9 to deliver services and provide education. No less than 85% of the projects include IEC components or substantial IEC activities, and over half (54%) involve the mobilization of community su?port groups to encourage the acceptance of IEC and/or services. The issues are therefore not whether outreach activities are being attempted, but how well these are targeted and how effectively IEC and delivery activities are designed.

# Targeting

It is hard to see how progress toward PHN objectives can be monitored, or adequate incentives to field staff be provided, without some form of quantitative targets La measur. against. Despite the fact that almost all PHN projects include the potentially quantifiable objectives of increasing the coverage and quality of PHN services, only 58% of the PHN projects sampled have numerical targets. An annual breakdown of the projects reviewed indicates that there has been no trend toward increasing quantification of targets in the last fi-e years. In addition, as the Bank's 1986 Review of Health Lending also noted, where there are targets, types of targets are inconsistent between projects, with some focusing on input and output targets; others including hard-to-measure impact targets; and few including process targets and indicators. Case 1, the Zimbabwe Family Health Project (1986), is a good example of a project with clearly quantified output and process targets, and carefully chosen indicators to measure progress.

Broad quantitative targets and indicators allow monitoring of progress across populations, but may or may not be adequate to track progress in reaching specific client groups, or to give outreach workers an incentive to provide services to them. To the degree that client communities are stratified by class and income groups, rather than being homogeneously poor, targeting of particular clients becomes more important. The Bank's PHN projects have made some effort to target their resources to particular groups, in that in 40% of the sample the projects were concentrated on districts with relatively low PHN status or access to services. Much less has been done to target project resources to the particula.rly disadvantaged within given communities. This is of concern, since in the typical PHN program, workers are too busy to provide services to all clients, and will concentrate on those who come to the clinic for care, or whose homes are easiest to visit for outreach. The poorest and most at risk may not belong to these groups; it is quite possible for high or rapidly increasing levels of service utilization to be coupled with low levels of care for the most disadvantaged. Only one outreach project, the Tamil Nadu Nutrition Project (1980, Case 2) appears to have made a systematic effort to identify and assist the most disadvantaged (as opposed to the broader group of pregnant and lactating mothers and children who are the general beneficiarie. of MCH services, and of fertile women who are the main targets of FP services, in the typical project). In the Tamil Nadu case, the use of growth monitoring to target supplementary feeding and other project measures on those children failing to thrive, and on their families, has proved highly cost-effective. A recent evaluation indicates that the project has had twice as much impact on malnutrition, for similar or less cost compared to less targeted rrograms operating in the same state.