iii PHN 1991 Sector Review _12 Populaton._ Thirteen projects in the<sup>FY91</sup> lending program provide direct support<sup>to family</sup> platnirtg -- up from eight last year.<sup>Lending volume</sup> rose as well, doubling from $169.3<sup>million in FY90</sup> to $340.3 million in FY91, with much<sup>of that in-</sup> crease attributable to the Bangladesh project,<sup>which</sup> was. advanced from FY92 during<sup>the fiscal year. The</sup> $340.3 million is a conservative estimate<sup>of direct</sup> lending to population, and represents<sup>about 25</sup> percent of the S1.3 billion committed<sup>to "pure' PHN</sup> projects and components. In addition<sup>to the provi-</sup> sion of family planning services and<sup>their integration</sup> into basic health services, support is<sup>also provided to</sup> policy and program development with<sup>a strong</sup> emphasis on building national capacities<sup>in these</sup> areas.

_13. Nutrition._ Bank support of nutrition is clearly manifest in the large growth In the<sup>numbei of</sup> operations, which support nutrition<sup>activity. Esti-</sup> mates of overall project resources for Bank-assisted nutrition activities have risen in the past<sup>three years</sup> from _$54.8_ million to $337.7 million<sup>to $470.4</sup> million. As with population, the Bank,<sup>itself, may</sup> sometimes finance only a modest share<sup>of total</sup> project resources for nutrition, while raising<sup>substan-</sup> tially more funds from other agencies.<sup>In addition to</sup> nutrition assistance provided through<sup>sector opera-</sup> tions, nine of sixteen adjustment operations<sup>approved</sup> in FY91 address nutrition. Projections for<sup>FY92-94</sup> lending for nutrition projects, and projects<sup>with</sup> significant nutrition components, continue<sup>the</sup> upward trend. At $1.2 billion this<sup>lending would</sup> more than double Bank lending for nutrition<sup>during</sup> the period FY89-91. Nutrition assistance<sup>is increas-</sup> ingly addressing micronutrient malnutrition.<sup>Despite</sup> additions to the technical nutrition staff<sup>this year, the</sup> Bank needs to increase further its<sup>institutional</sup> capacity to respond to the growing<sup>demand and</sup> opportunities for nutrition interventions.

_Special Theme: Institutional DevetoDment_<sup>_in Support_</sup> _of a Poverty Focus_ 14. The theme of this year's Annual<sup>Sector</sup> Review (ASR) is a blend of two special<sup>topics: (1)</sup> poverty, chosen by the Office of the<sup>Vice President</sup> for Sector Policy and Research (FRSVP)<sup>for inclu-</sup> sion in all FY91 Sector Reviews. and<sup>(2) manage-</sup> ment/institutional development, chosen<sup>by the</sup> Population, Health and Nutrition<sup>Division of the</sup> Fopuiation and Human Resources<sup>Department</sup> (PHRHN) in close consultation with PHN<sup>colleagues</sup> in operations.

_15._ A review of project experience both<sup>within</sup> and outside of the PHN sector reveals<sup>four condi-</sup> tions that have a strong influence on the<sup>success and</sup> sustainability of PHN operations: (1) enabling<sup>policy</sup> and pol'tical environment; (2) sound organizational structure; (3) adequate management<sup>capacity, and (4)</sup> adequate and reliable financing of<sup>essential sector</sup> activities over the long term. Tle main<sup>approach to</sup> the special topic was to review lessons<sup>learned from</sup> Bank implementation experience, with<sup>a view to</sup> identifying what management/institutional<sup>issues</sup> should be addressed in PHN sectors<sup>in order to</sup> assist national governments to bring about<sup>these four</sup> conditions for successful and sustainable<sup>activity.</sup> While the ASR presents both lessons of<sup>substance</sup> (what to do) and lessons of design and process<sup>(how</sup> to do it), it does not provide a complete<sup>set of</sup> guidelines for task managers and management. Rather it represents an initial attempt<sup>to address a</sup> difficult yet crucial dimension of PHN<sup>work, which</sup> has thus far received modest attention.<sup>PHRHN is</sup> considering a more thorough review and<sup>analysis of</sup> management/institutional development experience<sup>in</sup> PHN, both inside and outside of the Bank,<sup>which</sup> would eventually culminate in the production<sup>of such</sup> guidance.

16. _Lessons of Substance._ Both the institutional and organizational framework and the<sup>capacity for</sup> policy formulation and implementation<sup>need to be</sup> strengthened for more effective and efficient<sup>PHN</sup> activity. In summary, six dimensions of<sup>institutional</sup> strengthening should be considered when<sup>developing</sup> and implementing a PHN operation, particularly<sup>one</sup> with a poverty focus: (1) optimal use<sup>of institutional</sup> resources; (2) forming and strengthening<sup>local</sup> organizations; (3) intersectoral coordination<sup>between</sup> poverty-oriented institutions; (4) appropriate<sup>decen-</sup> tralization of health sector authority and responsibility, (5) sound organization of service delivery<sup>and</sup> promotional activities; and (6) strengthening<sup>of key</sup> components of the institutional frameworkl<sup>The</sup> following dimensions of management capacity<sup>for</sup>