**PHN 1992** Sector Review

9 2.22 In order for improved quality and access to have an impact on health, these services must be utilized. The Romania Human Resource Strategies Report acknowledges the problem of underutilization and suggests that the government remain responsive to consumer demand and find innovative ways to increase demand for social services. In Nigeria, the demand for health services is actually decreasing as the population increases. This decline in utilization has serious ramifications for the poor: while they use the public health services the most, they are also the group that relies most heavily on self-treatment. Assessing the demand for services is generally neglected in these reports, probably because of a lack of data. Only in the Poland report was demand given sufficient attention. Demand analysis should also be related to knowledge of the poor. While a few reports did estimate the overall demand for health services, much more detail than was generally included is needed for adequate project design. Again, Chapter V takes up this issue.

# C. **Supervision and Project Evaluation: Lessons Learned**

2.23 During FY92, the PHN sector had 107 projects under supervision, representing commitments of $5.3 billion. Africa has the highest number of projects under supervision (45 projects or 42 percent of the entire portfolio), amounting to $1.1 billion (Annex 1, Figure 1 provides more details).

2.24 During FY92, 19 percent of PHN operations under supervision were categorized as problem projects (with ratings of 3 or 4). While this represents an increase in the proportion of problem projects over the FY91 level for PHN (13 percent), it approximates the overall FY92 Bank average of 18 percent, indicating that the overall "health" of PHN projects under supervision is in line with the Bank average. The average supervision coefficient for PHN in FY92 was 17.0, exceeding the overall Bank average of 13 by 30 percent. At 20.9, the PHN supervision coefficient including local staff input exceeds the Bank average of 14.1 by almost half, but does reflec. a

> g3iter une of local staff for supervision than the B.ai4k .:veiage. This divergence from the Bank average is probably a reflection of the relative newness of the health sector and the consequent inexperience of weak health ministries in managing Bank projects, and also the increased attention to software components in PHN projects, which, while appropriate, tends to add to the complexity of operations.

2.25 Two project completion reports (PCRs) were produced in FY92 (Annex 1, Thble 8): the Yemen Health Development Project and the Mexico Water, Women and Development Project, which was canceled even before becoming effective due to the sudden availability of grant funds for activities initially slated for project support. The small number of PCRs produced during the year is a reflection of the small size of the PHN lending portfolio in the recent past. (Figure 1) 2.26 To compensate for the paucity of PCRs produced this year and to accommodate the growing importance and interest attached to the lessons of implementation experience, this ASR reviewed lessons learned as documented during the year in three sources: (1) Staff Appraisal Reports (SARs) for FY92 projects; (2) the PCR on Yemen Health; and (3) the Seventeenth Annual Report on Implementation and Supervision (ARIS) - Fiscal Year 1991.

2.27 Annex 3 provides a brief overview of lessons learned from these various sources, examples of good practices in SARs for analyzing lessons and incorporating them into new projectdesigns, a summary of PCR findings, and a compilation of lessons derived from the ARIS.

# **D. Policy, Research and Dissemination**

2.28 The PHN Department' maintains a diverse work portfolio that includes: awareness raising on pertinent PHN topics; conducting policy and program-relevant research; the preparation and publishing of technical papers; staff training; and the provision of direct program support to operations. Areas of focus of the division's work