ECONOMIC ANALYSIS FOR HEALTH PROJECTS

This paper applies to the health sector a method of projectanalysis advocated recently by Devarajan, Squire, and Suthiwart-Narueput.A health project evaluation should establish a firm justificationfor public involvement; establish the counterfactual—whatwould happen with and without the project; and determine thefiscal effect of the project and the appropriate levels of feesin conjunction with project evaluation. The evaluation shouldalso acknowledge the fungibility of project resources and examinethe incentives both for high-level public servants to shiftgovernment resources away from project-funded activities tothose that have not been evaluated and for lower-level contractorsand civil servants to provide good or bad service. Market failuresin health services and insurance markets should serve as a startingpoint for economic analysis, not as a reason to ignore economicsin health projects. Project outputs should be predicted aftertaking into account the reaction of consumers and providersin the private sector as well as market structures of supply,demand, and equilibrium for health services.      

Weak Links in the Chain: A Diagnosis of Health Policy in Poor Countries

Recent empirical and theoretical literature sheds light on thedisappointing experience with implementation of primary healthcare programs in developing countries. This article focuseson the evidence showing two weak links in the chain betweengovernment spending for services to improve health and actualimprovements in health status. First, institutional capacityis a vital ingredient in providing effective services. Whenthis capacity is inadequate, health spending, even on the rightservices, may lead to little actual provision of services. Second,the net effect of government health services depends on theseverity of market failures—the more severe the marketfailures, the greater the potential for government servicesto have an impact. Evidence suggests that market failures arethe least severe for relatively inexpensive curative services,which often absorb the bulk of primary health care budgets.A companion paper, available from the authors (seep. 219), offersa perspective on how government funds can best be used to improvehealth and well-being in developing countries. It gives an alternativeview of appropriate public health policy, one that focuses onmitigating the characteristic market failures of the sectorand tailoring public health activities to the government's abilityto deliver various services.      

ACHIEVING SOCIAL OBJECTIVES THROUGH PRIVATE TRANSFERS: A Review

Private interhousehold cash transfers are an important sourceof income in many developing countries. Among the countrieswhose experience is reviewed in the article, the proportionof all households receiving private transfers ranges from afifth to a half. The amounts received are large, particularlywhen compared with the incomes of the poorest households. Understanding more about these transfers is important for designingpolicy because, among other things, these remittances providesocial and economic benefits similar to those of public programs,such as unemployment insurance, pension support, educationalcredit, and health assistance. As such, private transfers maysupplement or overlap with public transfers, and, if privatedonors give less as public transfers increase, the effect ofpublic programs on beneficiaries would be less than originallyintended. Or the transfers may alter the distributional effectsof public programs: for again, if private donors give less aspublic transfers increase, they share in some of the benefitsof public programs.      

FINANCING INFRASTRUCTURE IN DEVELOPING COUNTRIES: LESSONS FROM THE RAILWAY AGE

In recent years suggestions for reforming the provision andfinancing of infrastructure services in developing countrieshave focused on private participation. This alternative to publicfinancing is seen as a way both to minimize the inefficienciesof public administration and to avoid the need for externalborrowing. In fact, for much of the nineteenth century, infrastructureprojects were privately financed and built. This approach, however,did not obviate the need for government intervention and foreigncapital. Because of the difficulties of assessing projects,investors were reluctant to commit their funds, and governmentsturned to subsidies and loan guarantees to encourage investment.Often, however, government intervention only replaced one setof problems with another. Investors with government-guaranteedloans had no incentive to monitor the firm's performance—alimitation that led to the diversion of funds and frustratedthe public interest. This article draws out the implicationsof this experience for policymakers in developing countriestoday.      

HOUSEHOLD RESPONSES TO PUBLIC HEALTH SERVICES: COST AND QUALITY TRADEOFFS

The effectiveness of government investments in health care dependson the public's response to price and quality as well as onwhether these expenditures actually improve health outcomes.Consumers, even those in low-income households, are willingto pay fees for better health care if the fees translate intoimproved access and reliability. But when prices rise withouta concomitant improvement in services, malnutrition and childmortality rates increase. The availability of basic health carehas a relatively greater impact on households with low incomesor low education, or both, than does the provision of more specializedservices. This article describes the types of services for whichhouseholds indicate they are willing to pay increased fees.It also indicates the potential gains from improving these services,as well as the consequences of moving faster on cost recoverythan on providing improved or better-targeted services.      

The Upside to Fiscal Challenges: Innovative Partnerships Between Public and Private Sector

The first U.S. public‐private partnerships, or P3s as they are now called, began over 200 years ago. These contractual arrangements between government entities and private companies for the delivery of services or facilities have long been used for water/wastewater, transportation, urban development, and the provision of social services. And the use of such partnerships is increasing because they provide an effective means for meeting public needs, maintaining a high level of public control, improving the quality of services, and increasing the cost‐effectiveness of traditional delivery methods. Although outsourcing of public services is sometimes used to accomplish many of the same goals, P3s are likely to be a solution when public funds are not available and when:

• ? Capital is required to upgrade the infrastructure and so achieve a lower cost, or higher quality, of services.
• ? The contract horizon in the P3 transaction is sufficiently long for the investor/operation to recoup investment dollars and a rate of return.
• ? City residents make payments for the service provided, creating the revenue stream for private profits.
• ? The private partner in the P3 has a low cost of capital, often attributable largely to a large and sophisticated balance sheet.

This article uses examples of several recent P3 contracts to illustrate their role in shifting risk and increasing collaboration between the public and private sectors.     

Agricultural Extension: Good Intentions and Hard Realities

What considerations lead policymakers to invest in agriculturalextension as a key public responsibility, and what factors andagency incentives explain differences in extension system performance?To help answer these questions, this article provides a frameworkoutlining farmers' demand for information, the public goodscharacter of extension services, and the organizational andpolitical attributes affecting the performance of extensionsystems. This conceptual framework is used to analyze severalextension modalities and their likely and actual effectiveness.The analysis highlights the efficiency gains that can come fromlocally decentralized delivery systems with incentive structuresbased on largely private provision, although in most poorercountries extension services will remain publicly funded.      

Formal Water Markets: Why, When, and How to Introduce Tradable Water Rights

In most countries the state owns the water resources and thehydraulic infrastructure, and public officials decide who getsthe water, how it is to be used, and how much will be chargedfor it. But costly inefficiencies in the supply and use of watersupport a shift from government provision to a market-basedapproach that is more effective and less wasteful. Markets can allow rapid changes in allocation in response tochanging demands for water and can stimulate investment andemployment as investors are assured of access to secure suppliesof water. Because of water's unique characteristics, such marketsdo not work everywhere; nor do they resolve all water-relatedissues. By designing appropriate water laws and regulationsand by strengthening private and public institutions to administerthem, formal water markets can effectively address rising demandsfor groundwater and for water found in rivers, lakes, and canals.Lessons from Chile's experience demonstrate that formal watermarkets can improve the economic efficiency of water use andstimulate investment.      

GOVERNMENT SPENDING IN DEVELOPING COUNTRIES: Trends, Causes, and Consequences

Throughout the twentieth century governments have been spendingever larger proportions of national income. Three issues arisein discussions about the growth of such spending as it pertainsto developing countries: How does it compare with expenditurein industrial nations? What explains the growth in spendingby developing country governments? And what are the effectson economic growth? Government expenditure as a share of GDPin low- and middle-income countries, on average, is lower thancomparable shares in industrial market economies and, with fewexceptions, is growing. Many factors, including ideology, demographics,a positive income elasticity for public goods, the rising costof public goods relative to private goods, and perhaps developmenttheory and practice, explain this growth. As for the relationshipbetween government expenditure and economic growth, the empiricalevidence does not reveal any strong correlation. The size ofgovernment may engender strong ideological debate, but the positionthat the aggregate level of government expenditure is a significantdeterminant of growth rates receives little support.      

Opting Out of Public Insurance: Is It Socially Acceptable?

The privatization of social services is being increasingly discussed. The market of social services is often characterized by market failures, like informational asymmetries, externalities, distributional problems, which all justify public intervention. But the quality of services provided by public authorities or by private insurers in the context of health insurance is different and could be observable. The public reimbursement of health care is often conditional on rules, like the choice of the physician or the hospital, that induce a disutility of using social insurance instead of private insurance. An alternative solution to a complete privatization is to allow some individuals to opt out. We can imagine that the government allows and even in some cases favors part of the population leaving the public health insurance system. We analyze the situations where the opting out is welfare improving. We then study the optimal policy depending on the characteristics of the economy considering a Rawlsian criterion.     

Public Social Spending in Africa: Do the Poor Benefit?

Education and health care are basic services essential in anyeffort to combat poverty and are often subsidized with publicfunds to help achieve that purpose. This paper examines theeffectiveness of public social spending on education and healthcare in several African countries and finds that these programsfavor not the poor, but those who are better-off. It concludesthat this targeting problem cannot be solved simply by adjustingthe subsidy program. The constraints that prevent the poor fromtaking advantage of these services must also be addressed ifthe public subsidies are to be effective.      

Walking up the Down Escalator: Public Investment and Fiscal Stability

When growth-promoting spending is cut so much that the presentvalue of future government revenues falls by more than the immediateimprovement in the cash deficit, fiscal adjustment becomes likewalking up the down escalator. Although short-term cash flowsmatter, too tight a focus on them encourages governments toinvest too little. Cash-flow targets also encourage governmentsto shift investment spending off budget by seeking private investmentin public projects, irrespective of its real fiscal or economicbenefits. To deal with this problem, some observers have suggestedexcluding certain investments (such as those undertaken by publicenterprises deemed commercial or financed by multilaterals)from cash-flow targets. These stopgap remedies may help protectsome investments, but they do not provide a satisfactory solutionto the underlying problem. Governments can more effectivelyreduce the biases created by the focus on short-term cash flowsby developing indicators of the long-term fiscal effects oftheir decisions, including accounting and economic measuresof net worth, and, where appropriate, including such measuresin fiscal targets or even fiscal rules. JEL codes: O23, E62, H60, H54     

THE RELATIVE EFFICIENCY OF PRIVATE AND PUBLIC SCHOOLS IN DEVELOPING COUNTRIES

Aside from revenue mobilization, one of the arguments for allowingthe private sector to assume a larger role in the provisionof education is that it would increase efficiency, as administratorsbecome more responsive to the needs of students and their parents.But what is the evidence? Based on case studies that compareprivate and public secondary education in Colombia, the DominicanRepublic, the Philippines, Tanzania, and Thailand, private schoolstudents generally outperform public school students on standardizedmath and language tests. This finding holds even after holdingconstant for the fact that, on average, private school studentsin these countries come from more advantaged backgrounds thantheir public. school counterparts. In addition, preliminaryevidence shows that the unit costs of private schools are lowerthan those of public schools. Although these results cannot,in themselves, be used as arguments for massive privatization,they indicate that governments should reconsider policies thatrestrain private sector participation in education. Furtherresearch is needed to determine whether some teaching and administrativepractices in private schools are applicable to public schools.      

Financial Reporting BY Local Government And The Disproportionate Requirements Of AAS 27

This paper discusses the economic characteristics, and related financial reporting issues, of goods and services provided by local government. These goods are grouped into three categories: public, private, and mixed public/private goods and services. Modified cash-based reports are found to be proper for government units that provide public and mixed goods, and accrual-based accounting is appropriate for units that provide private goods. When the provision of mixed goods and services by local government is not mandatory, the disclosure of the market value of the assets employed in producing these goods or services is also warranted.     

Privatization and Regulation of Transport Infrastructure in the 1990s

Although the link between improved infrastructure services andeconomic growth is uncertain, it is clear that reforms aimedat creating competition and regulating natural monopolies establishan environment conducive to private sector participation, incentivesfor companies to strive for efficiency savings that can ultimatelybe passed on to consumers, and greater provision of services(such as faster roll-out of infrastructure or innovative solutionsto service delivery for customers not connected to an existingnetwork). In determining the form that infrastructure restructuringmight undertake or the design of a regulatory agency, policymakerscan generally benefit from a review of the experiences of othercountries. A key element of any decisionmaking process shouldbe a review of how the various types of reform will affect theefficiency of the sector and whether they will increase privatefinancing of its significant investment needs.      

THE PUBLIC SUBSIDIZATION OF EDUCATION AND HEALTH IN DEVELOPING COUNTRIES: A Review of Equity and Efficiency

The public sector in developing countries has traditionallyplayed an important role in the financing of educational andhealth services. This review finds, however, that the shareof public subsidies in these two sectors is not progressive,that is, proportionately higher for individuals in the lowersocioeconomic groups. This distribution persists despite explicitpolicies of universal free provision in many countries. Thearticle argues that the extent and pattern of public spendingcontribute to underinvestment and to a misallocation of scarceresources within the education and health sectors.      

Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries

In an earlier article, the authors outline some reasons forthe disappointingly small effects of primary health care programsand identified two weak links standing between spending andincreased health care. The first was the inability to translatepublic expenditure on health care into real services due toinherent difficulties of monitoring and controlling the behaviorof public employees. The second was the "crowding out" of privatemarkets for health care, markets that exist predominantly atthe primary health care level. This article presents an approach to public policy in healththat comes directly from the literature on public economics.It identifies two characteristic market failures in health.The first is the existence of large externalities in the controlof many infectious diseases that are mostly addressed by standardpublic health interventions. The second is the widespread breakdownof insurance markets that leave people exposed to catastrophicfinancial losses. Other essential considerations in settingpriorities in health are the degree to which policies addresspoverty and inequality and the practicality of implementingpolicies given limited administrative capacities. Prioritiesbased on these criteria tend to differ substantially from thosecommonly prescribed by the international community.      

BEYOND RATE OF RETURN: REORIENTING PROJECT APPRAISAL

Traditional approaches to project appraisal fail in practiceto address two fundamental questions: whether a project belongsin the public or the private sector; and what effect any externalassistance associated with the project has on the country'sdevelopment. The first issue is of general interest to bothnational policymakers and international donors. If the governmentprovides a good or service that would otherwise have been providedby the private sector, the net contribution of the public projectcould be low. The second issue is of particular concern to donors.If financial resources are fungible, the project being appraisedmight well have been undertaken with out external financing.In this case, donor funds are actually financing some other,unappraised project. Both cases argue for a shift in the emphasisof project evaluation away from a concern with precise rate-of-returncalculations and toward broader sectoral analyses and publicexpenditure reviews. In this context, three areas critical forproper project appraisal include a consideration of the rationalefor public intervention, the fiscal impact of the project, andthe fungibility of external assistance.      

THE IMPACT OF HEALTH AND NUTRITION ON EDUCATION

Child health and nutrition are strongly associated with educationalachievement. But associations do not necessarily indicate causality;estimates generally are likely to be biased in one directionor the other. As a result analysts and policymakers should havemuch less confidence in findings about the effect of healthon schooling success than has been claimed in previous surveys.The evidence is more nuanced and qualified than is often recognizedbut may still support the conclusion that health may have considerableeffects on postschooling productivity. Policy implications pointtoward providing public subsidies for the collection, analysis,and dissemination of information about the links between healthand education; and toward providing services to improve thehealth of poor children.      

Private Opportunity,Public Benefit?

The newly elected Labour government has pledged to ‘reinvigorate the Private Finance Initiative’, as part of the new emphasis on ‘public/private partnerships’ in the delivery of core public services. This article assesses the merits of using private finance to deliver public services against three criteria: whether it will lead to additional investment in social infrastructure, whether it represents good value for the taxpayer's money and whether the use of private finance will reduce the public sector's flexibility to pursue its public service objectives. JEL classification: H54, H11.