12 Only about half of the 85% of projects that included an IEC component made provision for systematic feedback from clients about its effectiveness. Where this occurred, this was most commonly (44% of projects) through surveys or studies aimed at establishing changes in awareness and practice. In a minority of projects (about 8%), an effort was made to obtain feedback from service providers on a regular basis about the effectiveness of IEC. A particularly thorough effort to obtain feedback about the appropriateness of IEC messages was made in the Indonesia Nutrition and Community Health Proje.'t (1977, Case 6). This represents the Bank's only systematic attempt co date to apply social marketing techniques in the PHN sectors. Give.. the differentiated nature and distance of client populations and corresponding uncertainty about what IEC strategies and messages are appropriate, the fact that systematic qualitative feedback about IEC is not more widespread is cause for concern.

The same applies to feedback about the appropriateness of service delivery strategies, where only 36% of the projects had made provision for systematic qualitative feedba-k. This was accomplished in 23% of the projects through one-off surveys of client demand for, utilization of, and attitudes to services. Only 19% of the projects planned to do this through the development of regular feedback from clients, principally through the formation of local health committees to liaise with local service providers as for example in India Population 4 (1985) and the Guinea project (1987). Bank thinking about the development of qualitative feedback from clients in the PHN sectors appears to have lagged behind that in the agriculture sector. Feedback from clients is the driving force of the training and visit system of agricultural extension (Case 7), now being implemented in more than 40 countries.

By far the most important form of learning in the Bank's PHN projects has been through the development of management information systems for the collection, analysis and use of routine quantitative performance data. No less than 79% of the projects in the sample included efforts to strengthen managemert information sytems (MIS), the most systematic of which took place in the second, third and fourth India population projects (1980, 1983, and 1985; the early experience with this is documented in PHN Technical Note 85-3, 'Managing Health and Family Planning Delivery Through Management Information System"). To the extent that these MIS development efforts are successful, they will yield useful information on whether projects and interventions are progressing as planned. They will not, however, be a substitute for qualitative feedback from clients as a key source of information on yhy (as opposed to whether) implementation problems are occurring.

# Flexibility During Implementation

The inflexibility of their management procedures predisposes bureaucracies toward a "blueprint" approach to planning and implementation, whereas it is recognized that a "learning process" approach is more appropriate to the uncertainties of people-oriented development activities (World Development Reports No. 6, 1983, p. 92). A small minority (about 10O of the Bank's PHN projects have included specific institutional changes to