v

- _(e'_ itforts to coordinate aid, whether through formal<sup>cofinancing arrangements, or less</sup> formal means, are- being intensified, given acute shortages<sup>in resources for the</sup> sectors, and ale being facilitated by the policy/program<sup>approach mentioned above.</sup>

- ff) Key managernentAnstitutional development issues<sup>in the PHN sectors ara numerous</sup> and complex and are crucial to achieving improvements<sup>in PHN sector perfonnance.</sup> There is, however, some variance in the degree to which<sup>Bank interventions have</sup> attempted to address these issues. A number of interventions<sup>to strengthen the</sup> managen.ent of an institution or part of an institution<sup>are limited to the provision</sup> of training, technical assistance, additional staff and equipment,<sup>and have not</sup> addressed in depth more difficult and sensitive issues<sup>such as: the orgarnizational</sup> structure of ministries and of the programs and<sup>service delivery systems; the extent</sup> to which such organizational structu.es respond to<sup>decentralization policies;</sup> problems of inter-agency coordination and territorial issues.<sup>There are, howeve'</sup> notable examples of FY90 projects which have addressed<sup>these issues fully and</sup> squarely.

- (g) The use of local consultants and the participation<sup>of beneficiaries in project design,</sup> development and implementation is on the rise.;

- (h) Health financing issues continue to be rigorously addressed<sup>as a priority through</sup> lending, sector and research work;

- (i) Multi-sectoral operations, in the form of social development<sup>operations, a new</sup> feature of PHN lending, have presented new challenges<sup>to Bank staff in streamlining</sup> and coordinating roles and responsibilities within the<sup>Bank and at the national level;</sup>

- (J) In recognition of the important role NGOs play<sup>in the PHN sectors, increased</sup> attention has been focused on them both through project<sup>and sector work.</sup>

- (k) The momentum in nutrition activities which began following<sup>Reorganization has</sup> continued, and in some ways accelerated, during FY90.<sup>Lending has increased and</sup> the pipeline (or future nutrition operations is strong.<sup>Nutrition's linkages with</sup> sector operations outside of PHN including agricuiure,<sup>educat ion, women in</sup> development, and others, as well as with adjustment<sup>activities, have grown stronger</sup> during the year. Staff capacity has been strengthened through<sup>nutrition training</sup> courses and the recruitment and hiring of additional<sup>technical nutrition staff in</sup> three of the four Bank regions. Nevertheless, many<sup>departments still do not have</sup> staff experienced in nutrition operations. The Bank<sup>needs to develop more</sup> institutional capacity to respond to management's commitment<sup>to nutrition and the</sup> many emerging opportunities.

_5._ PHRHN's policy and research program focussed<sup>on a number of the salient issues</sup> outlined above. lbvo studies in process on fertility determinants<sup>and on family planning</sup> effectiveriess will assist Bank staff and national policymakers<sup>alike in the design and targeting of</sup> appropriate family planning programs and policies. Six other studies focus<sup>ont various health</sup> sector issues, including AIDS and adult mortality,<sup>safe motherhood, health policy in Africa,</sup> hospital resource use, disease control priorities and<sup>adult health. A micronutrient study is also</sup> in process, whose results should contribute to improvements<sup>in the effectiveness of nutrition</sup> interventions. PHRHN also manages a portfolio of<sup>eight Special Grants Programs, of which five</sup> target health sector issues, two population and one nutrition.<sup>During the year PHRHN</sup> produced 20 publications, including 2 books, 2 technical<sup>papers, 15 working papers and one</sup> other paper.