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ERD Technical Note No. 6

Economic Analysis of Health Projects:A Case Study in Cambodia

Erik Bloomand

Peter Choynowski

May 2003

Erik Bloom is an Economist in the Social Sectors Division, Mekong Department while PeterChoynowski is an Economist in the Economic Analysis and Operations Support Division,Economics Research Department, Asian Development Bank. The authors wish to thank InduBhushan, David Dole, James Knowles, and Xianbin Yao for useful comments.

Asian Development BankP.O. Box 7890980 ManilaPhilippines

2003 by Asian Development BankMay 2003ISSN 1655-5236

The views expressed in this paper are those of the author(s)and do not necessarily reflect the views or policies of theAsian Development Bank.

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.

Table of Contents

Abstract vii

I. Introduction 1

II. The Project and its Rationale 2

III. Economic Analysis 3

A. Least Cost Analysis 3

B. Calculation of the Economic Internal Rate of Return 4

C. Preliminary Assessment of the Incidence of Benefits 9

IV. Financial Sustainability of the Health Sector and Project 10

A. Fiscal Sustainability 10

B. Project Sustainability 13

V. Conclusions 13

References 14

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 futureprojects. It is based on an actual health project approved by the Asian DevelopmentBank for Cambodia that will be implemented over the period 2003-2006.

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. Interventions in health, as well 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 assessmentof 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 2000). It is based on the CambodiaHealth Sector Support Project (Loan 1940-CAM[SF]), approved by the Asian Development Bank(ADB) on 21 November 2002 (referred to hereafter as “the Project”). The technical note discusses the

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 Cambodia’s long-term fiscal position.

II. 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. Cambodia’s health indicatorsare among the worst in the Asian and Pacific region. Average life expectancy at birth is estimated atonly 56.4 years. Infant mortality is estimated to be 95 per 1,000 per live births, while the mortality 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 malnutrition. 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. In 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. Many public rural facilities have staff 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.

Investment 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 (2002), health equity is a centralfeature of “fairness and justice in social arrangements.” It 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 Project’s 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 malnutrition 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 Project’s scope consists of three components:

(i) buildings and civil works, medical and auxiliary equipment, training of healthservice providers, contracting of services to nongovernmental organizations,and supplies and drugs;

(ii) support programs addressing public health priorities 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.

In 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.

III. 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. In 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 different management models—contract-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. It 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 system’s 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: Identification 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• Identify 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 the cost data in terms of tradable 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 1447-CAM(SF): Basic Health 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 jointhe labor force. Numerous studies have shown that improvements in health have a significant effect onthe population’s 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 LESSLESSLESSLESSLESSCASECASECASECASECASE PPPPPARTICIPARTICIPARTICIPARTICIPARTICIPAAAAATIONTIONTIONTIONTION SICK DAYSSICK DAYSSICK DAYSSICK DAYSSICK DAYS OUT-OF-POCKETOUT-OF-POCKETOUT-OF-POCKETOUT-OF-POCKETOUT-OF-POCKET

IN IN IN IN IN 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 prescribedand 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 prevailing wages. This value of time 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. It also reflects 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.

Improving the health status of the population will lead to fewer days lost due to illness 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 availability of services. In 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.In 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 Project will require additional resources to cover operating and maintenance costs. It isassumed that for each dollar spent on investment, an additional $0.15 per year is spent on maintenanceand 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 Ministry of Health’s 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 effects 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 distortionary effectsof 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

In 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 with project costs. Three criteria 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 (EIRR). It has been the standard practice for ADB to use the EIRR criterion because not allinvestment opportunities are evaluated together and compared in terms of economic net present value.Thus, EIRR ensures that at least the project creates net benefits in excess of a discount rate represent-ing the next best alternative project in the economy. An acceptable project will have an EIRR abovethe critical discount rate of 12 percent in real terms. Box 2 provides a general framework for calculat-ing the EIRR 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 the 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 Internal 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 calculationdiscounts the cost and benefit streams at 12 percent in real terms.

YEARYEARYEARYEARYEAR ECONOMIC COSTSECONOMIC COSTSECONOMIC COSTSECONOMIC COSTSECONOMIC COSTS ECONOMIC BENEFITSECONOMIC BENEFITSECONOMIC BENEFITSECONOMIC BENEFITSECONOMIC BENEFITS NETNETNETNETNETCapitalCapitalCapitalCapitalCapital ContractingContractingContractingContractingContracting IncrementalIncrementalIncrementalIncrementalIncremental IncrementalIncrementalIncrementalIncrementalIncremental CostCostCostCostCost ECONOMICECONOMICECONOMICECONOMICECONOMIC

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 “Less 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 13percent. 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. More 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 Project’s 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 Project’s 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 project’s impact on the health of people in the targeted region and

SCENARIOSCENARIOSCENARIOSCENARIOSCENARIO ECONOMIC INTERNALECONOMIC INTERNALECONOMIC INTERNALECONOMIC INTERNALECONOMIC INTERNAL NETNETNETNETNETRATE 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. ADB’s 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 compilation and analysis. In cases where adetailed 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. It 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.

It was found that the Project covered more than 5 million 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 area’s 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.

It 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 Mondol Kiri andRattanak Kiri, which are among the poorest in the country, through measures that bridge linguistic andcultural 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, theamount 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. It is estimated that a basic package of publicly provided services costs be-tween $12 (World Development Report 1993) to $24 (Macroeconomics and Health Report 2001).

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 government’s contribution to total health care is estimatedat be 5 percent and development partners for the remaining 12 percent of the total. The government’seffort 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 country’s 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. In 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 Cambodia’s 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. It will 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. In practice, user fees arenormally charged, but many health workers also collect unauthorized fees to supplement their rela-tively small official salaries. In districts 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 trend 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).


12

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 2015. 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

Spe

ndin

g on

pri

mar

y he

alth

$24

$12

$-

Figure 1: Estimated Spendingon Basic Primary Health Care


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 all. Improving the efficiency of consumer health care spending will also increase the sustainabilityof the health sector and contribute to Cambodia’s long-term development.

The financial impact of the Project on government’s 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 DFIDalso providing funding for specific components. The ADB/DFID component of the Project will 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. CONCLUSIONS

This 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 EIRR 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


14

nongovernmental organizations ensures that the day-to-day operations of the health care facilities areefficient and the Project provides for the strengthening of institutional capacity in management, plan-ning, and evaluation at the national, provincial, and district levels so that the Project is properlymanaged and supervised.

The financial sustainability of the Project was also assessed on a fiscal and project level. Ananalysis of recent budgets and projected government expenditure concluded that there was a capacityand willingness in the government to allocate budgetary resources to the health sector and the pro-posed project. User fees will also supplement the financing of recurrent costs incurred by the projectfacilities and may eventually become a major source of independent finance.

The economic analysis of the Project relied largely on readily available data and surveys andcould be replicated in a wide range of health projects. Poverty estimates were based on poverty mapsthat are being developed for a large number of countries. The estimated project impact was based ona household survey. Although the survey was specifically designed for the health sector, data from anystandard household survey could be used to make similar estimates on the likely impact of healthinterventions.

This technical note demonstrates that the approach to an economic analysis of a health projectdoes not differ greatly from an economic analysis of projects in other sectors. The approach, the datarequirements, and the complexities of the analysis are similar. An economic analysis should thereforebe a standard requirement in the documentation and justification of a health project proposal.

References

Asian Development Bank, 2000. Handbook for the Economic Analysis of Health Sector Projects.Manila.

Bhushan, I., S. Keller, and B. Schwartz, 2002. Achieving the Twin Objectives of Efficiency and Equity:Contracting Health Services in Cambodia. Asian Development Bank, Manila, Philippines.

Dasgupta, P., 1993. An Inquiry into Well-Being and Destitution. Oxford: Oxford University Press.

Hammer, J. S., 1997. “Economic Analysis for Health Projects.” The World Bank Research Observer12(1):47-71.

Keller, S., and B. Schwartz, 2001. “Evaluation Report: Contracting of Health Service Pilot Project.”Asian Development Bank, Manila, Philippines. Unpublished.

Sen, A., 2002. “Why Health Equity?” Health Economics 11:659-66.

Strauss, J., and D. Thomas, 1995. “Human Resources: Empirical Modeling of Household and FamilyDecisions.” In J. Behrman and T. N. Srinivasan, eds., Handbook of Development Economics,Volume IIIA. Amsterdam: Elsevier.

World Bank, 1993. World Development Report 1993. Washington, D.C.

World Health Organization, 2001. Macroeconomics and Health Report 2001. Geneva.

15

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January 1994No. 54 Growth Triangles: Conceptual Issues

and Operational Problems—Min Tang and Myo Thant, February 1994

No. 55 The Emerging Global Trading Environmentand Developing Asia—Arvind Panagariya, M.G. Quibria,

and Narhari Rao, July 1996No. 56 Aspects of Urban Water and Sanitation in

the Context of Rapid Urbanization inDeveloping Asia—Ernesto M. Pernia and Stella LF. Alabastro,

September 1997No. 57 Challenges for Asia’s Trade and Environment

—Douglas H. Brooks, January 1998No. 58 Economic Analysis of Health Sector Projects-

A Review of Issues, Methods, and Approaches—Ramesh Adhikari, Paul Gertler, and

Anneli Lagman, March 1999No. 59 The Asian Crisis: An Alternate View

—Rajiv Kumar and Bibek Debroy, July 1999No. 60 Social Consequences of the Financial Crisis in

Asia—James C. Knowles, Ernesto M. Pernia, and

Mary Racelis, November 1999

20

No. 1 Estimates of the Total External Debt ofthe Developing Member Countries of ADB:1981-1983—I.P. David, September 1984

No. 2 Multivariate Statistical and GraphicalClassification Techniques Appliedto the Problem of Grouping Countries—I.P. David and D.S. Maligalig, March 1985

No. 3 Gross National Product (GNP) MeasurementIssues in South Pacific Developing MemberCountries of ADB—S.G. Tiwari, September 1985

No. 4 Estimates of Comparable Savings in SelectedDMCs—Hananto Sigit, December 1985

No. 5 Keeping Sample Survey Designand Analysis Simple—I.P. David, December 1985

No. 6 External Debt Situation in AsianDeveloping Countries—I.P. David and Jungsoo Lee, March 1986

No. 7 Study of GNP Measurement Issues in theSouth Pacific Developing Member Countries.Part I: Existing National Accountsof SPDMCs–Analysis of Methodologyand Application of SNA Concepts

—P. Hodgkinson, October 1986No. 8 Study of GNP Measurement Issues in the South

Pacific Developing Member Countries.Part II: Factors Affecting IntercountryComparability of Per Capita GNP—P. Hodgkinson, October 1986

No. 9 Survey of the External Debt Situationin Asian Developing Countries, 1985—Jungsoo Lee and I.P. David, April 1987

No. 10 A Survey of the External Debt Situationin Asian Developing Countries, 1986—Jungsoo Lee and I.P. David, April 1988

No. 11 Changing Pattern of Financial Flows to Asianand Pacific Developing Countries—Jungsoo Lee and I.P. David, March 1989

No. 12 The State of Agricultural Statistics inSoutheast Asia—I.P. David, March 1989

No. 13 A Survey of the External Debt Situationin Asian and Pacific Developing Countries:1987-1988—Jungsoo Lee and I.P. David, July 1989

No. 14 A Survey of the External Debt Situation inAsian and Pacific Developing Countries: 1988-1989—Jungsoo Lee, May 1990

STATISTICAL REPORT SERIES (SR)

No. 1 Poverty in the People’s Republic of China:Recent Developments and Scopefor Bank Assistance—K.H. Moinuddin, November 1992

No. 2 The Eastern Islands of Indonesia: An Overviewof Development Needs and Potential—Brien K. Parkinson, January 1993

No. 3 Rural Institutional Finance in Bangladeshand Nepal: Review and Agenda for Reforms—A.H.M.N. Chowdhury and Marcelia C. Garcia,

November 1993No. 4 Fiscal Deficits and Current Account Imbalances

of the South Pacific Countries:A Case Study of Vanuatu—T.K. Jayaraman, December 1993

No. 5 Reforms in the Transitional Economies of Asia—Pradumna B. Rana, December 1993

No. 6 Environmental Challenges in the People’s Republicof China and Scope for Bank Assistance—Elisabetta Capannelli and Omkar L. Shrestha,

December 1993No. 7 Sustainable Development Environment

and Poverty Nexus—K.F. Jalal, December 1993

No. 8 Intermediate Services and EconomicDevelopment: The Malaysian Example—Sutanu Behuria and Rahul Khullar, May 1994

No. 9 Interest Rate Deregulation: A Brief Surveyof the Policy Issues and the Asian Experience—Carlos J. Glower, July 1994

No. 10 Some Aspects of Land Administrationin Indonesia: Implications for Bank Operations—Sutanu Behuria, July 1994

No. 11 Demographic and Socioeconomic Determinantsof Contraceptive Use among Urban Women inthe Melanesian Countries in the South Pacific:A Case Study of Port Vila Town in Vanuatu—T.K. Jayaraman, February 1995

No. 12 Managing Development throughInstitution Building— Hilton L. Root, October 1995

No. 13 Growth, Structural Change, and OptimalPoverty Interventions—Shiladitya Chatterjee, November 1995

No. 14 Private Investment and MacroeconomicEnvironment in the South Pacific IslandCountries: A Cross-Country Analysis—T.K. Jayaraman, October 1996

No. 15 The Rural-Urban Transition in Viet Nam:Some Selected Issues—Sudipto Mundle and Brian Van Arkadie,

October 1997No. 16 A New Approach to Setting the Future

Transport Agenda—Roger Allport, Geoff Key, and Charles Melhuish

June 1998No. 17 Adjustment and Distribution:

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 Volatility of Private Capital Flows toAsian Developing Countries: Implicationsfor Multilateral Development Banks—Pradumna B. Rana, December 1998

No. 20 The Millennium Round and the Asian Economies:An Introduction—Dilip K. Das, October 1999

No. 21 Occupational Segregation and the GenderEarnings Gap—Joseph E. Zveglich, Jr. and Yana van der MeulenRodgers, December 1999

No. 22 Information Technology: Next Locomotive ofGrowth?—Dilip K. Das, June 2000

OCCASIONAL PAPERS (OP)

21

No. 15 A Survey of the External Debt Situationin Asian and Pacific Developing Countries: 1989-1992—Min Tang, June 1991

No. 16 Recent Trends and Prospects of External DebtSituation and Financial Flows to Asianand Pacific Developing Countries—Min Tang and Aludia Pardo, June 1992

No. 17 Purchasing Power Parity in Asian DevelopingCountries: A Co-Integration Test—Min Tang and Ronald Q. Butiong, April 1994

No. 18 Capital Flows to Asian and Pacific DevelopingCountries: Recent Trends and Future Prospects—Min Tang and James Villafuerte, October 1995

1. Improving Domestic Resource Mobilization ThroughFinancial Development: Overview September 1985

2. Improving Domestic Resource Mobilization ThroughFinancial Development: Bangladesh July 1986

3. Improving Domestic Resource Mobilization ThroughFinancial Development: Sri Lanka April 1987

4. Improving Domestic Resource Mobilization ThroughFinancial Development: India December 1987

5. Financing Public Sector Development Expenditurein Selected Countries: Overview January 1988

6. Study of Selected Industries: A Brief ReportApril 1988

7. Financing Public Sector Development Expenditurein Selected Countries: Bangladesh June 1988

8. Financing Public Sector Development Expenditurein Selected Countries: India June 1988

9. Financing Public Sector Development Expenditurein Selected Countries: Indonesia June 1988

10. Financing Public Sector Development Expenditurein Selected Countries: Nepal June 1988

11. Financing Public Sector Development Expenditurein Selected Countries: Pakistan June 1988

12. Financing Public Sector Development Expenditurein Selected Countries: Philippines June 1988

13. Financing Public Sector Development Expenditurein Selected Countries: Thailand June 1988

14. Towards Regional Cooperation in South Asia:ADB/EWC Symposium on Regional Cooperationin South Asia February 1988

15. Evaluating Rice Market Intervention Policies:Some Asian Examples April 1988

16. Improving Domestic Resource Mobilization ThroughFinancial Development: Nepal November 1988

17. Foreign Trade Barriers and Export GrowthSeptember 1988

18. The Role of Small and Medium-Scale Industries in theIndustrial Development of the PhilippinesApril 1989

19. The Role of Small and Medium-Scale ManufacturingIndustries in Industrial Development: The Experienceof Selected Asian CountriesJanuary 1990

20. National Accounts of Vanuatu, 1983-1987January 1990

21. National Accounts of Western Samoa, 1984-1986February 1990

22. Human Resource Policy and EconomicDevelopment: Selected Country StudiesJuly 1990

23. Export Finance: Some Asian ExamplesSeptember 1990

24. National Accounts of the Cook Islands, 1982-1986September 1990

25. Framework for the Economic and Financial Appraisalof Urban Development Sector Projects January 1994

26. Framework and Criteria for the Appraisaland Socioeconomic Justification of Education ProjectsJanuary 1994

27. Investing in AsiaCo-published with OECD, 1997

28. The Future of Asia in the World EconomyCo-published with OECD, 1998

29. Financial Liberalisation in Asia: Analysis and ProspectsCo-published with OECD, 1999

30. Sustainable Recovery in Asia: Mobilizing Resources forDevelopmentCo-published with OECD, 2000

31. Technology and Poverty Reduction in Asia and the PacificCo-published with OECD, 2001

32. Guidelines for the Economic Analysis ofTelecommunications ProjectsAsian Development Bank, 1997

33. Guidelines for the Economic Analysis of Water SupplyProjectsAsian Development Bank, 1998

SPECIAL STUDIES, COMPLIMENTARY (SSC)(Published in-house; Available through ADB Office of External Relations; Free of Charge)

Edited by Myo Thant and Min Tang, 1996$15.00 (paperback)

5. Emerging Asia: Changes and ChallengesAsian Development Bank, 1997$30.00 (paperback)

6. Asian ExportsEdited by Dilip Das, 1999$35.00 (paperback)$55.00 (hardbound)

7. Development of Environment Statistics in DevelopingAsian and Pacific CountriesAsian Development Bank, 1999$30.00 (paperback)

8. Mortgage-Backed Securities Markets in AsiaEdited by S.Ghon Rhee & Yutaka Shimomoto, 1999$35.00 (paperback)

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

1. Rural Poverty in Developing AsiaEdited by M.G. QuibriaVol. 1: Bangladesh, India, and Sri Lanka, 1994$35.00 (paperback)Vol. 2: Indonesia, Republic of Korea, Philippines,and Thailand, 1996$35.00 (paperback)

2. Gender Indicators of Developing Asianand Pacific CountriesAsian Development Bank, 1993$25.00 (paperback)

3. External Shocks and Policy Adjustments:Lessons from the Gulf CrisisEdited by Naved Hamid and Shahid N. Zahid, 1995$15.00 (paperback)

4. Indonesia-Malaysia-Thailand Growth Triangle:Theory to Practice

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2. Mongolia: A Centrally Planned Economyin TransitionAsian Development Bank, 1992$15.00 (paperback)

3. Rural Poverty in Asia, Priority Issues and PolicyOptionsEdited by M.G. Quibria, 1994$25.00 (paperback)

4. Growth Triangles in Asia: A New Approachto Regional Economic CooperationEdited by Myo Thant, Min Tang, and Hiroshi Kakazu1st ed., 1994 $36.00 (hardbound)Revised ed., 1998 $55.00 (hardbound)

5. Urban Poverty in Asia: A Survey of Critical IssuesEdited by Ernesto Pernia, 1994$18.00 (paperback)

6. Critical Issues in Asian Development:Theories, Experiences, and PoliciesEdited by M.G. Quibria, 1995$15.00 (paperback)$36.00 (hardbound)

7. Financial Sector Development in AsiaEdited by Shahid N. Zahid, 1995$50.00 (hardbound)

8. Financial Sector Development in Asia: Country StudiesEdited by Shahid N. Zahid, 1995$55.00 (hardbound)

9. Fiscal Management and Economic Reformin the People’s Republic of ChinaChristine P.W. Wong, Christopher Heady,and Wing T. Woo, 1995$15.00 (paperback)

10. From Centrally Planned to Market Economies:The Asian ApproachEdited by Pradumna B. Rana and Naved Hamid, 1995Vol. 1: Overview$36.00 (hardbound)Vol. 2: People’s Republic of China and Mongolia$50.00 (hardbound)Vol. 3: Lao PDR, Myanmar, and Viet Nam$50.00 (hardbound)

11. Current Issues in Economic Development:An Asian PerspectiveEdited by M.G. Quibria and J. Malcolm Dowling, 1996$50.00 (hardbound)

12. The Bangladesh Economy in TransitionEdited by M.G. Quibria, 1997$20.00 (hardbound)

13. The Global Trading System and Developing AsiaEdited by Arvind Panagariya, M.G. Quibria,and Narhari Rao, 1997$55.00 (hardbound)

14. Social Sector Issues in Transitional Economies of AsiaEdited by Douglas H. Brooks and Myo Thant, 1998$25.00 (paperback)$55.00 (hardbound)

SPECIAL STUDIES, OUP (SS,OUP)(Co-published with Oxford University Press; Available commercially through Oxford University PressOffices, Associated Companies, and Agents)

Asian Development BankVol. 1: An Overview, 2000 $20.00 (paperback)Vol. 2: Special Issues, 1999 $15.00 (paperback)Vol 3: Sound Practices, 2000 $25.00 (paperback)Vol. 4: People’s Republic of China, 1999 $20.00(paperback)Vol. 5: India, 1999 $30.00 (paperback)Vol. 6: Indonesia, 1999 $30.00 (paperback)Vol. 7: Republic of Korea, 1999 $30.00 (paperback)Vol. 8: Malaysia, 1999 $20.00 (paperback)Vol. 9: Pakistan, 1999 $30.00 (paperback)Vol. 10: Philippines, 1999 $30.00 (paperback)Vol. 11: Thailand, 1999 $30.00 (paperback)Vol. 12: Socialist Republic of Viet Nam, 1999 $30.00(paperback)

10. Corporate Governance and Finance in East Asia:A Study of Indonesia, Republic of Korea, Malaysia,Philippines and ThailandJ. Zhuang, David Edwards, D. Webb,& Ma. Virginita CapulongVol. 1: A Consolidated Report, 2000 $10.00 (paperback)Vol. 2: Country Studies, 2001 $15.00 (paperback)

11. Financial Management and Governance IssuesAsian Development Bank, 2000Cambodia $10.00 (paperback)People’s Republic of China $10.00 (paperback)Mongolia $10.00 (paperback)Pakistan $10.00 (paperback)Papua New Guinea $10.00 (paperback)Uzbekistan $10.00 (paperback)Viet Nam $10.00 (paperback)Selected Developing Member Countries $10.00 (paperback)

12. Government Bond Market Development in AsiaEdited by Yun-Hwan Kim, 2001$25.00 (paperback)

13. Intergovernmental Fiscal Transfers in Asia: Current Practiceand Challenges for the FutureEdited by Paul Smoke and Yun-Hwan Kim, 2002$15.00 (paperback)

14. Guidelines for the Economic Analysis of ProjectsAsian Development Bank, 1997$10.00 (paperback)

15. Handbook for the Economic Analysis of Water Supply ProjectsAsian Development Bank, 1999$10.00 (hardbound)

16. Handbook for the Economic Analysis of Health Sector ProjectsAsian Development Bank, 2000$10.00 (paperback)

17. Handbook for Integrating Risk Analysis in the EconomicAnalysis of ProjectsAsian Development Bank, 2002$10.00 (paperback)

18. Handbook for Integrating Povery Impact Assessment inthe Economic Analysis of ProjectsAsian Development Bank, 2001$10.00 (paperback)

19. Guidelines for the Financial Governance andManagement of Investment Projects Financed by theAsian Development BankAsian Development Bank, 2002$10.00 (paperback)

20. Handbook on Environment StatisticsAsian Development Bank, 2002, Forthcoming

23

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1. Asian Development Outlook (ADO; annual)$36.00 (paperback)

2. Key Indicators of Developing Asian and Pacific Countries (KI; annual)$35.00 (paperback)

JOURNAL(Published in-house; Available commercially through ADB Office of External Relations)

1. Asian Development Review (ADR; semiannual)$5.00 per issue; $8.00 per year (2 issues)

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