PHN 1991 Sector Review 13

# _a. Insitutional and Organzanonal Framewwork_

3.11 A sound institutional framework is critical to the efficient functioning of PHN sector activity. The following six dimensions of institutional strengthening should be considered when developing and implementir.g a PHN operation, particularly one with a poverty focus.

3.12 _Ophimal Use of Instituond Zrsouces._ The institutional framework for In-country PHN activity should encourage involvement of the various potential actors in the sector according to their comparative advantages. While there are notable exceptions, in many developing countries the public sector carries out the planning, financing and delivery of PHN services. Significant gains in quality and efflciency could be realized if the private commercial sector, NGOs, oDmmunity organizations, universities, national and regional institutions specializing in training, consulting, aud research, and other groups outside the public sector were encouraged to engage in sectoral activities. The audit report on the Philippines Second Population Project recommends greater reliance on NGOs and the private sector for undertaking health sector activity. According to the Sixteenth ARIS, the sucoful emergence of institutional pluralism should be accompanied by a reduction in size and a redefinition of the role of the public sector in PHN. Such a redefinition should preserve and, where appropriate, promote preventive health activity.

_3.13 Forming and Strengthewning of Local Organfzadons._ 7he evidence is overwhelming that the particpation of well-functioning local community -oups in the design and implementation oi PHN sector activity has a strong influence on project success and sustainability. OED's two reports on project sustainabilHey reveal that within the right institutional framework, beneficiaries can be mobilized to particpate in a wide range of activides: needs identification; project design; adaptation of project acivities and technologies to local needs; information collection, monitoring, and evaluation; management of activities on a local level promotion of services; and maintenance of Infrastructure. These groups offer communities a way to make decisions that will improve their lives, a power many of them would not otherwise have, especially those such as women and the poor, whose disadvantages have made them virtually powerless to improve their situations. PHN experience corroborates these findings: according to review work undertaken during the year, US the achievements of Indonesia's population program and India's lkmil Nadu Nutrition project are largely attributable to well-organized community involvement in promoting and managing basic services.

3.14 _Intsectwal Cordinon Between Povety. OMknted Instauion&_ Intersectoral coordination Is crucial to the efflciency of PHN sector actviy, but achieving it is a formidable management challenge. Strate4les for population, health, nutrition, and poverty alleviation each require the input of a number of line ministries. OED's review of Bank population assistance in eight countries$ cautions that such essential contributions will not be forthcoming unless deliberate efforts are made to ensure coordination, collaboration, and accountability. One need is for a well-articulated and politically endorsed macroeconomic and multisectoral policy. Also important are clearly defined responsibilities for the various ministries and agencies and a high-level, politically stable and capable agency to coordinate, promote, and monitor activity. The audit report for the Philippines Second Population project recommends assigning principal responsibility for family planning to the one agency that is the least politically vulnerable among reasonable candidates. This same recsamendation is made for the iutrition sector, based on lessons of experience6. The linisia Health and Population PCR noted that the institutional rivalry that interfered with the smooth implementation of that project might have been avoided had collaborative arrangements been better. The report further recommends that the Bank needs to be ready to intervene and help resolve interagency disputes.

3.15 _Decenralfiawon._ The extent to which health sector authority and responsibilities can and should be decentralized is a matter of some debate; there is no one correct solution to this issue, which would be applicable and equally appropriate in all countries. The definition of roles and the distribution of responsibilities across the various levels of government should be done with a view to achieving the appropriate and optimal contnbutions of each of those levels together and separately.