Economic Analysis of Health Projects

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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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ERD Technical Note No. 6Economic Analysis of Health Projects: A Case Study in Cambodia

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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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May 2003Erik Bloom and Peter Choynowski

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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 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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13

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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15

PUBLICATIONS FROM THE

ECONOMICS AND RESEARCH DEPARTMENT

ERD WORKING PAPER SERIES (WPS)

(Published in-house; Available through ADB Office of External Relations; Free of Charge)

N o. 1 C api ta li zi ng on Gl oba li za t ion

Barry Eichengreen, January 2002

No. 2 Policy-based Lending and Pover ty Reduct ion:

An Overview of Processes, Assessment

and Options

Richard Bolt and Manabu Fujimura

January 2002

No. 3 The Automot ive Supply Chain: Global Trends

and Asian Perspectives

Francisco Veloso and Rajiv Kumar

January 2002

N o. 4 I n t er na t iona l Com pet it iveness of As ian F i r ms :

An Analytical Framework

Rajiv Kumar and Doren Chadee

February 2002N o. 5 The In t er na t iona l Com pet it iveness of As ian

Economies in the Apparel Commodity Chain

Gary Gereffi

February 2002

N o. 6 Mone ta r y and F inancia l Cooper a t ion i n Eas t

AsiaThe Chiang Mai Initiative and Beyond

Pradumna B. Rana

February 2002

No. 7 Probing Beneath Cross-nat ional Averages : Pover ty ,

Inequality, and Growth in the Philippines

Arsenio M. Balisacan and Ernesto M. Pernia

March 2002

N o. 8 Pover t y, Gr ow t h, and I nequal it y in Tha il and

Anil B. Deolalikar

April 2002

No. 9 Microfinance in Nor theast Thailand: Who Benefi t s

and How Much? Brett E. Coleman

April 2002

No. 10 Poverty Reduction and the Role of Inst i tut ions in

Developing Asia

Anil B . Deolalikar, Alex B. Brilliant es, Jr.,

Raghav Gaiha, Ernesto M. Pernia, Mary Racelis

with the assistance of Marita Concepcion Castro-

Guevara, Liza L. Lim, Pilipinas F. Quising

May 2002

No. 11 The European Social Model: Lessons for

Developing Countries

Assar Lindbeck

May 2002

No. 12 Costs and Benefi ts of a Common Currency for

ASEAN

Srinivasa Madh ur

May 2002No. 13 Monetary Cooperat ion in East Asia: A Survey

Raul Fabella

May 2002

No. 14 Toward A Poli t ical Economy Approach

to Policy-based Lending

George Abonyi

May 2002

No. 15 A Framework for Es tabli shing Pr ior i t ies in a

Country Poverty Reduction Strategy

Ron Duncan and Steve Pollard

June 2002

No. 16 The Role of Infrastructure in Land-use Dynamics

an d Rice Production in Viet Na ms Mekong River

Delta

Christopher Edmonds

July 2002

No. 17 Effect of Decent ra li za t ion St ra tegy on

Macroeconomic Stability in Thailand

Kanokpan Lao-Araya

August 2002

N o. 18 Pover t y and Pa t t er ns of Gr ow th

Rana Hasan and M. G. Quibria

August 2002

No. 19 Why are Some Count r ies Richer than Others?

A Reassessm ent of Mankiw-Romer-Weils Test of

the Neoclassical Growth Model Jesus Felipe and John McCombie

August 2002

No. 20 Modernizat ion and Son Preference in Peoples

Republic of China

Robin Burgess and Juzhong Zhuang

September 2002

No. 21 The Doha Agenda and Development: A View from

the Uruguay Round

J. Michael Finger

September 2002

No. 22 Conceptual Issues in the Role of Education

Decentralization in Promoting Effective Schooling

in Asian Developing Countries

Jere R. Behrman, Anil B. Deolalikar, and Lee-

Ying Son

September 2002

No. 23 Promoting Effect ive Schooling through EducationDecentralization in Bangladesh, Indonesia, and

Philippines

Jere R. Behrman, Anil B. Deolalikar, and Lee-

Ying Son

September 2002

No. 24 Financia l Opening under the WTO Agreement in

Selected Asian Countries: Progress and Issues

Yun-Hwan Kim

September 2002

No. 25 Revisit ing Growth and Poverty Reduction in

Indonesia: What Do Subnational Data Show?

Arsenio M. Balisacan, Ernesto M. Pernia,

and Abuzar Asra

October 2002

No. 26 Causes of the 1997 Asian Financia l Cr is i s: What

Can an Early Warning System Model Tell Us?

Juzhong Zhuang and J. Malcolm DowlingOctober 2002

No. 27 Digital Divide: Determinants and Policies with

Special Reference to Asia

M. G. Quibria, Shamsun N. Ahmed, Ted

Tschang, and Mari-Len Reyes-Macasaquit

October 2002

No. 28 Regional Cooperat ion in Asia: Long-term Progress,

Recent Retrogression, and the Way Forward

Ramgopal Agarwala and Brahm Prakash

October 2002


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ERD POLICY BRIEF SERIES (PBS)

(Published in-house; Available through ADB Office of External Relations; Free of charge)

N o. 1 I s Gr ow th G ood Enough for t he Poor ?

Ernesto M. Pernia, October 2001

N o. 2 I ndi as Econom ic R efor m s

What Has Been Accomplished?

What Remains to Be Done?

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

Thang, January 2002

No. 4 Is Volat i li ty Buil t into Todays World Economy?

J. M alcolm Dowling and J.P. Verbiest,

February 2002N o. 5 Wha t E ls e B es ides Gr ow th Ma tt e rs t o Pover t y

Reduction? Philippines

Arsenio M. Balisacan and Ernesto M. Pernia,

February 2002

No. 6 Achieving the Twin Object ives of Efficiency and

Equity: Contracting Health Services in Cambodia

Indu Bhushan, Sheryl Keller, and Brad

Schwartz,March 2002

N o. 7 C auses of t he 1997 As ian F i nanci al Cr is is : Wha t

Can an Early Warning System Model Tell Us?

Juzhong Zhuang and Malcolm Dowling,

June 2002

No. 8 The Role of Preferent ia l Trading Arrangements

in Asia

Christopher Edmonds and Jean-Pierre Verbiest,

July 2002

No. 9 The Doha Round: A Development Perspect ive

Jean-Pierre Verbiest, Jeffrey Liang, and Lea

Sumulong

July 2002

No. 10 Is Economic Openness Good for Regional

Development and Poverty Reduction? The

Philippines

E. M. Pernia and P. F. QuisingOctober 2002

No. 11 Implicat ions of a US Dollar Depreciat ion for Asian


Emm a Fan

July 2002

N o. 12 D ange r s of D efl at ion

D. Brooks and P. F. Quising

December 2002

No. 13 Infras t ructure and Pover ty Reduct ion

What is the Connection?

I. Ali and E. Pernia

January 2003

ERD TECHNICAL NOTE SERIES (TNS)


No. 1 Cont ingency Calcula t ions for Envi ronmenta l

Impacts with Unknown Monetary Values

David Dole

February 2002

No. 2 Integrat ing Risk into ADBs Economic Analysis

of Projects

Nigel Rayner, Anneli Lagman-Martin,

and Keith Ward

June 2002

No. 3 Measur ing Wi ll ingness to Pay for Elect r ici ty

Peter Choynowski

July 2002

No. 4 Economic I ssues in the Des ign and Analys is of a

Wastewater Treatment Project

David Dole

July 2002

No. 6 Economic Analys is of Health Project s : A Case Study

in Cambodia

Erik Bloom and Peter Choynowski

May 2003

No. 29 How can Cambodia , Lao PDR, Myanmar , and Viet

Nam Cope with Revenue Lost Due to AFTA Tariff

Reductions?

Kanokpan Lao-Araya

November 2002

No. 30 Asian Regional ism and I t s Effect s on Trade in the

1980s and 1990s

Ramon Clarete, Christopher Edmonds, and

Jessica Seddon Wallack

November 2002

No. 31 New Economy and the Effect s of Indus t r ia l

Structures on International Equity MarketCorrelations

Cyn-Young Park and Jaejoon Woo

December 2 002

No. 32 Leading Indicators of Business Cycles in Malaysia

and the P hil ippines

Wenda Zhang and Juzhong Zhuang

December 2 002

No. 33 Technological Spillovers from Foreign Direct

InvestmentA Survey

Emma Xiaoqin Fan

December 2 002

No. 34 Economic Openness and Regional Development in

the Philippines

Ernesto M. Pernia and Pilipinas F. Quising

January 2003

No. 35 Bond Market Development in Eas t Asia :

Issues and Challenges

Raul Fabella and Srinivasa Madhur

January 2003

No. 36 Environment Stat ist ics in Central Asia: Progress

and Prospects

Robert Ballance and B ishnu D. Pant

March 2003No. 37 Electr ici ty Demand in the Peoples Republic of

China: Investment Requirement and

Environmental Impact

Bo Q. Lin

March 2003

No. 38 Foreign Direct Investment in Developing Asia:

Trends, Effects, and Likely Issues for the

Forthcoming WTO Negotiations

Douglas H. Brooks, Emma Xiaoqin Fan,

and Lea R. Sumulong

April 2003


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MONOGRAPH SERIES

(Published in-house; Available through ADB Office of External Relations; Free of charge)

E D R C R E P O R T S E R I E S ( E R )

N o. 1 ASEAN and t he As ian Deve lopm en t Bank

Seiji Naya, April 1982

No. 2 Development I ssues for the Developing East

and Southeast Asian Countries

and International Cooperation

Seiji Naya and Graham Abbott, April 1982

No. 3 Aid, Savings, and Growth in the Asian Region

J. Malcolm Dowling and Ulrich Hiemenz,

April 1982

N o. 4 D evel opm en t -or ien t ed Fo re ign I nvest m en t

and the Role of ADB

Kiyoshi Kojima, April 1982

N o. 5 The Mult il at e ra l D evel opm en t Banks

and the Intern ational Economys Missing

Public Sector

John Lewis, June 1982

N o. 6 N ot es on E xt er n al De bt of DM Cs

Evelyn Go, J uly 1982

N o. 7 Gr an t Elem en t in Ba nk Loa ns

Dal Hyun Kim, July 1982

N o. 8 S h ad ow Exch a n ge Ra t es a nd St a n da r d

Conversion Factors in Project Evaluation

Peter Warr, September 1982

N o. 9 Sm all and Medium -Sca le Manufact u r ing

Establishments in ASEAN Countries:

Perspectives and Policy Issues

Mathias Bruch and Ulrich Hiemenz,

January 1983

No. 10 A Note on the Third Ministerial Meeting of GATT

Jungsoo Lee, January 1983

No. 11 Macroeconomic Forecasts for the Republic

of China, Hong Kong, and Republic of Korea

J.M. Dowling, January 1983

No. 12 ASEAN: Economic Situat ion and Prospects

Seiji Naya, March 1983

No. 13 The Future Prospect s for the Developing

Countries of Asia


No. 14 Energy and St ructura l Change in the Asia-

Pacific Region, Summary of the Thirteenth

Pacific Trade and Development Conference


No. 15 A Survey of Empi r ica l Studies on Demand

for Electricity with Special Emphasis on Price

Elasticity of Demand

Wisarn Pupphavesa, June 1983

No. 16 Determinants of Paddy Product ion in Indones ia :

1972-1981A Simultaneous E quat ion Model

Approach

T.K. Jayaraman, June 1983

No. 17 The Phi lippine Economy: Economic

Forecasts for 1983 and 1984

J.M. Dowling, E. Go, and C.N. Castillo,

June 1983

No. 18 Economic Forecas t for Indonesia

J.M. Dowling, H.Y. Kim, Y.K. Wang,

and C.N. Castillo, June 1983

No. 19 Rela t ive External Debt Si tua t ion of Asian

Developing Countries: An Application

of Ranking Method

Jungsoo Lee, June 1983

No. 20 New Evidence on Yields, Fert il izer Applicat ion,

and Prices in Asian Rice Production

William James and Teresita Ramirez, July 1983

No. 21 Infla t ionary Effect s of Exchange Rate

Changes in Nine Asian LDCs

Pradumna B. Rana and J. Malcolm Dowling,

Jr., December 1983

No. 22 Effects of External Shocks on the Balance

of Payments, Policy Responses, and Debt

Problems of Asian Developing Countries

S eiji Naya, Decem ber 1983

No. 23 Changing Trade Pat terns and Pol icy Issues :

The Prospects for East and Southeast Asian


Seiji Naya and Ulrich Hiemenz, February 1984

No. 24 Small -Scale Indus t r ies in Asian Economic

Development: Problems and Prospects

Seiji Naya, February 1984

No. 25 A Study on the External Debt Indica tors

Applying Logit Analysis

Jungsoo Lee and Clarita Barretto,

February 1984

No. 26 Al ternat ives to Ins t itu t ional Credit Programs

in the Agricultural Sector of Low-Income

Countries

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

Balance of Payments and Real National

Income of Asian Developing Countries

Jungsoo Lee and Lutgarda Labios, January 1985

No. 29 Cause and Effect in the Wor ld Sugar Market :

Some Empirical Findings 1951-1982

Yoshihiro Iwasaki, February 1985

No. 30 Sources of Balance of Payments Problem

in the 1970s: The Asian Experience

Pradumna Rana, February 1985

No. 31 Indias Manufactured Exports: An Analysis

of Supply Sectors

Ifzal Ali, February 1985

No. 32 Meet ing Bas ic Human Needs in Asian


Jungsoo Lee and Emma Banaria, March 1985

No. 33 The Impact of Fore ign Capita l Inflow

on Investment and Economic Growth

in Developing Asia

Evelyn Go, May 1985

No. 34 The Climate for Energy Development

in the Pacific and Asian Region:

Priorities and Perspectives

V.V. Desai, April 1986

No. 35 Impact of Appreciat ion of the Yen on

Developing Member Countries of the Bank

Jungsoo Lee, Pradumna Rana, and Ifzal Ali,

May 1986

No. 36 Smuggling and Domestic Economic Policies

in Developing Countries

A.H.M.N. Chowdh ury, October 1986

No. 37 Public Inves tment Cr i ter ia : Economic Internal

Rate of Return and Equalizing Discount Rate

Ifzal Ali, November 1986

No. 38 Review of the Theory of Neoclassical Polit ical

Economy: An Application to Trade Policies

M.G. Quibria , December 1986

No. 39 Factors Influencing the Choice of Location:

Local and Foreign Firms in the Philippines

E.M. Pernia and A.N. Herrin, February 1987

No. 40 A Demographic Perspective on Developing

Asia and Its Relevance to the Bank

E.M. Pernia, May 1987

No. 41 Emerging I ssues in Asia and Socia l Cos t

Benefit Analysis

I. Ali, September 1988


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18

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

Southeast Asian Countries

William James, October 1981

No. 5 Asian Agr icul ture and Economic Development

William James, March 1982

No. 6 Infla t ion in Developing Member Count r ies :

An Analysis of Recent Trends

A.H.M. Nuruddin Chowdhury a n d

J. Malcolm Dowling, March 1982

N o. 7 I ndus t ria l G row th and Em ploymen t i n

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

Savings: Issues in Domestic Resource

Mobilization in Asian Developing Countries

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


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


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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19

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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20

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


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)


27/29

21

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


Finan cial Development: Bangladesh Ju ly 1986


Financial Development: Sri Lanka April 1987


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


in Selected Countries: Bangladesh June 1988


in Selected Countries: India June 1988


in Selected Countries: Indonesia June 1988


in Selected Countries: Nepal June 1988


in Selected Countries: Pakistan June 1988


in Selected Countries: Philippines June 1988


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


29. Financial Liberal isat ion in Asia: Analysis an d Prospects


30. Susta inable Recovery in Asia: Mobilizing Resources for

Development


31. Technology and Poverty Reduction in Asia an d the Pa cific


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

SPECIAL STUDIES, COMPLIMENTARY (SSC)


Edited by Myo Thant and Min Tang, 1996

$15.00 (paperback)

5. Emerging Asia : Changes and Challenges

Asian Development B ank, 1997

$30.00 (paperback)

6. Asia n E xpor ts

Edited by Dilip Das, 1999

$35.00 (paperback)

$55.00 (hardbound )

7. Development of Environment Stat ist ics in Developing

Asian and Pacific Countries

Asian Development B ank, 1999

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8. Mor tgage-Backed Secur i t ies Markets in Asia

Edited by S.Ghon Rhee & Yutaka Shimomoto, 1999

$35.00 (paperback)

9. Rising to the Challenge in Asia: A Study of Financial

Markets

1 . Rura l Pover ty in Developing Asia

Edited by M.G. Quibria

Vol. 1: Bangladesh, India, a nd Sr i Lanka , 1994

$35.00 (paperback)

Vol. 2: Indonesia, Republic of Korea, Philippines,

and Thailand, 1996

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2. Gender Indica tors of Developing Asian

and Pacific Countries

Asian Development Bank, 1993

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3. External Shocks and Pol icy Adjus tments :

Lessons from the Gulf Crisis

Edited by Naved Hamid and Shahid N. Zahid, 1995

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4. Indones ia-Malaysia-Thailand Growth Tr iangle:

Theory to Practice

SPECIAL STUDIES, ADB (SS, ADB)

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1. Informal Finance: Some Findings from Asia

Prabhu Ghate et. al., 1992

$15.00 (paperback)

2. Mongol ia : A Cent ra l ly Planned Economy

in Tra nsitionAsian Development Bank, 1992

$15.00 (paperback)

3. Rural Poverty in Asia, Priori ty Issues and Policy

Options

Edited by M.G. Quibria, 1994

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4. Growth Triangles in Asia: A New Approach

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Edited by Myo Thant, Min Tang, and Hiroshi Kakazu

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5. Urban Poverty in Asia: A Survey of Crit ical Issues

Edited by E rnesto Pernia, 1994

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6. Cr it i ca l I ssues in Asian Development :

Theories, Experiences, and Policies

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7. Financia l Sector Development in Asia

Edited by Shahid N. Zahid, 1995

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8. Financial Sector Development in Asia: Country Studies

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9. Fisca l Management and Economic Reform

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Christine P.W. Wong, Christopher Heady,

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Documents

Economic Analysis of Health Projects