13 encourage learning, problem-solving, innovation, and flexibility in implementation. The Indonesia Nutrition Project's social marketing approach is an example in the case of IEC (Case 6). In the case of both IEC and services, Bangladesh Population III (1985) is financing a Management Development Unit staffed by consultants external to the Ministry of Health to work in the districts where the project will be initially implemented in order to (a) provide on-the-spot advice with implementation problems, (b) identify systemic problems which cannot be solved in the field, and seek appropriate solutions in consultation with senior management; and (c) feed back the lessons from experience in the pilot districts into the nation-wide management strategy for service delivery. In this case, a learning process has been established through a centralized unit in direct touch with the field.

By contrast, the successful Tamil Nadu Nutrition Project (1980) was designed on the basis of a detailed blueprint, elaborated in the project implement- tion volume and not changed very significantly during implemer ltion. This approach probably fits the rather special nature of the project--food supplementation--which is characterized by (a) limited, clear goals (closer to a vertical program than an integrated, multipurpose MCH program), (b) a product (food) for which there is existing demand, and (c) the relative ease of measuring progress in quantitalive terms through weighing. Such an approach may be less suited to activities where demand has to be generated, and little is known about how to generate it. Comparisons have often been drawn between the Tamil Nadu project and the training and visit (T&V) extension management system, but these are only partially valid. The systems are alike in the rigid structure of their routines, specified in detail for each level of staff; but the Tamil Nadu system is geared to delivering a standardized project, whereas the T&V system is designed to constantly vary the product both over time and in different locations (Case 7). In the T&V case (in contrast, for example, to the Bangladesh project cited above), the learning process has been established in a decentralized way, through each and every field unit, so maximizing the potential responsiveness to local conditions.

The absence from most PHN project designs of specific managerial arrangements to foster innovation and flexibility during implementation does not mean that these do not occur in the majority of projects--although the inertia of bureaucratic management systems will tend to discourage their emergence. The limitations of a desk study leave unanswered the following important questions. (a) How often (and how) are performance problems identified through the MIS corrected? (b) Are project-financed KAP studies of client responses to IEC used to develop alternative strategies or shelved? (c) Is the feedback gained directly from clients through their participation in health committees, etc., listened to and acted on?

# Incentives

The Bank has not systematically studied the issue of field worker (as opposed to client) incentives in the PHN sectors, and has no generally accepted vocabulary or conceptual framework for approaching the subject. But for practical purposes, three broad types of action to increase