9 PHN 1991 Sector Review dialogue and operations in integrated human resource and social sector activities. Many projects now involve multiple line ministries and require significant coordination between the different parts of government (see Chapter 111). While these projects may be more complex and risky, they promise longterm payoffs as previously excluded ministries, particularly central ministries, such as planning and financing, are drawn toward a stronger commitment to social programs. The involvement of NGOs is on the increase. In nearly all twenty-eight of the PHN operations approved during the fiscal year, NGOs are assuming important roles in project implementation. lb a lesser, but still significant extent, NOOs are participating in the design of projects, as well (Ghana, Pakistan, Venezuela, for example). NGO involvement is particularly significant in projects with sector funds, where their role in eliciting from communities and in preparing, themselves, subproject proposals is certain to result in the design and support of PHN activity which is responsive to the needs of local populations and which is likely to be sustained.

2.19 The integration of PHN into broader human resource operations, was a welcome development, but not all projects need be multisectoral though planning must take place in a broader context. Indeed, as the sectors mature, specialized projects addressing specific needs may become increasingly important.

2.20 _Health._ In health there were three such specialized projects in FY9': the Korea Health Technology project, which seeks to expand the diagnostic and treatment capabilities of hospitals by upgrading equipment; the Algeria Pilot Public Health Management Project, which tests management tools for replicability nationwide; and the linisia Hospital Restructuring Support Project, which addresses issues of management capacity and service quality in the context of policy reform in the sector. The main thrust of health operations in FY91, however, has been on extending access to primary health care services in the context of poverty reduction.

2.21 Within primary health care, there has been considerable emphasis on maternal and child health services as well as on the Acquired Immune Deficiency Syndrc-Ae (AIDS) pandemic. Nutrition and population projects support important components of primary health care, and, so, share that emphasis, seeking to address the needs of young children and women and to integrate ard coordinate those services with other basic health services for greater efficiency and effectiveness. Thus the Bangladesh, Indonesia, and Pakistan projects aim at more effective integration of family planning with maternal child and health services than has previously been the case. The India Integrated Child Development project is strongly focused on nutrition, the Sri Lanka Poverty Alleviation project includes a nutrition fund aimed at improving the health of mothers and children, and the Honduras social development project includes pilot nutrition activities.

_2.22 Population._ Thirteen projects in the FY91 lending program provide direct support to family planning--up from eight last year. Lending volume rose as well, a doubling from $169.3 million in FY90 to $351.0 million (Annex 1 Tbble 8 and Figure 4). Most of the increase comes from the Bangladesh project ($61.5 million for population), advanced from the FY92 program; next year's program will be correspondingly reduced. Attribution of commitments to population in Bank PHN projects has always been difficult, but it has become increasingly so with the integration of PHN and other components. The $351.0 million FY91 total is a conservative estimate of direct lending and represents about 25 percent of the $1.3 billion committed to "pure" PHN projects and PHN components of social development projects, and over 50 percent of lending in PHN projects that include Bank assistance to population (Annex 1, Tbbles 8 and 9).

2.23 Cofinancing also made important contributions to family planning projects. The Bank made no direct contribution to family planning in the Zimbabwe Family Health project, but raised $17.7 million for population from other donors. In the Bangladesh family planning program, the Bank's allocation of $61.5 million of its assistance to family planning represents 34 percent of the IDA credit, but the total project ($600 million), commits over 60 percent to population. The Nigeria Population project will do much to promote a strong institutional framework for policy and program development, at both national and local levels, while building national consensus on the importance of reduced fertility for national and individual progress. The Pakistan Family Health