PHN 1991 Sector Review 18 _L Improved pknWng and management of technical asslstance,_ with the full participation of the government right from the planning stage. A recently completed report by a Bankwlde task force on technical assistance presents recommendations that have great relevance to work in PHN.<sup>16</sup>

# C Evaluation of FY91-Apprioved PHN Operations Against Lessons Larmed

# 1. _Ovenriw_

3.30 hs sectiop loks at the twenty-eight PHN operations approved in FY91 from the perspectve of management and institutional development and poverty alleviation. (Summary descriptions of the full set of objectives and components of each of these operations are presented in Annex 2.) 3.31 The FY91-approved portfolio of PHN operations has a strong _poveny_ focus: twenty-six of the twenty-eight projects support the provision of basic services to targeted poor and vulnerable segments of national populations. The two remaining projects, which support the hospital sector In oDuntries where access to basic services is universal emphasize effidency and equity issues. The Ibnisia Hospital Restructuring Support project is intended to improve equity in the financing of health services by changing the balance of financial burden sharing among the state, Insurers, and patients. This project is complenmented by another FY91 operation in Ibnisia to streagthen basic health services, especialy maternal and child health and family planning services. The Korea Health lbchnology project aims to increase equity by improving the geographical distribution of biomedical equipment, thereby making it more accessible to the population at large. The project has excluded high-cost equipment, in part because the cost of using such equipment is not reimbursed by the national insurance, and consequently, the equipment is not accessible to the poor. With the exception of the Yemen Socal Emergency project, processed in rapid response to the crisis in the Gulf, all projects support the implementation of government policies, that embrace the primary health care philosophy. And most of these operations were refined and reformed through dialogue conducted in the course of sector and lending worL Many, If not most, of the FY91 projects support and are supported by structural adjustment operations (El Salvador, Egypt, Madagascar, Zaire, to name a few), which emphasize growth and poverty alleviation. PHN projects leveraged by these adjustment operations have been particulary successful in encouraging governmeats to reallocate resources in favor of basic services, which would benefit the poor and vulnerable groups in particular. In this regard, many PHN projecs are using PERs/PlRs to encourage and monitor appropriate resource allocation and to ensure the financial sustainability of social sector policy.

3.32 Virtually all FY91 operations support _instiutional development_ and improvements in _management_ capacity. A predominant feature of such assistance is support of decentralization policy in the PHN sector by strengthening lower-level planning, decision-making, and financial management; encouraging community participatlon; and redefining and limiting the role of central govermmenL Significant efforts have been made to involve NOOs and communities in the design and implementation of operations, although less so at the design stage than during implementation. Some operations also made a modest effort to explore the role of the private sector in the PHN sectors. The Korea Health lbchnology project is unique in this regard as the first IBRD operation in which 100 percent of the loan proceeds will be on-lent to the private sector (hospitals). There were noteworthy efforts to develop national capacity in infolknation collection and analysis, including research and monitoring and evaluation activity, which have been somewhat neglected in the past (El Salvador, India, Indonesia, Mali, Pakistan, Zaire, and Zambia, to name a few). Also, improvements are evident in the Bank's PHN support to human resources management: many components aimed at improving staff performance are more comprehensive than they have been in the past, including not only training (pre-service and inservice) and supervision, but also assistance to establish or improve operational guidelines, job descriptions, 'operational norms, re-deployment schemes, manpower planning, recruitment practices, and greater and more thoughtful attention to incentives.