12 important role in service delivery. This is the case in Bank-financed projects in the Africa region, and in the India project. In Haiti, health NGOs were involved in the consultations leading to project preparation. While a number of NMOs have worked in the EMENA region for many years, particularly in the Levantine countries and the Yemen Arab Republic (where one was involved in the Bank's first health project), tb.--. ave not, traditionally, been a common, or well-accepted, part of the political or social pocess. NGOs linked to the distribution of food aid did make a valued contribution until recently, but these programs have been much reduced or phased out in the last few years, partly because food aid is now handled primarily by the World Food Program. NOOs indigenous to the area are relatively new and smaii, and the Bank has not yet found ways to involve them in Bank-assisted projects.

24. In the Africa region, where government health services may reach less than half the population, NGOs have long played an important part in providing health, and more recently, family planning services. Recognition of this contribution has led the Bank to greater efforts to involve NGOs in Bank projects, efforts which have necessitated dialogue with governments to overcome some of the difficulties involved in this process. NGOs play an integral role in a number of FY90 approved projects in the Africa region, with substantial population components. In lbnzania, the Ministry of Health and UMATI, the family planning association of Tanzania, take joint responsibility for population and family planning activities. In Kenya, wl'ere the recent Demographic and Health Survey revealed that NGOs and other nongovernment providers account for almost 30 percent of family planning services delivered, government support for NCOs has been strot.6, and the project again finances improvements in service delivery and quality through NGOs. In Lesotho, two health and family planning NGOs are identified as beneficiaries of the project, together with the MOH. In The Gambia and Cameroon, too, NGOs are assisted through the project: in The Gambia to strengthen community-based distribution, and in Cameroon by way of cofinancing from USAID. In India, the government has for some time recognized the contribution of NGOs, and has put in place a system for grant assistance. The seventh project contains a very substantial component to strengthen NGO involvement (Annex 4, para. _5)._ 25. The Population NGO Special Grants Program (para. 38), administered by PHRDR, has complemented this process by its strategy of stimulating collaboration in Africa between governments and NGOs, and strengthening technical and administrative capacity in NGOs. Other questions regarding the increased use of NGOs are being addressed by research in the regions and in PHRHN. For example, a study of the sustainability of NGOs is being undertaken through the Third Kenya Population Project -- an important issue in Kenya, and in other African countries, since the major part of NGO funding is coming from external sources. The issue will also be addressed in the sector work on alternative channels for family planning being done in many of the Africa sector operating divisions. In India, a study of NGOs produced jointly by the National Institute for Health and Family Welfare, and the Bank', addresses questions of technical capacity in NGOs, the organizational arrangements for managing collaboration with NGOs at the government level, the administration of grants, and alternative mechanisms for channelling technical and financial support to NGOs. The policy paper now underway in PHRHN, addressing Family Planning Program Effectiveness, is also examining the role of NGOs, and the implications for national programs. (This study is described more fully in Annex 9 paras. 9-13).

> t *Strengthening the Role of Non-Governmental Organizations in the Health and Family Welfare Program", produced in Green Cover, June 1990