issues and Operational Implications
Ashfaque H. Khan and Yun-Hwan Kim,
July 1999
No. 67 Fiscal Policy, Income Distr ibution and Growth
Sailesh K. Jha, November 1999
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Establishments in ASEAN Countries:
Perspectives and Policy Issues
Mathias Bruch and Ulrich Hiemenz, March 1983
No. 15 Income Dist r ibut ion and Economic
Growth in Developing Asian Countries
J. Malcolm Dowling and David Soo, March 1983
No. 16 Long-Run Debt-Servicing Capacity of
Asian Developing Countries: An Application
of Critical Interest Rate Approach
Jungsoo Lee, June 1983
No. 17 External Shocks , Energy Pol icy ,
and Macroeconomic Performance of AsianDeveloping Countries: A Policy Analysis
William James, July 1983
No. 18 The Impact of the Current Exchange Rate
System on Trade and Inflation of Selected
Developing Member Countries
Pradumna Rana, September 1983
No. 19 Asian Agriculture in Transit ion: Key Policy Issues
William James, September 1983
No. 20 The Trans it ion to an Indust r ia l Economy
in Monsoon Asia
Harry T. Oshi m a, October 1983
No. 21 The Significance of Off-Farm Employment
and Incomes in Post-War East Asian Growth
Harry T. Oshima, January 1984
No. 22 Income Dis t r ibut ion and Pover ty in Selected
Asian Countries
John Malcolm Dowling, Jr., November 1984No. 23 ASEAN Economies and ASEAN Economic
Cooperation
Narongchai Akr asanee, Novem ber 1984
No. 24 Economic Analysis of Power Projects
Nitin Desai, January 1985
No. 25 Exports and Economic Growth in the Asian Region
Pradumna Rana, February 1985
No. 26 Pat terns of External Financing of DMCs
E. Go, May 1985
No. 27 Indus tr ia l Technology Development
the Republic of Korea
S.Y. Lo, Ju ly 1985
No. 28 Risk Analys is and Project Select ion:
A Review of Practical Issues
J.K. Johnson, August 1985
No. 29 Rice in Indonesia: Price Policy and Comparat ive
Advantage I. Ali, January 1986
No. 30 Effect s of Fore ign Capi ta l Inflows
on Developing Countries of Asia
Jungsoo Lee, Pradumna B. Rana,
and Yoshihiro Iwasaki, April 1986
No. 31 Economic Analys is of the Environmenta l
Impacts of Development Projects
John A. Dixon et al., EAPI,
East-West Center, August 1986
No. 32 Science and Technology for Development:
Role of the Bank
Kedar N. Kohli and Ifzal Ali, November 1986
No. 33 Satel li t e Remote Sens ing in the Asian
and Pacific Region
Mohan Sundara Rajan, December 1986
No. 34 Changes in the Expor t Pat terns of Asian and
Pacific Developing Countries: An EmpiricalOverview
Pradumna B. Rana, January 1987
No. 35 Agr icul tura l Pr ice Pol icy in Nepal
Gerald C. Nelson, March 1987
No. 36 Implica t ions of Fall ing Pr imary Commodity
Prices for Agricultural Strategy in the Philippines
Ifzal Ali, S eptem ber 1987
No. 37 Determining Ir r iga t ion Charges : A Framework
Prabhakar B. Ghate, October 1987
No. 38 The Role of Fert i lizer Subsidies in Agricultural
Production: A Review of Select Issues
M.G. Quibria, October 1987
No. 39 Domest ic Adjus tment to External Shocks
in Developing Asia
Ju ngsoo Lee, October 1987
No. 40 Improving Domestic Resource Mobilizat ion
through Financial Development: Indonesia
Philip Erquiaga, November 1987
No. 41 Recent Trends and I ssues on Foreign Direct
Investment in Asian and Pacific Developing
Countries
P.B. Rana, March 1988
No. 42 Manufactured Expor t s from the Phi lippines :
A Sector Profile and an Agenda for Reform I. Ali, September 1988
No. 43 A Framework for Evaluat ing the Economic
Benefits of Power Projects
I. Ali, August 1989
No. 44 Promot ion of Manufactured Expor t s in Pakis tan
Jungsoo Lee and Yoshihiro Iwasaki,
September 1989
No. 45 Educat ion and Labor Markets in Indones ia :
A Sector Survey
Ernesto M. Pernia and David N. Wilson,
September 1989
No. 46 Indust r ia l Technology Capabi li t ies
and Policies in Selected ADCs
Hiroshi Kakazu, June 1990
No. 47 Designing St ra tegies and Pol icies
for Managing Structural Change in Asia
Ifzal Ali, June 1990No. 48 The Complet ion of the Single European Commu-
nity Market in 1992: A Tentative Assessment of
its Impact on Asian Developing Countries
J.P. Verbiest and Min Tang, June 1991
No. 49 Economic Analysis of Investment in Power
Systems
Ifzal Ali, June 1991
No. 50 External Finance and the Role of Mul t il a tera l
Financial Institutions in South Asia:
Changing Patterns, Prospects, and Challenges
Ju ngsoo Lee, November 1991
No. 51 The Gender and Pover ty Nexus : I ssues and
Policies
M.G. Quibria, November 1993
No. 52 The Role of the State in Economic Development:
Theory, the East Asian Experience,
and t he Malaysian Case Jas on Brown , Decem ber 1993
No. 53 The Economic Benefi ts of Potable Water Supply
Projects to Households in Developing Countries
Dale Whittington and Venkateswarlu Swarna,
January 1994
No. 54 Growth Tr iangles : Conceptual I ssues
and Operational Problems
Min Tang and Myo Thant, February 1994
No. 55 The Emerging Global Trading Environment
and Developing Asia
Arvind Panagariya, M.G. Quibria,
and Narhari Rao, July 1996
No. 56 Aspects of Urban Water and Sani ta t ion in
the Context of Rapid Urbanization in
Developing Asia
Ernesto M. Pernia and Stella LF. Alabastro,
September 1997No. 57 Challenges for Asias Trade and Environment
Douglas H. Brooks, January 1998
No. 58 Economic Analysis of Health Sector Projects-
A Review of Issues, Methods, and Approaches
Ramesh Adhikari, Paul Gertler, and
Anneli Lagman, March 1999
No. 59 The Asian Cr is is : An Al ternate View
Rajiv Kumar and Bibek Debroy, July 1999
No. 60 Social Consequences of the Financial Crisis in
Asia
James C. Knowles, Ernesto M. Pernia, and
Mary Racelis, November 1999
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N o. 1 Es t im a t es of t he Tot a l Ext e rna l D eb t of
the Developing Member Countries of ADB:
1981-1983
I.P. David , Septem ber 1984
N o. 2 Mult iva ri at e S t a t is t ica l and G raph ica l
Classification Techniques Applied
to the Problem of Grouping Countries
I.P. David and D.S. Maligalig, March 1985
N o. 3 G r os s Na t iona l P r oduct (G NP) Meas u rem en t
Issues in South Pacific Developing Member
Countries of ADB
S.G. Tiwari, September 1985
N o. 4 Es t im a t es of Com parab le Savi ngs i n Sel ect ed
DMCs
Hananto S igit, December 1985
N o. 5 K ee pin g Sa m ple S ur ve y De sign
and Analysis Simple
I.P. David, December 1985
N o. 6 E xt er n al De bt S it u at ion in As ia n
Developing Countries
I.P. David and Jungsoo Lee, March 1986
N o. 7 S tu d y of GN P Me as ur em en t I ss ue s in t h e
South Pacific Developing Member Countries.
Part I: Existing National Accounts
of SPDMCsAnalysis of Methodology
and Application of SNA Concepts
P. Hodgkinson, October 1986
N o. 8 S t udy of G NP Meas u r em en t I ss ues in t he Sou t h
Pacific Developing Member Countries.
Part II: Factors Affecting Intercountry
Comparability of Per Capita GNP
P. Hodgkinson, October 1986
N o. 9 Survey of t he Ext er na l D eb t Sit ua ti on
in Asian Developing Countries, 1985
Jungsoo Lee and I.P. David, April 1987
No. 10 A Survey of the External Debt Si tua t ion
in Asian Developing Countries, 1986
Jungsoo Lee and I.P. David, April 1988
No. 11 Changing Pat tern of Financia l Flows to Asian
and Pacific Developing Countries
Jungsoo Lee and I.P. David, March 1989
No. 12 The Sta te of Agr icul tura l Sta t is t ics in
Southeast Asia
I.P. David, March 1989
No. 13 A Survey of the External Debt Si tua t ion
in Asian and Pacific Developing Countries:
1987-1988
Jungsoo Lee and I.P. David, July 1989
No. 14 A Survey of the External Debt Situa t ion in
Asian and Pacific Developing Countries: 1988-1989
Ju ngsoo Lee, May 1990
STATISTIC AL R EP OR T SER IE S (SR )
No. 1 Pover ty in the Peoples Republ ic of China:
Recent Developments and Scope
for Bank Assistan ce
K.H. Moinuddin, November 1992
No. 2 The Eas tern I s lands of Indones ia : An Overview
of Development Needs and Potential
Brien K. Parkinson, January 1993
N o. 3 R ur a l I n st it u t iona l F inance in B ang lades h
and Nepal: Review and Agenda for Reforms A.H.M.N. Chowdhury and Marcelia C. Garcia,
November 1993
No. 4 Fisca l Defici t s and Current Account Imbalances
of the South Pacific Countries:
A Case Study of Vanuatu
T.K. Jayaraman, December 1993
No. 5 Reforms in the Transi t ional Economies of Asia
Pradumna B. Rana, December 1993
No. 6 Environmenta l Challenges in the Peoples Republ ic
of China and Scope for Bank Assistance
Elisabetta Capannelli and Omkar L. Shrestha,
December 1 993
N o. 7 Sust a inab le D evel opm en t Envi ronm en t
and Poverty Nexus
K.F. Jalal, December 1993
N o. 8 I n t er m ed ia t e Se rv ice s and Econom ic
Development: The Malaysian ExampleSutanu Behuria and Rahul Khullar, May 1994
N o. 9 I n t er e st R a t e D er egu la t ion : A B ri ef Su r vey
of the Policy Issues and the Asian Experience
Carlos J. Glower, July 1994
No. 10 Some Aspects of Land Adminis t ra t ion
in Indonesia: Implications for Bank Operations
Sutanu Behuria, July 1994
No. 11 Demographic and Socioeconomic Determinants
of Contraceptive Use among Urban Women in
the Melanesian Countries in the South Pacific:
A Case Study of Port Vila Town in Vanuatu
T.K. Jayaraman, February 1995
N o. 12 Manag ing Deve lopm en t t h r ough
Institution Building
Hilton L. Root, October 1995
N o. 13 G r ow th , S tr uct u r a l Change , and O pt im a l
Poverty Interventions
S hiladitya Chatterjee, November 1995
No. 14 Pr ivate Inves tment and Macroeconomic
Environment in the South Pacific Island
Countries: A Cross-Country AnalysisT.K. J ayaraman , October 1996
No. 15 The Rura l-Urban Trans it ion in Viet Nam:
Some Selected Issues
Sudipto Mundle and Brian Van Arkadie,
October 1997
No. 16 A New Approach to Set ting the Future
Transport Agenda
Roger Allport, Geoff Key, and Charles Melhuish
June 1998
N o. 17 Adjus t men t and Di st r ibu t ion :
The Indian Experience
Sudipto Mundle and V.B. Tulasidhar, June 1998
No. 18 Tax Reforms in Viet Nam: A Selective Analysis
Sudipto Mundle, December 1998
No. 19 Surges and Volat i li ty of Private Capital Flows to
Asian Developing Countries: Implications
for Multilateral Development BanksPradumna B. Rana, December 1998
No. 20 The Mi llennium Round and the Asian Economies :
An Introduction
Dilip K. Das, October 1999
No. 21 Occupat ional Segregat ion and the Gender
Earnings Gap
Joseph E. Zveglich, Jr. and Yana van der Meulen
Rodgers , December 1999
No. 22 Information Technology: Next Locomotive of
Growth?
Dilip K. Das, June 2000
OCCASIONAL PAPERS (OP)
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No. 15 A Survey of the External Debt Si tuat ion
in Asian and Pacific Developing Countrie
s: 1989-1992
Min Tang, June 1991
No. 16 Recent Trends and Prospect s of External Debt
Situation and Financial Flows to Asian
and Pacific Developing Countries
Min Tang and Aludia Pardo, June 1992
No. 17 Purchas ing Power Par i ty in Asian Developing
Countries: A Co-Integration Test
Min Tang and Ronald Q. Butiong, April 1994
No. 18 Capital Flows to Asian and Pacific Developing
Countries: Recent Trends and Future Prospects
Min Tang and James Villafuerte, October 1995
1. Improving Domestic Resource Mobilizat ion Through
Financial Development: Overview S eptember 1985
2. Improving Domestic Resource Mobilizat ion Through
Finan cial Development: Bangladesh Ju ly 1986
3. Improving Domestic Resource Mobilizat ion Through
Financial Development: Sri Lanka April 1987
4. Improving Domestic Resource Mobilizat ion Through
Financial Development: India Decem ber 1987
5. Financing Public Sector Development Expenditure
in Selected Countries: Overview January 1988
6. Study of Selected Industr ies: A Brief Report
April 1988
7. Financing Public Sector Development Expenditure
in Selected Countries: Bangladesh June 1988
8. Financing Public Sector Development Expenditure
in Selected Countries: India June 1988
9. Financing Public Sector Development Expenditure
in Selected Countries: Indonesia June 1988
10. Financing Public Sector Development Expenditure
in Selected Countries: Nepal June 1988
11. Financing Public Sector Development Expenditure
in Selected Countries: Pakistan June 1988
12. Financing Public Sector Development Expenditure
in Selected Countries: Philippines June 1988
13. Financing Public Sector Development Expenditure
in Selected Countries: Thailand June 1988
14. Towards Regional Cooperat ion in South Asia:
ADB/EWC Symposium on Regional Cooperation
in South Asia February 1988
15. Evaluating Rice Market Intervention Policies:
Some Asian Examples April 1988
16. Improving Domestic Resource Mobilization Through
Finan cial Development: Nepa l Novem ber 1988
17. Foreign Trade Barriers and Export Growth
September 1988
18. The Role of Small and Medium-Scale Industr ies in the
Industrial Development of the Philippines
April 1989
19. The Role of Small and Medium-Scale Manufacturing
Industries in Industrial Development: The Experience
of Selected Asian Countries
January 1990
20. National Accounts of Vanuatu , 1983-1987
January 1990
21. National Accounts of Western Samoa, 1984-1986
February 1990
22. Human Resource Policy and Economic
Development: Selected Country Studies
July 1990
23. Export Finance: Some Asian Examples
September 1990
24. National Accounts of the Cook Islands, 1982-1986
September 1990
25. Framework for the Economic and Financial Appraisal
of Urban Development Sector Projects January 1994
26. Framework and Cri teria for the Appraisal
and Socioeconomic Justification of Education Projects
January 1994
27. Invest ing in Asia
Co-published with OECD, 1997
28. The Future of Asia in the World Economy
Co-published with OECD, 1998
29. Financial Liberal isat ion in Asia: Analysis an d Prospects
Co-published with OECD, 1999
30. Susta inable Recovery in Asia: Mobilizing Resources for
Development
Co-published with OECD, 2000
31. Technology and Poverty Reduction in Asia an d the Pa cific
Co-published with OECD, 2001
32. Guidelines for th e Economic Analysis of
Telecommun ications Projects
Asian Development Ba nk , 1997
33. Guidelines for the Economic Analysis of Water Su pply
Projects
Asian Development Ba nk , 1998
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Asian Development Bank, 1993
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Prabhu Ghate et. al., 1992
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