PHN 1992 **Sector Review** 36 of their needs and demands for basic health, family planning and nutrition services is an essential component of PHN sector work as it influences and informs policy dialogue and the design and targeting of Bank investments in PHN. Household-based social surveys (already found in several social sector projects) can contribute to analysis of demand.

- Reforms in policy, financing and organization must be decided at the national level, based on felt needs of a variety of actors, and should be pilot tested and further researched before implementing nationwide.

# _2 Quality of Projects_

_5.5_ Overall, the PHN projects approved during the fiscal year cover the selected indicators of quality reviewed in Chapter IV. The great majority of these projects provide in some way for: flexibility and learning throughout implementation; project management arrangements that will serve to build capacities of existing structures and institutions; and monitoring and evaluation activities that will permit assessment of impact as well as process indicators. The ways in which these activities are carried out, however, vary from project to project and the following suggestions for improving work in this regard, drawn from particularly good project designs and documented lessons of experience, are offered here.

- Providing built-in flexibility in initial project design allows for the redirection of projects that are not going well. Operational research and pilot testing are extremely useful, bot1h in facilitating information flow _and_ ir. encouraging learning-by-doing, and provide an effective vehicle fo'! introducing flexibility into projects.

- Involving implementing agencies and beneficiaries in project design will ensure that plans are feasible and understood by those who will manage the project and that services will be utilized by intended beneficiaries.

- Ensuring that project complexity, as indicated by the number of components, the extent of conditionalities and the number of donors and implementing agencies, does not exceed national or Bank capacity for project management should contribute to smooth and timely implementation.

- ° In order to monitor project performance effectively, both process and impact indicators should be established in sufficient detail and numbers and agreed with project implementors at the outset. While process indicators are amenable to routine monitoring, impact indicators may best be tracked through special studies or operational research.

# 3. _Quality of PHN Services_

5.6 Low quality of services is consistently raised and addressed in PHN operations across the board. However, for the most part, analysis and interventions focus on issues of technical quality and the need for strengthening outreach activities for promotional and preventive activities. Relatively little is done to assess or address the more subjective and culturally charged dimensions of quality. Again, lessons of experience and innovative features of the FY92 portfolio offer the following guidance in this regard:

- v When assessing and addressing issues of low quality of services in project and sector work, PHN staff should consider not only issues of technical