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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


Foreword

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.

I. Introduction

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.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

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.

Providing information

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


V. Conclusions

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


References

Devarajan, S., L. Squire, and S. Suthiwart-Narueput. 1995. "Reviving Project Appraisal at the World Bank." Policy Research Working Paper 1496. World Bank. Washington, D.C.

Futures Group International. 1996. "Etude de l'Impact Socio-economique du VIH/SIDA a Madagascar." Projet Banque mondiale Credit CR1697-MAG. Washington, DC.

Hammer, J. 1996. Economic Analysis for Health Sector Projects. Policy Research Department World Bank. Washington, D.C.

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.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1998 Gale, Cengage Learning. All rights reserved.

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Author:Dayton, Julia
Publication:World Bank HIV/AIDS Interventions - Ex-Ante and Ex-Post Evaluation
Date:Jun 1, 1998
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