World Bank HIV/AIDS interventions: ex-ante and ex-post evaluation.
Contents Foreword iv Abstract v I. Introduction II. Public economics and priorities for HIV prevention and treatment Prioritizing among HIV/AIDS interventions III. World Bank projects that support HIV/ AIDS interventions World Bank projects focusing primarily on HIV/ AIDS Providing information Promoting safer behavior among those most likely to contract and spread HIV HIV/AIDS interventions supported by other Bank projects IV. Ex-ante and ex-post project evaluation V. Conclusions Appendix A: Country assistance strategies and HIV/ AIDS Appendix B: Analysis of HIV/ AIDS in World Bank economic and sector work Appendix C: World Bank projects with an HIV/ AIDS component Appendix D: The link between economic and sector analysis and project success References
The AIDS epidemic is one of the greatest development challenges of the 20th century. Since 1986 the World Bank has supported member country efforts to fight the epidemic in many ways, including lending, economic and sector analysis, grant support, technical assistance, and policy advice. This paper is the first comprehensive desk study of all World Bank HIV/AIDS-related activities from the perspective of public economics. It was prepared as a background paper for the recent World Bank Policy Research Report, Confronting AIDS: Public Priorities in a Global Epidemic. The paper is intended primarily for the use of World Bank staff, but we hope that it will also provide guidance to governments, other international agencies, and nongovernmental agencies in the design and implementation of HIV prevention and mitigation programs. Learning from World Bank experience can help the Bank, together with its member countries, to confront the AIDS epidemic more effectively.
Between 1986 and 1996, the World Bank committed over US $ 550 million to HIV/AIDS prevention and mitigation efforts. This paper assesses the appropriateness of Bank interventions from the perspective of public economics and reviews the economic evaluation and implementation of projects. It focuses on 27 countries, selected either because AIDS is a particularly severe problem or because the Bank is especially active in the country (Table 1). (1)
This study follows three previous reports on HIV/AIDS interventions supported by the World Bank. The first set out an agenda for World Bank action in Africa (World Bank, 1988). The second and third reports also focused on Africa and updated the Bank strategy (Lamboray and Elmendorf 1992 and World Bank 1996). Lamboray and Elmendorf (1992), building on the 1988 strategy, concluded that additional World Bank efforts should focus on promoting behavioral change among core groups, treating other sexually transmitted diseases, and on convincing central financial and planning agencies in African governments to focus on AIDS and its implications for development. The third report, AIDS Prevention and Mitigation in Sub-Saharan Africa: A Strategy for Africa (World Bank 1996), identified five new tasks for the Bank: (i) help to generate political commitment to OAU declarations on AIDS; (ii) work more vigorously to change behavior; (iii) intensify national programs according to a typology of countries based on severity of prevalence levels; (iv) increase the analysis of AIDS and its impact on development goals in economic and sector work; and (v) improve the design and implementation of cost-effective approaches to mitigate the consequences of AIDS.
Whereas past reviews have taken primarily a public health perspective, this paper evaluates the Bank's role from the perspective of public economics. It also reviews, for the first time, World Bank AIDS activities in all regions of the world. The paper focuses on World Bank lending, although reviews of HIV/AIDS coverage in Country Assistance Strategies and country economic and sector work are included in Appendices A and B, respectively. Section II discusses the public economics rationale for AIDS interventions. Section III reviews Bank lending for HIV/AIDS prevention and mitigation interventions. Section IV evaluates ex-ante and ex-post project evaluation. The final section draws conclusions.
II. Public economics and priorities for HIV prevention and treatment (2)
The principles of public economics provide a framework for making decisions about which activities merit government action and, among these, which should be priorities. From this perspective, there are two main reasons for government intervention: to maximize total social well-being--usually correcting a market failure and thereby enhancing efficiency--and to promote a more equitable distribution of well-being among social groups. Based on these principles, the recent World Bank Policy Research Report Confronting AIDS: Public Priorities in a Global Epidemic identified three activities in which governments have an indispensable role in ensuring the efficiency and equity of HIV prevention programs.
First, governments have a role in providing public goods related to prevention, such as the collection and dissemination of information about the epidemic. Information about the HIV/AIDS epidemic and how to avoid infection is a true public good. This means that those who gain access to new information subtract none of its value from others. Although in some case it is possible to restrict access to information by, for example, selling it, the information is often passed on to people who did not purchase it. Because of this, private firms, on their own, are likely to produce less information than is socially optimal and so there is reason for the public sector to subsidize or provide public goods. This is particularly true of epidemiological surveillance of infection rates, for which the value lies in making the results well-known. But the public role for producing information also includes country-specific information on how to identify and reach people at the highest risk of becoming infected with HIV and spreading it to others. In addition, research that will improve the effectiveness of prevention interventions is also a public good.
Second, governments need to support programs that reduce the negative externalities of risky behavior among people most likely to contract and spread HIV. An externality occurs when a transaction between two parties creates an unpriced effect on another party. In the context of HIV in developing countries, the largest externalities arise in the context of consensual sexual relations. Although the individuals involved can weigh their own individual risks, their activities still have consequences for their other (current and future) sexual partners. Ideally, those involved would consider these effects and decide to engage in safer sex. But the problem is that behavior--safe or risky--is difficult to prove. This means that individuals are likely to under-invest in activities that reduce the risk of infecting future partners, such as using condoms and treating other STDs. Because of the enormous positive externalities (of lowering HIV transmission) associated with these two activities, there is a clear role for governments to invest in them. Since HIV is transmitted sexually, the positive externalities of using condoms and being free of STDs are greatest for those individuals who have many sexual partners or needle-sharing partners. The more focused prevention interventions are on these groups, the more effective they will be in reducing HIV transmission.
Another example of an externality is mother-to-child transmission. Although this is a clear example of an externality in that the infant cannot control his or her exposure to HIV, the role for developing governments in directly preventing mother-to-child transmission may be limited in the context of scarce resources. This is because the externalities created by mother-to-child transmission are not very large as compared with externalities created others (e.g. those with many sexual or needle-sharing partners). Although mother-to-child is a horrible tragedy, it does not result in many secondary infections. Preventing the mother from becoming infected by HIV in the first instance may be the best strategy for developing countries, and this can be done most effectively with HIV prevention programs for those who have the largest number of partners.
Third, the government has a role in promoting equity by ensuring that the most destitute are not denied access to the means to protect themselves from HIV. The government may want to subsidize clean blood for the poor, who cannot afford to purchase it. Safety net programs that help to reduce the vulnerability of poor households are especially important for those households that experience the death of a prime-age adult from AIDS. When women have low status, they are in a weak position for bargaining safer sexual relations. Thus, governments should also work to improve the status of women by expanding educational and employment opportunities and providing more legal protection. These policies merit support for economic and social reasons beyond the context of the AIDS epidemic, but the presence of the epidemic exacerbates the need for them.
Prioritizing among HIV/AIDS interventions
Using these principles of public economics and some general intuition about cost-effectiveness, it is possible to prioritize among types of interventions (Box 1). The exact mix of interventions will necessarily vary by country, depending on: (i) the stage and characteristics of the AIDS epidemic, which vary dramatically from country to country; (ii) the cost-effectiveness of particular interventions in that country; (iii) the level of resources available to confront HIV/AIDS, which usually depends on the level of economic development of the country; and (iv) the political support and implementation capacity in the country. (3)
Three prevention priorities are particularly efficient and potentially very cost-effective: (i) condom promotion/subsidy for high risk groups; (ii) STD treatment for high risk groups; and (iii) financing operational research and surveillance. There are other important policies that should be supported for reasons other than AIDS. These include improving the status of women, enforcing laws against rape and exploitation of minors, and supporting anti-poverty programs that help reduce the vulnerability of poor household. Finally, broad-based mass-media information campaigns, subsidized HIV testing and financing clean blood are not generally not as efficient or cost-effective.
Box 1: Prioritizing Government HIV/AIDS Interventions Based on Public Economics PRIORITY INTERVENTIONS: * Finance operational research and disease surveillance * Treatment STDs, particularly for high risk groups * Promote/subsidize condoms for high risk groups * Improve status of women by expanding educational and employment opportunities and more legal protection (1) * Enforce laws against rape and exploitation of minors (1) * Support anti-poverty programs that help reduce the vulnerability of poor household to the loss of a prime age adult (1) OTHER (NON-PRIORITY) INTERVENTIONS * Broad-based mass-media information campaign * Subsidy for HIV testing for individuals * Provision of safe blood (1) There are other social reasons for supporting these policies, but the AIDS epidemic increases their importance.
III. World Bank projects that support HIV/AIDS interventions (4)
Between 1986, when it started lending for HIV/AIDS interventions, and 1996, the World Bank financed 60 projects in 41 countries, for a total commitment of US$ 552 million. This included nine free-standing AIDS projects and 52 projects with an AIDS component. Eight of the projects have been completed and about a dozen projects with an AIDS component were under of preparation as of June 1996. Since then, another freestanding AIDS project, the Argentina AIDS and STD Control Project (US$ 15 million) has been approved and at least two more are planned (for India and Guinea Bissau). All except one of the existing project are in the health or human resources sector and the implementing agency is almost always the Ministry of Health. The exceptions is the Uganda Transport Rehabilitation Project, which supports an AIDS awareness campaign in Districts that participate in the rural feeder roads campaign. The Bank also provides support for HIV prevention and mitigation through various grant programs (Box 2).
Box 2: World Bank Grant Support for HIV/AIDS Prevention and Mitigation The Bank finances grants for HIV prevention and mitigation and it also administers grant programs for other organizations. Most grant support is provided through four umbrella programs: the Special Grants Program, the Japanese Program for Human Resources Development, the NIARSH East Africa Initiative and the World Bank Small Grants Program. The Special Grants Program recently funded a $9 million dollar, three-year program to support UNAIDS and several regional HIV prevention initiatives. The main purpose of the grant is to support the global effort to prevent the transmission of HIV/AIDS. UNAIDS, which has been established to inspire, focus and strengthen this effort, is the executor of this 'bundle' grant to support four activities: * UNAIDS. The grant provides US $ 1 million to support efforts to coordinate HIV/AIDS policies, programs and funding. UNAIDS helps to establish a stronger link between AIDS and broader social, developmental and humans rights issues, in addition to providing policy, strategic and technical guidance. * The Western Africa HIV/AIDS Prevention Project. The project facilitates a coordinated response to the epidemic in three ways: (i) advocacy--mobilizing political and opinion leaders throughout West Africa to address HIV/AIDS issues; (ii) pilot interventions--testing innovative ideas, particularly those relating to cross-border issues and commercial sex work; (iii) capacity strengthening--enhancing capacity to identify, design, implement and monitor/evaluate inter-country and multi-sector projects. * The Latin American and Caribbean Regional Initiative for AIDS/STD Control. The overall objective of the grant is to mobilize and unify national and international efforts against HIV and other STDs. The project will be implemented over a period of three years and will finance (i) a series of regional studies on the epidemiology of HIV/AIDS, the impact of the epidemic on health service utilization and costs, and cost-effectiveness of alternatives, among other topics; (ii) a series of regional seminars and (iii) one regional conference. * The South-East Asia HIV/AIDS Project. The project serves Cambodia, Laos, Malaysia, Myanmar, Philippines, Thailand, Viet Nam, and the Yunnan Province in China by assisting them to strengthen national and regional responses to HIV/AIDS. This includes promoting and facilitating analytical work, policy tools and intervention options, consensus building and institutional development. The Japanese Program for Human Resources Development (PHRD) sponsored a range of small research projects, mostly on the impact of AIDS, that help to guide the design of forthcoming Bank projects. The NIARSH Eastern Africa Initiative, financed by a group of donors, provides 1.3 million in funding for a range of prevention activities in Eastern Africa. The World Bank Small Grants Program has made five grants in support of AIDS related activities, for a total of US $ 56,000. (1) In four of the five grants, the funding helped to support an NGO or a network of NGOs to host a conference or workshop. These have included a workshop sponsored by Education International, an NGO based in Togo, on 'School Health and HIV/AIDS prevention' and another workshop organized by HelpAge Zimbabwe on the impact of AIDS on older people. A grant to an Indonesia NGO Yayansan Kusuma Buana (YKB) supported the publication and dissemination of IEC materials for distribution at STD service outlets, public health facilities, and by other NGOs. (1) The five grants were: USS 10,000 to HelpAge Zimbabwe for a workshop; USS 6,000 to Swaziland Network of AIDS Service Organizations for a workshop; US $15,000 to Education International (Togolese NGO) for a workshop; USS 14,000 to YayasanKusuma Buana (Indonesian NGO) for IEC materials; and USS 11,000 to the Asia Center in Thailand for an AIDS prevention seminar in Bangkok. Source: Internal Bank grant proposal documents
A regional breakdown of this lending shows that almost half of the lending, US$ 274 million was directed towards 42 projects in the Sub-Saharan Africa region (Figure 1). Lending for four projects in Latin America amounted to USS 173 million, much of which was allocated for the large loan for Brazil. The Bank has supported seven loans, equivalent to US$ 131 million, for HIV/AIDS interventions in South and East Asia, including two free-standing loans for national AIDS prevention programs in India and Indonesia. Bank financing of AIDS prevention and mitigation activities in other regions of the world was more limited. Three projects in each the Eastern and Central Europe and the Middle East and North Africa regions have supported AIDS interventions.
Overall, most Bank lending for 'AIDS interventions took place between 1992 and 1994, when the Bank financed many of its large, free-standing AIDS projects, such as those for India (USS 84 million) and Brazil (US $ 160 million) (Figure 2). Lending in the 1980s was disbursed in smaller amounts, usually as components of larger loans to countries in Africa.
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One-third of the projects with HIV/AIDS components (21 project) and about the same proportion of lending (USS 202 million) was for countries with a generalized epidemic (Table 2). Over half of the lending (US$ 291 million) was for the 26 projects in countries with a concentrated epidemic. Total lending for countries with generalized epidemics was less than lending to countries with concentrated epidemics, because the former are mostly in Sub-Saharan Africa where loan sizes are smaller on average. The remaining USS 59 million was lent for 13 project in countries with a nascent epidemic or for which the stage of the epidemic is unknown.
World Bank projects focusing primarily on HIV/AIDS
An in-depth review of the ten Bank HIV/AIDS-focused projects (including Argentina) evaluated the extent to which the Bank has supported interventions in three priority areas. These areas, which were identified in Confronting AIDS, include:
1. Information collection (including level and trends of HIV/other STDs, prevalence of high-risk behavior and characteristics of those who practice it, cost of interventions and their impact on HIV incidence)
2. Promoting safer behavior among those most likely to contract HIV (including lowering costs of condom use, lowering costs of safe injecting behavior, treating STDs, working with NGOs, and improving the status of women)
3. Promoting equitable access for the poor to prevention and treatment. Generally speaking, it was not possible to evaluate the exact allocation of funds to these areas, as project documents rarely disaggregated spending along the same categories. A rough approximation was possible for only two projects, Indonesia and Kenya (Box 3).
Box 3: Spending Allocations for Priority Interventions for Two Bank Projects What share of Bank project funds support interventions in the three priority areas? This question is answered for the two HIV/AIDS-focused projects for which this information was available in the Staff Appraisal Reports. (Other Bank projects did not disaggregate spending along similar lines.) These projects are not necessarily representative of the Bank's entire lending portfolio; it would be helpful to collect this type of information on all Bank projects with HIV/AIDS components to indentify patterns in spending. The Indonesia HIV/AIDS and STDs Prevention and Management Project devoted about 40 percent of project base costs for interventions in the three priority areas. This included: 5 percent for targeted IEC, 23 percent for STD services, and 12 percent for surveillance. In addition, 27 percent of project base costs financed other types of IEC, including mass media programming and campaigns in the workplace, schools and universities and among health providers. Another 22 percent of the base cost financed the improvement of laboratory services. In the Kenya Sexually Transmitted Infections Project, 42 percent of total project costs (USS 42.7 million) have been allocated to interventions in the three priority areas. This includes support for surveillance, operational research, monitoring and evaluation, condom promotion, treatment for STDs, and support for innovative NGO outreach activities to target high-risk groups. The rest of the project finances other activities such as mass media, programs to build national and district capacity, project management, activities to care for HIV/AIDS patients and efforts to improve occupational safety. Source: Staff Appraisal Reports
One issue that complicates the evaluation of Bank loans is that they often provide financial support for interventions not already being financed from other sources. In some situations, therefore, the Bank does not support priority interventions because these have already received adequate support from government agencies or other donors. To take this into account, this review also looked at the extent to which the project documentation discussed the role of other donors and organizations and efforts to collaborate with them.
The Bank provided strong support for surveillance of HIV and other STDs. All 10 projects supported activities to improve national surveillance systems. The India project has financed sentinel surveillance among high-risk groups (sex workers, IDUs, truck drivers and TB patients). The Burkina Faso Population and AIDS Control Project is supporting special prevalence studies among miners, prisoners, migrants, TB patients, and pregnant women. The Argentina AIDS and STD Control Project plans to establish HIV and STD surveillance system with about 20 sentinel centers, although it is not clear whether these will focus on high-risk groups.
Most of the projects supported behavior studies, but only two identified the specific need to focus on groups most likely to engage in high-risk behavior. Studies are planned on the behavioral risk factors of IDUs in Brazil and on the commercial sex industry in Indonesia. All projects support at least one study of cost-effectiveness or the economic impact of AIDS.
Promoting safer behavior among those most likely to contract and spread HIV
Seven of the 10 projects (those for Argentina, Burkina Faso, India, Indonesia, Kenya, Uganda, Democratic Republic of Congo) had some discussion of the need to target prevention services to the highest risk groups. Project documentation included limited discussion about how these groups were identified, how they would be reached, or what additional information was needed to reach them effectively. Eight of 10 projects planned to contract NGOs to provide outreach services to high-risk groups. The projects in Burkina Faso, Chad and Kenya have established separate funds to support innovative NGO activities.
Four projects discussed efforts to target condom promotion to high-risk groups. In Brazil, the project supported an intervention to promote condoms among IDUs. The project in Burkina Faso subsidized condoms for those at highest risk. The project for Uganda also promoted condoms with an emphasis on expanding access for high risk groups. The project for Democratic Republic of Congo promoted condom distribution at non-traditional distribution points such as bars, nightclubs, and hotels, as well as promoting condom high-risk groups, including sex workers. Students and employees were also identified by the SAR as high-risk groups, although no evidences was provided to support this claim.
Only the Brazil project discussed specific efforts to lower costs of safe injecting behavior. This included outreach efforts to promote and distribute products for needle cleansing, experimentation with syringe distribution and the distribution of 2.5 million condoms to IDUs. We might have also expected this type of programmatic support in India or Indonesia. These two projects provided targeted IEC for IDUs but had no support for behavioral interventions to lower risk.
All ten projects supported STD treatment services, but only the Kenya project documentation discussed specific efforts to target these services to those most at risk. There was a special emphasis on reaching those at increased risk: youth, men living away from home, truck drivers, and sex workers. One project supported efforts to improve the status of women. The Burkina Faso project provides support for enhancing public understanding of women's rights and problems, including financing seminars and international study tours.
Promoting equitable access for the poor to prevention and treatment. The Argentina project will establish entities to provide medical care to those without insurance and for care for AIDS orphans and hospice care. Several of the projects support various types of treatment, but do not focus these efforts towards the most disadvantaged.
Collaboration with other donors. The degree of collaboration with other donor organizations varied substantially across the projects. The projects for Burkina Faso, Chad, Uganda were jointly financed with others donors and the project documentation discussed a well-coordinated effort. The project for Indonesia, although financed solely by the World Bank, included an extensive discussion of the project would complements efforts of other organizations. In Argentina and Brazil, there was no discussion of the HIV/AIDS programs that already exist in country or of efforts to collaborate with other donors. Other project documents had very limited discussion of the roles of other donors, and it was therefore difficult to know if they supported priority interventions.
HIV/AIDS interventions supported by other Bank projects
Among the 51 projects with a component for HIV/AIDS-related activities, most projects supported four types of interventions: (i) operational research, surveillance, and monitoring; (ii) information, education and communication (IEC) regarding HIV/AIDS awareness; (iii) treatment of STDs; and (iv) condom promotion (Appendix C). The provision of information (i) is always a priority, although operational research is most useful when it focuses on groups at highest risk for contracting and transmitting HIV. Interventions in the other three categories are appropriate when they reach groups at highest risk.
Over half of the 51 projects (57 percent) funded operational research, surveillance, and/or monitoring and evaluation activities. Projects in countries with a concentrated epidemic were more likely to support operational research and surveillance (68 percent) than were projects in other countries. Operational research addressed topics such as measuring the cost effectiveness of various interventions, assessing the economic impact of AIDS and program monitoring and evaluation (see Box 3). Most of these projects also finance epidemiological surveillance of HIV, and some of them also support surveillance of other STDs. Almost half of the operations (43 percent) funded mass-media education for the population at-large. Fewer projects (about 33 percent) supported IEC targeted to high-risk groups, although these types of interventions are likely to be much more effective than mass-media campaigns in reducing HIV transmission.
Half of the projects financed assistance for the treatment of STDs, including support for developing protocols for treating STDs, training health care providers on how to diagnose and treat STDs, providing drugs to treat the STDs, and paying the full costs of STD treatment. It is not clear the extent to which these interventions targeted groups at highest risk for infection, although expanding iieatment for these groups is most important.
About a third of the projects also support treatment for HIV/AIDS patients such as treating opportunistic infections (especially TB), providing drugs and counseling, designing protocols for treatment and training medical staff on appropriate treatment. The Uganda Sexually Transmitted Infections Prevention and Control Project, for example, supports all of these as well as financing community and home-based health care and social support for people with AIDS.
About half of the projects promote condom use and/or finance the provision of condoms. For example, the project in Guinea Bissau support the social marketing of condoms. The extent to which Bank support was focussed on the highest-risk groups was difficult to establish, but not enough project documents discussed which groups were at highest risk for sexual transmission and how to best reach them.
Box 4: The Socioeconomic Impact of AIDS in Madagascar As of 1995, only 20 cases of AIDS had been reported in Madagascar. Yet, a combination of factors could cause the epidemic to explode in the near future. These include: high levels of STDs, extensive prostitution and promiscuity, low use of condoms, high rates of poverty, and an increase in the dislocation of the family and internal migration. Nevertheless, Madagascar has the opportunity to control the spread of HIV. In support of efforts to control the spread of AIDS, the Bank's Economic Management and Social Action Project sponsored operational research to estimate the potential growth of the epidemic and on the socio-economic impact of AIDS in Madagascar. Although only 20 cases of AIDS had been reported, it is estimated that at least an additional 130 cases are unreported. About 5,000 individuals are estimated to be infected with HIV. Two future scenarios were modeled: a controlled epidemic resembling that of Thailand and a rapid growth epidemic like that being experienced by Kenya. In the slow-growth scenario, HIV prevalence would reach 3 percent of the general population in 2015, and in the full-blown scenario, HIV prevalence would reach 15 percent by 2015. The direct costs of caring for AIDS patients in 2015 will be between USS 10.75 and 52.75 millions (1996 dollars at 4000 FMG/dollar), depending on the severity of the epidemic. These figures are likely to be on the low side as they do not include the costs of treating opportunistic infections. The analysis considers the burden on public health expenditures and concludes that at the present rates of growth of the Ministry of Health budget, the sector will not be able to absorb these costs, particularly the high scenario. A range of indirect costs are also considered but not estimated. By 2015, there will be between 107,000 and 548,000 AIDS orphans. Source: Etude de I'impact socio-economic du VIH/SIDA a Madagascar (Juin 1996)
IV. Ex-ante and ex-post project evaluation
Two recent studies have shown that good economic analysis leads to better projects. Analysis by Belli and Pritchett (1995) found that projects with poor economic analysis were 7 times more likely to perform poorly than were projects with good economic analysis. Belli (1996) repeated the analysis an additional (fourth) year of project performance rating and found that the relationship holds even stronger. In a separate analysis, Robert Schneider (World Bank 1995) measured the intensity of sector work in the three years preceding a project and found that the more sector work done, the higher the probability of success. This section assesses the quality of the economic analysis in project preparation, and Box 6 discusses the available evidence from ex-post evaluation. An analysis of the link between economic and sector analysis and project success is presented in Appendix D.
Devarajan, Squire and Suthiwart-Narueput (1995) identified ways in which the World Bank can improve the economic analysis of its projects. Hammer (1996) applied their approach to the project analysis in the health sector. He proposed four aspects of economic analysis that should be covered in health project evaluation, which are outlined in Box 5.
Box 5: Desiderata for Project Analysis in the Health Sector 1. Establish a firm justification for public involvement. This usually involves identifying market failures and discussing how and why public intervention is appropriate. 2. Examine the counterfactual. What would happen with and without the project? 3. Determine the fiscal effect of the project. In the health sector, this usually involves discussing the appropriate level of user fees. 4. Acknowledge the fungibility of project resources and examine the incentives facing public servants. Source: Hammer (1996)
With a very few exceptions, only the free-standing AIDS-focused projects included economic analysis related to the AIDS interventions. For this reason, this section is limited to the nine completed or ongoing projects that address AIDS as their primary focus. Table 3 discusses the projects in terms of the desiderata identified by Hammer (1996). The first, rationale for public involvement, was almost never explicitly discussed, but rather implicit in the project document. An exception is the Brazil AIDS and STD Control Project, which cited the large negative externalities to the AIDS epidemic and the problems with imperfect information.
Two forecasting models were utilized. The WHO epidemiological model developed by Chin and Sato was used in the analyses for the projects in Brazil, India and Democratic Republic of Congo (which only forecasted future AIDS incidence, without estimating the project impact). The InterAgency Working Group-AIDS model developed by the US Census Bureau was used for Indonesia. The assumptions listed in Table 7 indicate wide variation from project to project. The fact that no assumptions were discussed for several of the projects suggests that future project analysis should carefully document the assumptions under which the calculations were made, as they can dramatically affect the results.
Only three of the nine projects identified a counterfactual for the project and presented cost-benefit or cost-effectiveness analysis comparing the various options. The project analyses for Brazil, India and Indonesia provided extensive analysis of the alternatives. The Brazil project used the WHO epidemiological model to estimate the future incidence of HIV/AIDS in the presence and absence of the project. The analysis then calculated the direct and indirect costs saved with the project in place. Both the India and Indonesia project analyses included the 'without project' scenario and three possible 'with project' scenarios, which varied according to the effectiveness of the project interventions. For example, the three scenarios in the analysis for India were reducing the incidence of HIV/AIDS by 20,30 or 40 percent. The 30 percent scenario (considered by the authors to be conservative) was then used to calculate the direct and indirect costs saved by the project. The analysis also calculates the internal rate of return on government direct costs, which was estimated to be 26.7 percent. None of the project analyses estimate the impact separately for each component of the projects.
Among the other six projects, direct and indirect benefits were only estimated partially. For the projects in Burkina Faso and Democratic Republic of Congo, direct and indirect costs per AIDS case were calculated, but the number of cases averted as result of the project was not estimated. (5) The analysis for Chad, Kenya, Uganda and Zimbabwe did the opposite: they estimated how many people would be reached by the project (although not how many AIDS cases would be averted), but did not estimate the indirect or direct costs saved by the project.
With respect to the last two desiderata, only a few of the projects discuss the fiscal impact of the project, mostly raising cost recovery issues and estimating the impact of the project on recurrent costs. Problems related to fungibility were rarely discussed.
Box 6: Lessons Learned from Completed Projects Eight projects with AIDS components have been completed, including one free-standing AIDS project (Democratic Republic of Congo). The four available completion reports indicate mixed results (see table below). Two of the four project outcomes (Democratic Republic of Congo and Cameroon) were rated as unsatisfactory by both the task manager (ICR in table) and the operations evaluation department (EVM in table). In both cases the project had only modest impact and was not considered to be sustainable in the future. Weak project management and limited government commitment were cited as reasons for poor performance in both projects. Most of the four project completion reports identified similar factors (not limited to the AIDS-related intervention) that contributed to poor project implementation, suggesting priorities for future projects: * A strong government commitment is key: The Niger project credited government commitment as the main reason for project success and the other three projects indicated that lack of commitment to the goals of the project hindered project implementation. * Simple project design is best: 'Simple' is broadly defined as supporting few interventions, that are easily implemented and working with a limited number of implementing agencies. Both the Gambia and Cameroon projects found that the complex design of several of their components hindered project implementation. * Strengthening management capacity is important: All four projects cited poor management capacity, especially financial management, as an impetus to effective project implementation. * Appraisal must be thorough: Weak project appraisal was cited as one of the main reasons for poor project implementation in Cameroon. The Democratic Republic of Congo project did not adequately consider the possibilities of rapid macroeconomics change, which led to severe project implementation problems. Additional project experience on AIDS intervention (World Bank 1996) provided the following additional lessons: * Interventions in the earlier stages of the epidemic have a greater impact and a higher benefit-cost ration that interventions at a later stage. * Large-scale condom promotion and marketing has resulted in large observed changes in sexual behavior and significant increases in condom use. * Efforts to control STDs should be integrated with AIDS prevention efforts. * NGOs can play an important role on reaching high risk groups. Project Ratings for 4 completed projects Project: Outcome Sustainability (rating source) Cameroon SDA(ICR) unsatisfactory uncertain (EVM) unsatisfactory unlikely Gambia Hlth Dev (ICR) Niger 1st Health (ICR) satisfactory likely Democratic Republic of Congo AIDS (ICR) unsatisfactory unlikely Project: Institutional. USS (rating source) Development Committed Cameroon SDA(ICR) modest 21.5 million (EVM) negligible Gambia Hlth Dev (ICR) 4.7 million Niger 1st Health (ICR) partial 25.1 million Democratic Republic of Congo AIDS (ICR) negligible 8.1 million Project: Percent (rating source) Canceled Cameroon SDA(ICR) 81.7 (EVM) Gambia Hlth Dev (ICR) 6.9 Niger 1st Health (ICR) 1.3 Democratic Republic of Congo AIDS (ICR) 60.9 Notes: ICR= implementation completion report (prepared by task manager); PCR=project completion report (prepared by task manager); EVM=evaluative memorandum (prepared by OED). The possible ratings are: (i) outcome: highly satisfactory, satisfactory, unsatisfactory, highly unsatisfactory; (ii) sustainability: likely, unlikely, uncertain; (iii) institutional development: substantial, partial, and negligible. Source: World Bank project completion reports
Between 1986 and 1996, over US $ 550 million in World Bank loans has supported interventions specifically aimed at preventing HIV/AIDS and mitigating its effects. This paper reviews Bank activities in all regions of the world from a public economics perspective. The paper focuses on the Bank's lending program, although the conclusion presented here also draw on review of the Bank Country Assistance Strategies and country economic and sector work (Appendices A and B, respectively).
The recent World Bank Policy Research Report, Confronting AIDS: Public Priorities in a Global Epidemic, identified three priority areas for government support: (i) information collection; (ii) promotion of safer behavior among those most likely to contract and transmit HIV; and (iii) and protection for the poorest groups in society from contracting HIV and support to mitigate the negative consequences of HIV/AIDS among these groups. Bank projects are evaluated based on the extent to which they supported interventions in these areas.
The Bank provided extensive assistance for efforts to collect information. All ten of the HIV/AIDS-focused projects financed surveillance of HIV and other STDs. Most of them also supported behavior studies, and all ten had plans for at least one cost-effectiveness study. Only a few, however, indicated a plan to focus these activities on the population groups most at risk in the country. About 60 percent of the 51 projects with an HIV/AIDS component supported operational research, surveillance, evaluation and monitoring activities, although the focus on groups at highest risk was limited.
Support for interventions to reduce risky behavior among those most likely to contract and transmit HIV was less extensive. Most of the ten HIV/AIDS-focused projects contracted NGOs to provide outreach services to high risk groups, but there was very limited discussion of how these groups had been identified or what additional information was needed to reach them effectively. Four projects supported condom promotion programs targeted to high-risk groups. Only the Brazil project provided specific support for interventions to support safe injecting behavior. All ten projects financed STD treatment, but only one planned to focus these services on those most at risk. Finally, only one project provided support for efforts to protect the poorest groups in society from contracting HIV or programs to mitigate the negative consequences of HIV/AIDS among these groups.
Most of the projects were not based on strong economic analysis. With a very few exceptions, only the free-standing AIDS-focused projects included any ex-ante economic analysis of the proposed AIDS interventions. Only one-third of these projects, however, prepared adequate cost-benefit or cost-effectiveness analysis. As of October, 1996, ex-post evaluations were only available for four of the eight completed projects and their assessment was generally unsatisfactory.
Country Assistance Strategies and sector analyses, have only addressed HIV/AIDS issues in limited manner. Consideration of the AIDS epidemic was not central in most of the Country Assistance Strategies, the principle strategic planning documents, although coverage was most extensive in countries with generalized epidemics. The best documents discussed how the development strategy would affect the HIV/AIDS epidemic, or vice-versa, and what the government was doing about this problem. Most of the sector analysis of HIV/AIDS was in health sector reports, and very few reports estimated the economic effects of AIDS. The coverage and quality varied, and few reports provided estimates of the potential public (and/or private) costs of AIDS for the health sector or the cost-effectiveness of the various health interventions. Analysis of the broader consequences of AIDS such as its relationship with poverty, and its effects on other sectors and the macroeconomy was limited.
This reviews the extensive support provided by the World Bank for a wide-range of HIV/AIDS interventions. It also identifies a weakness in the Bank's lending program: many of the activities supported by the Bank have not been well-focused on the groups in the population most at risk for HIV infection. Few of the HIV/AIDS Bank projects based support for interventions explicitly on the principles of public economics or have relied on sound economic analysis in ex-ante or ex-post evaluation. Thus, the two primary challenges for the Bank are to provide more support for prevention activities that focus on the groups at highest risk for contracting and spreading HIV and to improve the ex-ante and ex-post economic evaluation of HIV/AIDS projects.
Appendix A: Country assistance strategies and HIV/AIDS
The Country Assistance Strategy (CAS) is the central planning document guiding World Bank activities in each borrowing country. It is prepared by World Bank staff and consists of a short, concise discussion of the major developmental challenges facing the country, the Government's economic development plan, and the World Bank's strategy to support government efforts. It includes a description of the current and future lending program and the plan for analytical work.
How do the CASs incorporate concerns about the AIDS epidemic and what sorts of strategies do they recommend for dealing with the epidemic? (Box Al provides general guidelines for incorporating AIDS issues in CASs.) A review of the CASs for 25 countries (6) found that coping with AIDS was not central to any of the country strategies. The AIDS epidemic was not discussed in 11 of the 25 CASs, including those for Haiti, where the incidence of AIDS is relatively high, and in Viet Nam, where the disease is spreading quickly (Table Al). An additional seven CASs briefly mentioned AIDS as a health issue, but did not describe the problem or how to address it in any detail. The remaining seven CASs included a more extensive discussion of AIDS issues.
Box A1: When Should a CAS Discuss AIDS? At a minimum all CASs for countries with a mature or developing AIDS epidemic should consider AIDS issues in the CAS. First, the CAS should discuss whether the development strategy proposed by the country and the Bank has either (a) the potential to exacerbate the epidemic or conversely, (b) whether the presence of the epidemic could hamper the achievement of the development objectives. To the extent that there are such effects, the document should say what the government is doing to address them. Second, the Bank's overarching objective is to help countries to reduce poverty. In countries with a severe epidemic, the epidemic is likely to impoverish many and push the already-poor deeper into poverty. When this is the case, the CAS should include some discussion of the implications of the AIDS epidemic on the poverty reduction strategy in the country. How do AIDS survivors fit into the current safety nets? Are they only candidates if otherwise poor (usually the best policy)? If there is no safety net, is the country really too poor to afford one? Is the government doing all it can to promote, rather than hamper, private assistance efforts by NGOs and/or communities?
The degree to which AIDS issues were addressed in the CAS varied by stage of the epidemic. Those countries with a high HIV prevalence (over 5 percent of the general adult population, according to WHO estimates) included a more in-depth discussion of the AIDS epidemic. They discussed the incidence or prevalence of the disease, in some cases indicating changes over time and the main modes of transmission. For example, the CAS for Malawi asserted that AIDS is spreading in epidemic proportions, with HIV infection in the 15-19 age group estimated at about 20 percent in urban and 8 percent in rural areas. Life expectancy in Malawi has declined from 46 years in 1980 to 44 in 1993 as a result of AIDS mortality. Two of the CASs, those for Tanzania and Uganda, also considered problems with the spread of other STDs.
Few of the documents communicated a country strategy for dealing with HIV/AIDS. Only ten CASs discussed any actions taken by the Government or the Bank to fight the HIV/AIDS epidemic, and all of these were for countries with either high or medium prevalence rates. These CASs included five countries that proposed STD and/or AIDS prevention or care, five that reported plans for analysis of HIV/AIDS and six that mentioned other HIV/AIDS interventions in a very general way. The Burundi CAS, after identifying the 'looming threat of AIDS' as a key constraint to economic development, mentioned that the Government is supporting education campaigns and the promotion of condoms to help slow the spread of STDs and HIV/AIDS. It did not, however, detail the Bank's support for these efforts except to mention that an AIDS rapid assessment survey was on-going.
Research from the Kegara region of Tanzania indicated that the poor and other vulnerable groups are the most severely affected by a death from AIDS of an adult in the household. These findings suggested that targeted programs for the poor are likely to be effective in mitigating the affects of AIDS (Over et al, forthcoming). This suggests the need for strong links between targeted poverty programs and AIDS mitigation efforts. The CASs for Burundi and Uganda were the only ones to make this link when they identify plans for specific targeted programs. The Uganda CAS, which indicated the need for specific targeted programs for vulnerable groups such as AIDS patients and AIDS widows and orphans, describes how two Bank projects will support the areas in Uganda most devastated by the AIDS epidemic.
Educating girls and other interventions to raise the status of women are additional ways in which governments can help to slow the spread of AIDS. About half of the 25 CASs discuss the poor status of women and/or the low educational enrollment rates of girls. Almost all of these CASs also outline measures supported by the Bank to improve the status of women or expand education for girls. Yet none of them made the link between support for these measures and potentially lowering the transmission of HIV/AIDS.
There are several other issues related to HIV/AIDS that one might have expected to see discussed in the CASs. The financial impact of the epidemic on the health sector and recommended policies to mitigate it has traditionally been one of the first policy considerations. Only two of the CASs (Cote d'Ivoire and Tanzania) alluded to this issue generally, but neither provided actual estimates of the cost of the impact. The effects on labor force productivity or on macroeconomic indicators could have been covered in some of the countries with high HIV prevalence, but they were not. The relationship between the AIDS epidemic and family planning activities was not discussed in any of the CASs.
Table A1: Selected HIV/AIDS Issues covered in 25 Country Assistance Strategies Describes Incidence/ Recommends Prevalence or Means Analysis of of Transmission of HIV/AIDS Country HIV/AIDS Generalized Epidemic Burkina Faso [check] [check] Burundi [check] Congo, [check] Democratic Republic of Cote d'Ivoire Haiti Kenya Malawi [check] Rwanda [check] Tanzania [check] Uganda [check] [check] Zambia [check] Zimbabwe Concentrated Epidemic Brazil China Honduras [check] India Thailand [check] Vietnam Nascent Epidemic (or * for stage not known) Indonesia Kyrgyz Republic * Mexico Morocco Philippines Romania * Yemen Total: 25 7 5 Recommends Recommends Targeted STD/AIDS Programs for Vulnerable Prevention (S) Groups (e.g. aid for Country or Care (+) widows & orphans) Generalized Epidemic Burkina Faso [check] Burundi [check] [check] Congo, Democratic Republic of Cote d'lvoire Haiti Kenya Malawi [check] Rwanda Tanzania Uganda + [check] Zambia Zimbabwe [check]+ Concentrated Epidemic Brazil China Honduras India Thailand Vietnam Nascent Epidemic (or * for stage not known) Indonesia Kyrgyz Republic * Mexico Morocco Philippines Romania * Yemen Total: 25 5 1 Note: There is no CASs for Botswana or Central African Republic. Source: Author's review
Appendix B: Analysis of HIV/AIDS in World Bank economic and sector work
This section discusses the coverage of AIDS in World Bank economic and sector work from 1990 to the present for the 27 selected countries. A previous review (World Bank 1996) of the sector work completed since 1991 for 12 African countries found that consideration of AIDS was greatest in poverty assessments, policy framework papers, and country assistance strategies, and least in public expenditure reviews and country economic memorandums. As a follow-up to that study, this paper reviews the following for each country (when available): country economic memorandum (CEM), poverty assessment, public expenditure review (PER), health sector reviews and gender analysis.
When the analysis for each country is considered as a whole, the economic and sector work for countries at an advanced stage of the AIDS epidemic included more extensive analysis of AIDS issues than did the sector work for countries where AIDS is less widespread (Table B1). The sector work for four (Malawi, Tanzania, Uganda, and Zambia) of the countries with a mature AIDS epidemic included economic analysis of the epidemic, in addition to a summary of trends in incidence and/or prevalence. In particular, the CEMs and poverty assessments for these countries considered the impact of AIDS on the economy at large, or on efforts to reduce poverty. Consideration of the effects of the epidemic on the macroeconomy has been most comprehensive for Tanzania, Zambia, and Uganda, and the main findings of the analysis are presented in Box B1. Overall, however, the inclusion of economic analysis of the AIDS epidemic was very limited in the reports reviewed and, with the above exceptions, AIDS was almost always considered in the more narrow context of a health sector issue.
Among the report types, the health sector analysis and joint CEM/Poverty assessment documents contained the most extensive economic analysis of AIDS. The most comprehensive analysis in the joint CEM/poverty assessments was highlighted above. Three-fourths of the health/social sector analyses reviewed included substantial coverage of AIDS issues. The most in-depth analysis is presented in the Tanzania AIDS Assessment and Planning Study, which includes analysis of incidence and prevalence of the epidemic, the likely demographic impact, and economic analysis of the costs of the epidemic and possible sectoral and macroeconomic effects. (7) The Malawi Population Sector Study contains extensive modeling of the potential demographic impacts of HIV/AIDS, considering several scenarios depending on the severity of the AIDS epidemic.
Discussion of AIDS was generally absent among the stand-alone CEMs, with the exception of the reports for Cote d'Ivoire, Indonesia and Zambia. The Cote d'Ivoire CEM draws on analysis done for other countries to predict how the epidemic is likely to affect the Ivoirian economy. Based on this analysis, the report lays out priority activities that should be part of a comprehensive government strategy. The Indonesia CEM highlighted the fact that STDs are becoming a more serious health problem and considers the per capita costs of several basic health care interventions, including those for TB and STD care and AIDS prevention. The Zambia CEM considered various ways in which the AIDS epidemic threatens to undermine prospects for economic growth, as discussed in Box B1.
Among the poverty assessments, analysis of AIDS issues varied. The reports for Cote d'Ivoire, Kenya and Malawi focused on how AIDS increased poverty by imposing additional costs on an already impoverished society. The report for Zimbabwe asserted that the AIDS crisis is exacerbated by the poverty situation. Poor men often go to urban areas to seek work, leaving the wife and family at home, and are at higher risk of sexual encounters outside of marriage and of infecting their family. In addition, the burden of caring for AIDS patients is often left to women in rural areas. The report suggests that a systematic and vigorous IEC campaign, along with affordable and easy access to condoms are needed to reduce transmission of AIDS.
This review confirms the finding in the World Bank report (1996) that PERs generally included very little analysis of the AIDS epidemic and its potential impact on the public budget or civil service. A few of the PERs did, however, provide a discussion of the public economics rationale for government intervention in the health sector, often finding a role for the government in fighting AIDS. For example, the Indonesia PER outlines three economic rationales for public involvement in the health sector: public good, equity and market failures. It cites communicable disease control and epidemiological surveillance as two types of public goods that should be publicly supported. Treating STDs, including AIDS, should be publicly supported because of their equity implications, as the report asserts (without evidence) that the poor are more likely to get these diseases. The PER for the Philippines asks the question: What can national government do that will not be done by the people themselves or by the local government? The main candidates are infectious disease control and health education campaigns of various types (smoking, HIV prevention, and nutrition), where many of the benefits of the activity will accrue to people outside the jurisdiction in which the health expenditures are borne. Local government may underprovide these policies, either because effects directly transcend political boundaries or because migration spreads the effects of interventions across jurisdictions. None of the PERs reviewed, however, took the next logical step of analyzing costs of the alternative public interventions to fight AIDS.
Box B1: Analysis of the Impact of AIDS on Growth and Macroeconomic Projections Tanzania. The rising prevalence of AIDS can be expected to affect the macroeconomy through a number of channels, which can be grouped into two broad categories. First, declines in 'healthiness' have four effects: reduced labor productivity; increased health care expenditures; reduced savings; and reduced human capital investments. Second, rising mortality rates, particularly among children and sexually active adults, reduce the population growth rate and change the age structure. A modeling exercise that took into account these effects, estimated that the presence of AIDS reduced the average real GDP growth rate in the 1985-2010 period by between 15 and 28 percent, from 4.0 percent per annum to 2.9-3.4 percent per year (depending on the productivity and savings parameters chosen). Over a 25 year period this decreases potential output by between (1980) Tsh 15 billion to Tsh 25 billion. The impact on growth of potential per capita GDP is more moderate, decreasing it by only 12 percent in the worst case scenario. Under the simulation, per capita GDP growth is forecast to grow an average annual rate of 0.7 percent in the hypothetical situation without AIDS, while with AIDS growth rates range between 0.3 and 0.8 percent per annum. (Tanzania AIDS Assessment and Planning Study. World Bank, 1992) Zambia. It is not easy to separate the impact of AIDS from the impact of other factors on such important variables as fertility rates and birth control practices, but recent research suggests that the impact of AIDS on population growth rates will be larger than earlier estimated. From an aggregate level of well over 3 percent in the 1980s, the current population growth rate is estimated at 2.8 percent. Estimates from various sources for the rate of population growth in 2005 vary from 1.7 to 2.3 percent. It is even more difficult to assess the impact on GDP projections. In some areas, such as cotton, it is not likely to have much direct effect, but for domestic food crops, such as maize, one would expect a proportionate reduction. Looking at the economy as a whole, the impact of AIDS on total output depends on the extent to which the impact is disproportionately on the more highly skilled workers, the degree of incapacity to work of AIDS patients, and the substitutability of unemployed workers for AIDS victims. One estimate using cross sectional production functions suggests that with prevalence rates of 20 percent, a two to one ratio of skilled incidence to unskilled incidence, and assuming that 50 percent of the direct AIDS costs come out of direct savings, the impact on per capita output is a negative 0.2 percent per year. In other words, if using these assumptions AIDS decreases annual population growth rates by one percentage point. AIDS would decrease output growth rates by 1.2 percentage points. (Zambia Country Economic Memorandum. World Bank, 1996) Uganda. Prospects for accelerated growth are likely to be adversely affected by the AIDS epidemic. WHO projects that the number of HIV-infected people could increase to more that 1.9 percent by 1998. In 1993-98, 565,000 adults and 250,000 children will die from AIDS. HIV prevalence is found to be higher in urban areas and among the more educated occupational groups in Uganda. Instead of the labor force growing from 400,000 to 1.1 million by 2010, it is estimated to reach only 740.000 because of deaths among workers between the ages of 35 and 50. Studies on the economic impact of AIDS are less conclusive. Nonetheless, private savings and investment, labor supply, and hence growth are likely to be adversely affected by the epidemic. In the hard-hit areas, less land is under cultivation and farmers have shifted to less-labor intensive crops (no specific evidence is cited to support these assertions). Interest in long-term planning and investments has decreased. Health expenditures per capita are likely to go up, but as resources are limited, the time required to care for the sick may further reduce labor input and hence growth. (Uganda: The Challenge of Growth and Poverty Reduction, World Bank, 1996) Table B1: AIDS Analysis in World Bank Economic and Sector Work, 1990-96 Poverty Country CEM Assessment Generalized Epidemic Botswana Burkina Faso Burundi ++R * Central African Republic ++R Congo, Democratic Republic Cote d'Ivoire ++R ++R Haiti Kenya - ++ Malawi +++ Rwanda ++R * Tanzania ++R * Uganda +++R * Zambia +++ +++R Zimbabwe ++R * Concentrated Epidemic Brazil - - China - - Honduras + India - - Mexico - - Thailand - - Vietnam + Nascent Epidemic or Unknown Stage Indonesia +++ - Kyrgyz Republic - - Morocco - Philippines - Romania Yemen - - Health Sector Country PER Work Generalized Epidemic Botswana Burkina Faso - Burundi - Central African Republic Congo, Democratic Republic Cote d'Ivoire - - Haiti Kenya Malawi - ++R Rwanda Tanzania +R +++R Uganda + +++R Zambia R Zimbabwe + Concentrated Epidemic Brazil China - Honduras India - ++R Mexico Thailand Vietnam - Nascent Epidemic or Unknown Stage Indonesia +R + Kyrgyz Republic - Morocco - Philippines +R Romania Yemen - * Joint PER/Poverty Assessment. Legend: A blank indicates that there was no recent report to review - no discussion of HIV/AIDS + a brief mention of HIV/AIDS, but no in-depth discussion ++ incidence and/or prevalence rates discussed +++ incidence and/or prevalence rates discussed, plus economic analysis, including cost analysis and/or macro/sectoral analysis R policy recommendations given Source: Author's review Appendix C: World Bank Projects with an HIV/AIDS Component PRIORITY INTERVENTIONS (when targeted to high-risk groups) Condom STD Country Project Promotion Treatment Generalized Epidemic Benin Health Services Benin Health and Population 1 1 Burundi Population and Health Cote d'Ivoire Integrated Health Services 1 1 Guinea-Bissau Social and Infrastructure 1 Guinea-Bissau Social Sector Haiti First Health Kenya Third Population 1 Kenya Fourth Population Kenya Health Rehabilitation 1 Lesotho Second PHN 1 Malawi PHN Rwanda First Population 1 Tanzania Health and Nutrition 1 Uganda First Health Uganda Transport Zambia Health Sector 1 Sub-total 3 8 Share 18% 47% Concentrated epidemic Angola Health 1 Brazil NE Endemic Disease Cameroon SDA 1 Cameroon Health, Fertility, and Nutrition 1 1 Chad Health and Safe Motherhood 1 China Infectious and Endemic Disease 1 China Comprehensive Maternal and Child 1 China Disease Prevention 1 1 Gambia National Health Development 1 1 Guinea Health Services 1 Guinea Health and Nutrition 1 Honduras Nutrition and Health 1 Malaysia Health Development Mali 2nd Pop and Rural Water 1 Niger Health 1 1 Niger Population 1 Niger Health II 1 1 Nigeria National Population 1 Nigeria Imo Health and Population 1 Nigeria Health System 1 Senegal Human Resources Development 1 Togo Population and Health 1 1 Sub-total 14 12 Share 64% 55 % Nascent Epidemic Madagascar Economic Management and Social Action Madagascar Health Sector Improvement 1 Mauritania Health and Population 1 Morocco Social Priorities- Basic Health 1 1 Morocco Second Health Papua New Pop and Family Planning 1 1 Guinea Yemen Family Health 1? Sub-total 3 3 Share 43% 43% Stage of epidemic unknown Comoros Population and Human Resources Equatorial Guinea Health Improvement 1 Kyrgyz Republic Health Sector Reform 1 Macedonia, FYR Health Sector Romania Health Services Sub-total 1 2 Share 20% 40% Grand Total 21 25 Share 41% 49% PRIORITY INTERVENTIONS (when targeted to high-risk groups) Operational Research, Surveillance Targeted Evaluation, Country Project IEC and Monitoring Generalized Epidemic Benin Health Services Benin Health and Population 1 1 Burundi Population and Health 1 Cote d'Ivoire Integrated Health Services 1 Guinea-Bissau Social and Infrastructure Guinea-Bissau Social Sector 1 Haiti First Health 1 Kenya Third Population Kenya Fourth Population 1 Kenya Health Rehabilitation 1 Lesotho Second PHN 1 1 Malawi PHN 1 Rwanda First Population 1 Tanzania Health and Nutrition Uganda First Health 1 1 Uganda Transport 1 Zambia Health Sector 1 1 Sub-total 8 9 Share 47% 53% Concentrated epidemic Angola Health 1 Brazil NE Endemic Disease 1 Cameroon SDA 1 Cameroon Health, Fertility, and Nutrition Chad Health and Safe Motherhood 1 China Infectious and Endemic Disease 1 China Comprehensive Maternal and Child China Disease Prevention 1 1 Gambia National Health Development 1 Guinea Health Services 1 Guinea Health and Nutrition 1 Honduras Nutrition and Health 1 1 Malaysia Health Development Mali 2nd Pop and Rural Water Niger Health 1 ? Niger Population 1 Niger Health II 1 Nigeria National Population 1 Nigeria Imo Health and Population 1 Nigeria Health System 1 Senegal Human Resources Development 1 1 Togo Population and Health 1 Sub-total 6 15 Share 27 % 68% Nascent Epidemic Madagascar Economic Management and Social Action 1 Madagascar Health Sector Improvement 1 1 Mauritania Health and Population 1 Morocco Social Priorities- Basic Health Morocco Second Health Papua New Pop and Family Planning 1 1? Guinea Yemen Family Health 1? 1? Sub-total 2 3 Share 29% 43% Stage of epidemic unknown Comoros Population and Human Resources 1 1 Equatorial Guinea Health Improvement 1 Kyrgyz Republic Health Sector Reform Macedonia, FYR Health Sector Romania Health Services Sub-total 1 2 Share 20% 40% Grand Total 17 29 Share 33% 57% PRIORITY INTERVENTIONS (when targeted to high-risk groups) Mass-media Treatment IEC of AIDS and Operational Country Project Infections Generalized Epidemic Benin Health Services 1 Benin Health and Population 1 1 Burundi Population and Health 1 1 Cote d'Ivoire Integrated Health Services 1 1 Guinea-Bissau Social and Infrastructure 1 Guinea-Bissau Social Sector 1 Haiti First Health Kenya Third Population Kenya Fourth Population Kenya Health Rehabilitation Lesotho Second PHN 1 1 Malawi PHN 1 Rwanda First Population Tanzania Health and Nutrition Uganda First Health 1 1 Uganda Transport Zambia Health Sector 1 Sub-total 8 7 Share 47% 41 % Concentrated epidemic Angola Health Brazil NE Endemic Disease 1 1 Cameroon SDA 1 1 Cameroon Health, Fertility, and Nutrition 1 Chad Health and Safe Motherhood 1 China Infectious and Endemic Disease China Comprehensive Maternal and Child China Disease Prevention 1 Gambia National Health Development Guinea Health Services Guinea Health and Nutrition 1 Honduras Nutrition and Health 1 Malaysia Health Development 1 Mali 2nd Pop and Rural Water Niger Health Niger Population 1 Niger Health II 1 1 Nigeria National Population 1 Nigeria Imo Health and Population 1 Nigeria Health System Senegal Human Resources Development Togo Population and Health 1 1 Sub-total 11 6 Share 50% 27% Nascent Epidemic Madagascar Economic Management and Social Action Madagascar Health Sector Improvement 1 Mauritania Health and Population Morocco Social Priorities- Basic Health 1 1 Morocco Second Health Papua New Pop and Family Planning Guinea Yemen Family Health 1? Sub-total 2 1 Share 29% 14% Stage of epidemic unknown Comoros Population and Human Resources Equatorial Guinea Health Improvement Kyrgyz Republic Health Sector Reform 1 Macedonia, FYR Health Sector Romania Health Services 1 Sub-total 1 1 Share 20% 20% Grand Total 22 15 Share 43% 29% OTHER INTERVENTIONS Blood Safety (equipment HIV Testing supplies and Country Project and training) Counseling Generalized Epidemic Benin Health Services Benin Health and Population ? Burundi Population and Health 1 Cote d'Ivoire Integrated Health Services Guinea-Bissau Social and Infrastructure 1 Guinea-Bissau Social Sector Haiti First Health 1 Kenya Third Population Kenya Fourth Population Kenya Health Rehabilitation 1 Lesotho Second PHN 1 Malawi PHN 1 Rwanda First Population ? Tanzania Health and Nutrition Uganda First Health 1 Uganda Transport Zambia Health Sector Sub-total 4 3 Share 24% 18% Concentrated epidemic Angola Health Brazil NE Endemic Disease 1 Cameroon SDA 1 Cameroon Health, Fertility, and Nutrition Chad Health and Safe Motherhood China Infectious and Endemic Disease China Comprehensive Maternal and Child China Disease Prevention Gambia National Health Development Guinea Health Services Guinea Health and Nutrition Honduras Nutrition and Health 1 1 Malaysia Health Development 1 Mali 2nd Pop and Rural Water Niger Health ? Niger Population Niger Health II 1 Nigeria National Population Nigeria Imo Health and Population 1 Nigeria Health System Senegal Human Resources Development Togo Population and Health 1 Sub-total 5 3 Share 23% 14% Nascent Epidemic Madagascar Economic Management and Social Action Madagascar Health Sector Improvement Mauritania Health and Population Morocco Social Priorities- Basic Health Morocco Second Health Papua New Pop and Family Planning Guinea Yemen Family Health Sub-total 0 0 Share 0% 0% Stage of epidemic unknown Comoros Population and Human Resources 1 Equatorial Guinea Health Improvement Kyrgyz Republic Health Sector Reform Macedonia, FYR Health Sector 1? 1 Romania Health Services 1 Sub-total 1 2 Share 20% 40% Grand Total 10 8 Share 20% 16% OTHER INTERVENTIONS Amount Total for Country Project Bank HIV/AIDS Generalized Epidemic Benin Health Services 18.60 0.60 Benin Health and Population 27.80 1.20 Burundi Population and Health 14.00 1.20 Cote d'Ivoire Integrated Health Services 40.00 3.00 Guinea-Bissau Social and Infrastructure 5.00 0.05 Guinea-Bissau Social Sector 8.80 1.00 Haiti First Health 28.20 1.70 Kenya Third Population 12.20 7.00 Kenya Fourth Population 35.00 5.00 Kenya Health Rehabilitation 31.00 1.00 Lesotho Second PHN 12.10 0.90 Malawi PHN 55.50 0.23 Rwanda First Population 19.60 2.40 Tanzania Health and Nutrition 47.60 5.00 Uganda First Health 52.50 1.66 Uganda Transport 75.00 0.50 Zambia Health Sector 56.00 tbd Sub-total 538.90 32.44 Share Concentrated epidemic Angola Health 19.90 0.75 Brazil NE Endemic Disease 109.00 6.60 Cameroon SDA 21.50 0.40 Cameroon Health, Fertility, and Nutrition 43.00 0.40 Chad Health and Safe Motherhood 18.50 0.10 China Infectious and Endemic Disease 90.00 0.48 China Comprehensive Maternal and Child 100.00 0.40 China Disease Prevention 129.60 0.48 Gambia National Health Development 5.60 0.10 Guinea Health Services 19.70 1.00 Guinea Health and Nutrition 24.60 tbd Honduras Nutrition and Health 25.00 0.67 Malaysia Health Development 50.00 16.00 Mali 2nd Pop and Rural Water 26.60 1.40 Niger Health 27.80 0.35 Niger Population 17.60 0.60 Niger Health II 40.00 1.70 Nigeria National Population 78.50 tbd Nigeria Imo Health and Population 27.60 1.00 Nigeria Health System 70.00 tbd Senegal Human Resources Development 35.00 0.60 Togo Population and Health 14.20 1.00 Sub-total 993.70 34.03 Share Nascent Epidemic Madagascar Economic 22.10 0.43 Management and Social Action Madagascar Health Sector Improvement 31.00 1.60 Mauritania Health and Population 15.70 0.20 Morocco Social Priorities- Basic Health 68.00 tbd Morocco Second Health 104.00 8.00 Papua New Pop and Family Planning 6.90 0.66 Guinea Yemen Family Health 36.60 0.25 Sub-total 284.30 11.14 Share Stage of epidemic unknown Comoros Population and Human Resources 13.00 0.29 Equatorial Guinea Health Improvement 5.50 0.23 Kyrgyz Republic Health Sector Reform 18.50 0.50 Macedonia, FYR Health Sector 16.90 0.77 Romania Health Services 150.00 21.50 Sub-total 203.90 23.29 Share Grand Total 2020.80 100.90 Share Notes: A question mark (?) indicates the SAR was ambiguous regarding this intervention; tbd = to be determined. Source: Author's review
Appendix D: The link between economic and sector analysis and project success
The relationship between the amount of sector work prepared prior to the project and project success was investigated following a method similar to the one used in World Bank (1995). 'Project success' was measured using the average project implementation rating from project supervision reports (as reported in the MIS), evaluated on a four-scale criteria: high satisfactory (1), satisfactory (2), unsatisfactory (3), and unsatisfactory (4). The average project implementation rating was 'satisfactory' (2) and there was very little variation by region (Table D-1).
The amount of high quality sector work was measured by the number of sector reports completed in the three years preceding the project, as documented in the World Bank Reports database. Another measure of the amount of sector work is the number of staff weeks dedicated to sector analysis during the three years preceding project approval, although this measure does not take into account the quality of the analysis, (9) Projects in Sub-Saharan Africa had the fewest average number of completed health sector reports per project (0.5 per project). In contrast, projects in South Asia were most likely to have more completed sector work--an average of almost 1 completed report per project-although the countries in this region seemed to have spent more staff weeks preparing sector work.
Neither of these variables was significant in predicting project success, nor were they significantly related to the measure of project success. (10) This may be due to the small sample size (53 projects were include in the analysis) or the limited variation in project implementation ratings (almost all project received a '2').
The nine projects that focused primarily on AIDS prevention and mitigation tend to perform the same as the overall average (1.9 compared with 2.0) (Table D-2). A higher average number of sector reports was completed (0.9 per project) and the average staff weeks spent on health sector work during the previous three years was over twice as high as the average for all projects--111.6 compared with 45.8. Based on previous analysis (World Bank 1995), we would expect these projects to have a higher probability of success than the other AIDS related projects.
Table D-1: Implementation Ratings and Previous Health Sector Work for Projects with AIDS components, by Region Region Average Number of Implementation Completed Rating (1) Health Sector Reports in Previous 3 Fiscal Years Sub-Saharan Africa 2.0 0.5 South and East Asia 2.1 0.9 Latin America 2.0 0.8 Other regions 1.8 0.6 Average of all projects 2.0 0.6 Region Staff Weeks Spent on Health Sector Work in Previous 3 Fiscal Years Sub-Saharan Africa 44.4 South and East Asia 212.5 Latin America 33.0 Other regions 30.9 Average of all projects 45.8 (1) The average of all supervision implementation ratings as of 10/31/96. Scale: l=highly satisfactory; 2=satisfactory; 3=unsatisfactory; 4=highly unsatisfactory. Source: World Bank MIS reports Table D-2: Implementation Ratings and Sector Work Preceding Project for the Nine Free-standing AIDS Projects Number of Completed Health Sector Average Reports in Implementation Previous 3 Project Rating (1) Fiscal Years Brazil AIDS and STD Control 2 2 Burkina Faso Population and AIDS Control 2 0 Chad Population and AIDS Control 1 1 India National AIDS Control 2 2 Indonesia HIV/AIDS and STD 2 1 Kenya STI 2 0 Uganda STI 2 0 Democratic Republic of Congo 2 0 National AIDS Control Zimbabwe STI Prevention and Care 2 2 Average 1.9 0.9 Staff Weeks Spent on Health Sector Work in Previous 3 Project Fiscal Years Brazil AIDS and STD Control 54.3 Burkina Faso Population and AIDS Control 10.9 Chad Population and AIDS Control 45.4 India National AIDS Control 212.5 Indonesia HIV/AIDS and STD Kenya STI 195.8 Uganda STI 205.3 Democratic Republic of Congo 76.7 National AIDS Control Zimbabwe STI Prevention and Care 91.6 Average 111.6 Source: World Bank MIS tables
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Lamboray, J-L. and A.E. Elmendorf. 1992. Combating AIDS and Other Sexually Transmitted Diseases in Africa: A Review of the World Bank's Agenda for Action. World Bank Discussion Paper, Africa Technical Department Series Number 181. Washington, D.C.
World Bank. 1995. Economic and Sector Work and Results on the Ground. Operations Policy Department. Washington, D.C.
World Bank. 1996. "AIDS Prevention and Midgation in Sub-Saharan Africa: A Strategy for Africa " Human Resources and Poverty Division, Technical Department, Africa Region. Report number 15569. Washington, D.C.
World Bank. 1997. Confronting AIDS: Public Priorities in a Global Epidemic. Policy Review Report. New York: Oxford University Press.
(1) This paper reviews the same 12 African countries reviewed in World Bank (1996).
(2) This section is based on Confronting AIDS: Public Priorities in a Global Epidemic, World Bank, 1996.
(3) Political support and implementation capacity in the country will not be discussed in this paper.
(4) This review is based on the project descriptions in the Staff Appraisal Reports (SAR). Any additions and/or changes made to the project since then have not yet reflected in this discussion.
(5) The project for Burkina Faso estimates how many couples will be using condoms and assumes 90 percent efficacy of condoms use. It then estimates the direct costs saved, assuming that all of these couples would become HIV-positive without wearing condoms. According to epidemiological trends in HIV/AIDS, this last assumption is completely unreasonable.
(6) There is no CAS for Botswana or Central African Republic.
(7) Eight more AIDS assessments are at various stages of preparation.
(8) The assumption is that reports must be of a sufficiently high quality to be recorded in this database.
(9) The source for this information is the MIS.
(10) Regressing the project implementation rating on the number of reports completed and, separately, the number of staff weeks both yielded statistically insignificant results (N=53). The Pearson's correlation between project success and number of reports completed was 0.07 (, p=-.75) and between project success and staff weeks of sector work was 0.08, (p=0.56). The correlation between staff weeks spent health sector analysis and reports completed was also insignificant (Pearson's correlation 0,19, p=.15), suggesting that these two indicators are not measuring the same thing and are not good proxies for each other.
Table 1: Stages of the Epidemic for 27 Developing Countries Nascent Concentrated Generalized Less than More than 5 percent 5 percent or more of 5 percent of high risk groups women in urban of high risk infected, less than 5 antenatal clinics groups infected percent of women in infected urban antenatal clinics infected Indonesia Brazil Botswana Morocco China Burkina Faso Philippines Honduras Burundi Yemen India Central African Republic Mexico Congo Thailand Cote d'Ivoire Vietnam Haiti Kenya Malawi Rwanda Stage of Epidemic Tanzania Unknown: Uganda Kyrgyz Republic Zambia Romania Zimbabwe Source: Statistical appendix, Table 2, Confronting AIDS: Public Priorities in a Global Epidemic Table 2: Bank Lending for HIV/AIDS Interventions Stage of the Number of Number of Total Lending Epidemic Projects Countries for HIV/AIDS Components (US $ millions) Generalized 21 14 202 Concentrated 26 16 291 Nascent 8 6 36 Stage unknown 5 5 23 TOTAL 60 41 552 Source: Appendix C Table 3: Economic Analysis for Nine AIDS-focused Projects Analysis of Costs, Benefits and Rationale for Counterfactuals Public Project Involvement Assumptions Model Brazil AIDS and Imperfect Two sets of WHO Expanded STD Control information; assumptions: 1. Program of Four externalities (i) as of 1991, Immunization components: 425,000 people model (i) prevention currently through IEC and infected; (ii) medical staff widespread training; transmission (ii) treatment began in 1980; services; (iii) annual (iii) incidence of institutional HIV continues development to to increase build capacity until 1999. 2. to deal with (i) and (ii) HIV/AIDS same as above, (mainly plus (iii) training and incidence upgrading of increases only laboratories); until 1995 and (iv) surveillance, then decrease research and evaluation. Burkina Faso Not explicitly 1. a loss per None Population and discussed AIDS death of AIDS Control 43 yrs for men Three and 49 yrs per components: woman 2. (i) family incidence rate planning; of .173 per (ii) STD/HIV/AIDS thousand 3. prevention and discount rate treatment; of 3 percent (iii) grants for private sector. Chad Population Not explicitly None given None specified and AIDS discussed Control Four components: (i) reinforce implementation of natl population policy (ii) HIV/AIDS/STDs prevention (iii) social marketing of condoms; (iv) promoting participation of private sector and NGOs India National Not explicitly 1. 1991 WHO AIDS Control discussed underlying Expanded Project prevalence of Program of 200,000 HIV + Immunization Five components: in risk groups Model (i) promote public and 200,000 awareness and people in the community support general (ii) improve blood population safety 2. 8 percent (iii) build discount rate surveillance 3. each AIDS and clinical case is management associated with capacity 30 related (iv) Improve STD illnesses, or clinical services which 20 will (v) strengthen incur medical management care at USS 10 capacity per illness at national and (1992 $), state levels increasing 8 percent/yr. 4. every patient with AIDS will require 250 days of care, of which 25 will require hospital care at US$30/day Indonesia HIV/AIDS Not explicitly 1. demographics Inter Agency and STDs discussed based on 1980 Working Prevention and 1990 Group AIDS and Management censuses model 2. host/virus (i) two pilot contact: programs for IEC (i) HIV 'seed' and strengthening was 1000 in of STD care 1990; (ii) central (ii) STD and activities to circumcision improve STD rates assumed delivery, 3. Sexual surveillance, mixing patterns laboratory based on improvements, and census and IEC community surveys 4. Mode of transmission: 95 percent sexual contact Kenya STI Project Not explicitly None given None discussed presented Three components: (i) strengthen institutional capacity (ii) prevention of STIs (iii) address social and economic consequences, including drugs for opportunistic infections and support to NGOs. Uganda STI Project Not explicitly None None discussed Three components: (i) prevent sexual transmission of AIDS & other STDs (ii) mitigation of personal impact of AIDS (iii) institutional development Democratic Not explicitly 1. current WHO model Republic discussed level of of Congo National infection of 6 AIDS Control percent in urban and 1 Four components: percent in (i) IEC and condom rural areas distribution 2. Conversion (ii) integration of rate of 4 AIDS control percent/year activities 3 (iii) operational seroprevalence research stays at 2 per (iv) institutional 1000 4. strengthening estimates of the number of treated cases base on projected health coverage. Zimbabwe STI Not explicitly None given None Prevention and discussed Care Five components: (i) condom provision (ii) STD treatment (iii) drugs for opportunistic infections (iv) supplies for HIV diagnosis and blood screening (v) biomedical security supplies Analysis of Costs, Benefits and Counterfactuals Benefits Costs Counter- Project Considered factual? Direct Brazil AIDS and IBRD and Yes, 2 300,000 lives STD Control government scenarios saved by 2001, Four costs equaling $US components: considered 594 million in (i) prevention direct through IEC and treatment costs medical staff (present value training; in 1992) (ii) treatment services; (iii) institutional development to build capacity to deal with HIV/AIDS (mainly training and upgrading of laboratories); (iv) surveillance, research and evaluation. Burkina Faso Bank, other 1992 scenario Ambulatory Population and donors, and (pre-project) treatment and AIDS Control government is the only one hospitalization Three costs considered cost $US 416 components: calculated (1992) per (i) family case. planning; (ii) STD/HIV/AIDS Costs prevention and averted by treatment; project not (iii) grants accurately for private calculated. sector. Chad Population IDA, other No Project would and AIDS donor, alleviate the Control Four government and burden' of components: community costs HIV/AIDS on (i) reinforce are analyzed about 12,000 implementation AIDS patients, of natl 21,000 population families, policy 45,000 orphans (ii) HIV/AIDS/STDs and the nation. prevention IEC and social (iii) social marketing are marketing of expected to condoms; produce (iv) promoting behavioral participation changes among of private 415,000 high sector and NGOs risk people. Benefits of project not valued in monetary terms. India National AIDS IDA, other Yes, By 2000, AIDS Control Project donors and without incidence government project and would be Five components: costs three 'with 500,000/yr (i) promote public considered project' without the awareness and scenarios-- project and community support AIDS 100,000, (ii) improve blood reduced by 150,000, or safety 20 percent, 200,000 in each (iii) build 30 percent of the AIDS surveillance or 40 scenarios. and clinical percent as a management result of the Direct cost capacity project savings at (iv) Improve STD current prices clinical services for the 30 (v) strengthen percent management scenario would capacity total US$388.4 at national and million for the state levels govt, and US$ 100.4 in private costs. Internal rate of return on govt direct costs = 26.7 percent Indonesia HIV/AIDS IBRD and Yes, 4 total 5000 fewer and STDs government (baseline AIDS cases by Prevention costs plus three) 2005; 22,500 and Management considered by 2010. (i) two pilot Present value programs for IEC of direct and strengthening treatment costs of STD care in Jakarta (ii) central US$6.3 for 2005 activities to and US$19.2 for improve STD 2010 delivery, surveillance, laboratory improvements, and IEC Kenya STI Project IDA, other No Evidence on the donors and govt success in Three components: costs are lowering (i) strengthen considered transmission of institutional AIDS and cost- capacity effectiveness (ii) prevention of of treating STIs STDs in a core (iii) address group in social and Nairobi. economic consequences, Condoms will be including drugs distributed to for opportunistic 5 million infections and people. 1.7 support to NGOs. million people will receive care for infections. Direct cost of project not calculated. Uganda STI Project IDA, other No 6650 TB donors and govt patients will Three components: costs are be treated; (i) prevent sexual considered Condoms will be transmission of distributed to AIDS & other STDs 4 million (ii) mitigation of people; 1.9 personal impact of million people AIDS with HIV will (iii) receive care institutional for infections; development 7,000 health workers will receive protective supplies. Direct costs saved are not estimated. Democratic IDA, other No, scenario Direct costs of Republic donors, without project AIDS presented of Congo National government and is the only one for each year AIDS Control beneficiary considered 8993 and for costs 2000 and 2010. Four components: considered The average (i) IEC and condom cost of each distribution AIDS patient (ii) integration of (per year--on AIDS control average activities patients die (iii) operational within the year research after clinical (iv) institutional manifestations strengthening of the disease) is USS 229 in constant 1986 dollars. Direct benefits of project not calculated. Zimbabwe STI IDA, other Only current 65,000 TB Prevention and donor and govt costs patients will Care costs considered receive considered treatment; Five components: condoms will be distributed to (i) condom 700,000 people; provision 180,000 people (ii) STD treatment with HIV will (iii) drugs for receive care; opportunistic 5,000 health infections care workers (iv) supplies for will have HIV diagnosis and protective blood screening supplies; and (v) biomedical 575,000 people security supplies will be tested. Direct benefits of project not Benefits Project Indirect Fiscal Impact Fungibility Brazil AIDS and Indirect plus Incremental STD Control direct costs recurrent cost Four estimated at estimated at components: US$1.2 billion US$ 150.3 (i) prevention (present value million through IEC and in 1992) medical staff training; (ii) treatment services; (iii) institutional development to build capacity to deal with HIV/AIDS (mainly training and upgrading of laboratories); (iv) surveillance, research and evaluation. Burkina Faso Cost per AIDS Population and case = $US AIDS Control 7,488 (1992). Three components: (i) family planning; (ii) STD/HIV/AIDS Project prevention and benefits not treatment; calculated. (iii) grants for private sector. Chad Population None given Very limited Not discussed and AIDS incremental Control Four effect on components: recurrent costs (i) reinforce implementation of natl population policy (ii) HIV/AIDS/STDs prevention (iii) social marketing of condoms; (iv) promoting participation of private sector and NGOs India National By 2000, Recurrent AIDS loss to costs Control Project national implications income are small but Five components: avoided costs of (i) promote public US$2.5-3.0 dealing with awareness and billion AIDS community support patients will (ii) improve blood likely safety escalate (iii) build surveillance and clinical management capacity (iv) Improve STD clinical services (v) strengthen management capacity at national and state levels Indonesia HIV/AIDS Total: Impact on Not discussed and STDs US$140 government Prevention million by recurrent and Management 2005 and costs not US$551 evaluated (i) two pilot million by programs for IEC 2010 and strengthening of STD care (ii) central activities to improve STD delivery, surveillance, laboratory improvements, and IEC Kenya STI Project Total direct Recurrent Risk that and indirect cost broad Three components: costs of AIDS implications government (i) strengthen to the country are estimated support may institutional could reach 15 to be small not capacity percent of GDP materialize (ii) prevention of by the year and govt STIs 2000 (about $US capacity may (iii) address 19,000 per AIDS be too weak to social and case). implement economic consequences, Indirect costs including drugs saved from for opportunistic project not infections and calculated. support to NGOs. Uganda STI Project None Recurrent Risk that cost broad Three components: implications government (i) prevent sexual are estimated support may transmission of to be small not AIDS & other STDs materialize (ii) mitigation of and govt personal impact of capacity may AIDS be too weak to (iii) implement institutional development Democratic Healthy life Cost recovery Poor managerial Republic years saved per assessed and capability is a of Congo National case of project project risk AIDS Control infection would affordability be 6.2 and compared with Four components: based on annual other health (i) IEC and condom incomes in interventions distribution Democratic (ii) integration Republic of of AIDS control Congo, this is activities equivalent to (iii) operational US$5,512 in research urban areas and (iv) institutional USS 893 in strengthening rural areas. The average would be about US$4,600, which is about 20 times higher that the direct costs of AIDS. Benefits of project not estimated. Zimbabwe STI Indirect costs Cost recovery Prevention and are about 20 discussed Care times direct costs--as much Five components: as US$21,300 per case. (i) condom provision Benefits of (ii) STD treatment project not (iii) drugs for estimated. opportunistic infections (iv) supplies for HIV diagnosis and blood screening (v) biomedical security supplies Source: Project Staff Appraisal Reports.