metadata: authors: 0: author: Vaillancourt, Denise
1: author: Brown, Stacye
count: World
docna: 0: docna: Population, health, and nutrition : annual
            operational review for fiscal 1992
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Nutrition,Inequality
teratopic: Urban Development,Health, Nutrition and Population,Finance and Financial Sector Development,Poverty Reduction
abstracts: cdata!: Population, health, and nutrition (PHN)
            lending decreased in fiscal 1992 from the record levels of
            fiscal 1991, in both the amount and the number of
            operations. Lending amounted to $961.6 million for 16
            projects, compared with $1,567.6 million for 28 projects in
            fiscal 1991. This temporary dip in PHN lending is
            attributable largely to pipeline factors. Fiscal 1993
            lending is projected to recapture if not exceed the fiscal
            1991 level, and projections for fiscal 1993 and fiscal 1995
            are for a continued increase in lending volume. PHN projects
            approved in fiscal 1992 have been responsive to the World
            Bank's objective of poverty alleviation. Collectively,
            fiscal 1992 projects cover the essential features of good
            poverty work but the depth and quality of poverty work
            varies across projects. Drawing from the good practices
            observed and lessons recorded in this year's portfolio,
            the review offers the following suggestions, among others,
            for strengthening PHN interventions to alleviate poverty:
            poverty information and monitoring must be accompanied by
            dissemination and sensitization activities to strengthen
            national understanding of poverty-related issues and
            national commitment to resolving them through the proper
            policy; community involvement in project design and
            development requires clearly defined and carefully designed
            institutional and procedural mechanisms, and a concerted
            effort to make them work; it is essential that PHN sector
            work identify poor and vulnerable groups and assess their
            needs and demands for basic health, family planning, and
            nutrition services; and even the most demand-driven project
            designs targeted to clearly identified poverty groups
            require promotional activities to ensure that these groups
            participate in and benefit from project initiatives. Health
            lending is now a decade old, and many innovations in PHN
            lending have emerged only in the past four or five years.
            This review demonstrates that good practices and new and
            promising ideas - well worth emulating - are scattered
            across PHN work. Overall, PHN work is moving in the right
            direction and the quality of work is generally seen to be
            improving. Welcome trends (which should be encouraged and
            reinforced) include serious attention to the poorest, most
            vulnerable populations, growing consideration of the demand
            of target groups, and increased attention to monitoring and
            evaluation of sector performance.
repnme: repnme: Population, health, and nutrition : annual
            operational review for fiscal 1992
display_title: Population, health, and nutrition :
            annual operational review for fiscal 1992
listing_relative_url: /research/1993/07/698978/population-health-nutrition-annual-operational-review-fiscal-1992
topicv3: Poverty m1326687 695,Nutrition m1326779 644,Population, Aging and Health m1327736 640,Health, Nutrition and Population m1327755 621,Health m1504661 3480
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Urban Development,Health, Nutrition and Population,Finance and Financial Sector Development,Poverty Reduction
origu: Pop & Human Resources Department (PHR)
no_of_pages: 94
model_extractions: **Policy Research**

**Population, Health, and Nutrition**

WPS 1152 This paper is a product of the Population, Health and Nutrition Department. Copies are available free from the World Bank, 1818 H Street NW, Washington, DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (July 1993, 77 pages).

Population, health, and nutrition (PHN) lending decreased in fiscal 1992 from the record levels of fiscal 1991, in both the amount and the number of operations. Lending amounted to $961.6 million for 16 projects, compared with $1,567.6 million for 28 projects in fiscal 1991.

This temporary dip in PHN lending is attributable largely to pipeline factors. Fiscal 1993 lending is projected to recapture if not exceed the fiscal 1991 level, and projections for fiscal 1994 and fiscal 1995 are for a continued increase in lending volume.

PHN projects approved in fiscal 1992 have been responsive to the World Bank's objective of poverty alleviation. Collectively, fiscal 1992 projects cover the essential features of good poverty work but the depth and quality of poverty work varies across projects. Drawing from the good practices observed and lessons recorded in this year's portfolio, the review offers the following suggestions, among others, for strengthening PHN interventions to alleviate poverty:

* Poverty information and monitoring must be accompanied by dissemination and sensitization activities to strengthen national understanding of poverty-related issues and national commitment to resolving them through the proper policy.

* Community involvement in project design and development requires clearly defined and carefully designed institutional and procedural mechanisms, and a concerted effort to make them work.

- It is essential that PHN sector work identify poor and vulnerable groups and assess their needs and demands for basic health, family planning, and nutrition services.

* Even the most demand-driven project designs targeted to clearly identified poverty groups require promotional activities to ensure that these groups participate in and benefit from project initiatives.

Health lending is now a decade old, and many innovations in PHN lending have emerged only in the past four or five years. This review demonstrates that good practices and new and promising ideas - well worth emulating - are scattered across PHN work.

Overall, PHN work is moving in the right direction and the quality of work is generally seen to be improving. Welcome trends (which should be encouraged and reinforced) include serious attention to the poorest, most vulnerable populations, growing consideration of the demand of target groups, and increased attention to monitoring and evaluation of sector performance.

The Policy Research Working Paper Series disseminates the findings of work under way in theBank. An objective of the series is to get these findings out quickly, even if presentations are less than fully polished. The findings, interpretations, and conclusions in these papers do not necessarily represent official Bank policy.

Produced by the Policy Research Dissemination Center
# Population, Health, and Nutrition Annual Operational Review for Fiscal 1992

by Denise Vaillancourt Stacye Brown and Others Population, Health, and Nutrition Department
# ABBREVIATIONS AND ACRONYMS

|AFIPN<br>AIDS|Africa Technical Department, Population, Health and Nutrition Division<br>Acquired Immuno-deficiency Syndrome|
|---|---|
|ARIS|Annual Review of Implementation and Supervision|
|ASR|Annual Sector Review|
|ECA|Europe an Central Asia Region|
|EDI|Economic Development Institute|
|FY|Fiscal Year (July1- June 30)|
|IBRD|International Bank for Reconstruction and Development|
|IDA|International Development Association|
|IEC|Information, Education and Communication|
|IES|Income and Expenditure Survey|
|KNH|Kenyatta National Hospital|
|LAC|Latin America and the Caribbean Region|
|LATHR|Latin America and the Caribbean Technical Department, Human Resources<br>Division|
|LSMS|Living Standards Measurement Survey|
|MCH|Maternal and Child Health|
|MENA|Middle East and North Africa Region|
|MIS|Management Information System|
|MOHFW|Ministry of Health and Family Welfare|
|MOPH|Ministry of Public Health|
|MPND|Ministry of Planning and National Development|
|NGO|Non-govemmental Organization|
|OED|Operations Evaluation Department|
|PCR|Project Completion Report|
|PHN|Population, Health and Nutrition|
|PHRHN|Population, Health and Nutrition Division of the Population and Human<br>|
||Resources Department (As of January 1, 1993, this division has become the PHN|
||Department)|
|PMP|Private Medical Practitioners|
|PVO|Private Voluntary Organization|
|SAR|Staff Appraisal Report|
|SIMAP|Social Impact Amelioration Program and Agency|
|STD|Sexually-Transmitted Disease|
|UNDP|United Nations Development Programme|
|WDR|World Development Report|
|WHO|World Health Organization|
|WID|Women in Development|
|WPS|Wki P Si|
||orng aper eres|
# TABLE OF CONTENTS

Page

## EXECUTIVE SUMMARY

|I.<br>INTR|ODUCTION: PURPOSE AND SCOPE OF REVIEW ..........................|1|
|---|---|---|
|II.<br>OVE|RVIEW<br>.............................|3|
|A.|Lending ................................................|3|
||1.<br>Trends in the Lending Portfolio ........<br>........................|3|
||2.<br>Regional Distribution and IBRD/IDA Commitments ....................|5|
||3.<br>Cofinancing ............................................|6|
||4.<br>Project Funds by Expenditure Category ...........................|6|
|B.|Sector Work .<br>..............................................|7|
|C.|Supervision and Project Evaluation: Lessons Learned ..............|9|
|D.|Policy, Research and Dissemination<br>.....................|9|
|E.|Population, Health and Nutrition Content of Projects ............<br>.|11|
||1.<br>Population ............................................|11|
||2.<br>Health ..............................................|12|
||3.<br>Nutrition .............................................|13|
|III.<br>SPEC|IAL TOPIC: PHN'S CONTRIBUTION TO THE BANK'S POVERTY||
|ALL|EVIATION OBJECTIVE ..|15|
|A.|Background ..........|15|
|B.|Context ..........|15|
||1.<br>What ..........|15|
||2.<br>Who ..........|16|
||3.<br>How..........|16|
|C.|The Bank's Role ...............................................|17|
|D.|Evaluation of FY92 Portfolio of PHN Projects: An Overview ...................|17|
||Category 1:<br>Multisectoral Interventions for Poverty Alleviation||
||(Poverty Projects) .17||
||Category 2:<br>Provision of Basic Social Services to the Poor||
||as Primary Objective .18||
||Category 3:<br>PHN Interventions Whose Benefits to Poor||
||Are Important But Not Primary Objective .18||
|E.|Special Features of Poverty Interventions in the FY92||
||Portfolio .20||
||1.<br>Poverty Information and Monitoring ..............................|20|
||<br>2.<br>Understanding and Responding to the Needs and Demands||
||of the Poor ..........<br>........................|20|
||3.<br>Targeting ..................................|22|
||4.<br>Reforms in Policy, Financing and Organization .......<br>.............|..<br>23|
||4.a<br>Institutional Reforms .................................|24|
||4.b<br>Financial Reforms ...........|25|
# **TABLE** OF CONTENTS **(Cont'd)**

|IV.<br>A BRI|EF LOOK AT QUALITY .......................<br>29|
|---|---|
|A.|Quality of PHN Projects<br>....................<br>......................<br>29|
||1.<br>Strategy: Addressing Both Short- and Long-Term Needs ....<br>............<br>29|
||2.<br>Flexibility/Opportunities for Learning and Fine-tuning .................<br>30|
||3.<br>Project Management ......................................<br>30|
||4.<br>Monitoring and Evaluation ..................................<br>31|
|B.|Quality of PHN Services<br>...................<br>......................<br>32|
||1.<br>India AIDS Project .........<br>..............................<br>33|
||2.<br>Sector Report on Quality of Health Care in Cote d'Ivoire ....<br>............<br>33|
|V.<br>PROS|PECTUS .........<br>35|
|A.|Future Work Portfolio<br>. ..........<br>.<br>.<br>............<br>35|
|L.|Conclusions and Recommendations.<br>..........<br>..............<br>35|
||1.<br>Poverty..<br>...............<br>35|
||2.<br>Quality of Projects..<br>...............<br>36|
||3.<br>Quality of PHN Services..<br>...............<br>36|
||4.<br>Overview..<br>...............<br>37|
|TEXT TABLE<br>|S:<br> <br>|
|1.|Non-PHN Projects with PHN Components ...........<br>...<br>. ...<br>.. .. . .. .. .. .<br>. 3|
|2.|Composition of PHN Projects Approved in FY91 and FY92 .......<br>. . . . . . . . . . . . .<br>. 4|
|3.|Trends in Lending to the PHN Sector by Region, FY90-92 .......<br>. . . . . . . . . . . . . .<br>. 4|
|4.|Sectoral Composition and Funding Characteristics of PHN<br> <br>|
||Portfolio, FY92 ..............................<br>.......<br>......<br>....<br>. 5|
|5.|Cofinancing from Official Sources in PHN Projects, FY91 and FY92 .....<br>. . . . . . . . .<br>. 7|
|6.|Classification of FY92 PHN Projects by Poverty Objectives and Content ..... . . . . . .<br>.<br>19|
|TEXT FIGUR<br>|ES:<br>|
|1.|Lending for the Population, Health and Nutrition Sector,|
||FY 80-92..<br>..........................................<br>3|
|2.|Regional Distribution of PHN Lending, FY92 ...........<br>.. .. .. .. .. .. .. . .. .<br>. 6|
|3.|Breakdown of Total Project Costs by Expenditure Category .......<br>. . . . . . . . . . . . . .<br>. 7|
|ANNEXES:||
|1.<br>Statist|ical Annex<br>.<br>.<br>..<br>......<br>39|
|Tables|:|
|1.|FY92 Population, Health and Nutrition Portfolio .........<br>.. . . .. . . .. . . .. . . .<br>. 41|
|2.|Primary Health Care Component of PHN Lending, FY92 .......<br>. . . . . . . . . . . . .<br>. 42|
|3.|Population, Health and Nutrition Lending Volume, FY80-92 .......<br>. . . . . . . . . . . .<br>. 43|
|4.|FY92-Approved PHN Projects: Funds Components ........<br>. .. . . . . . . .. . . . . .<br>. 44|
|5.|IBRD/IDA Financing of PHN Projects, FY1980-92 ........<br>. .. . . . . . . .. . . . . .<br>. 45|
|6.|Population, Health and Nutrition Sector Reports Completed by<br>|
||Region, FY83-92 .46|
|7.|Population, Health and Nutrition Sector Reports|
||Completed in FY92 .47|
# TABLE OF CONTENTS (Cont'd)

|8.<br>9.|Operations Evaluation Department Reports on PHN Sector, FY92 ......<br>. . . <br>Lending for Population in the FY92 PHN Lending Program ......<br>. . . . . . .|. . . . . .<br>. 49<br> . . . . . .<br>. 50|
|---|---|---|
|10.|Lending for Population Projects and Components by||
||Region, FY87-92..<br>..................................|51|
|11.|PHN Projects with Nutrition Components, FY92 ..............<br>.. ...<br>..|.<br>.. ..<br>.<br>52|
|12.|Nutrition in FY92 Bank Projects.<br>. .<br>.................|...<br>53|
|13.|Nutrition in Structural and Sector Adjustment Operations,<br>FY92 .55||
|Figur|es:||
|1.|PHN Projects under Supervision, FY92 .56||
|2.|Population Lending Trends .57||
|3.|Total Project Resources for Nutrition, FY81-92 .58||
|2.<br>Loan|and Credit Summaries of FY92-Approved PHN Operations.<br>. . .<br>..............|59|
|3.<br>A Su|mmary and Assessment of Lessons Leamed ...........................|....<br>.<br>71|

## This report was prepared by PHRHN, which has recently become the new PHN Department.

The task manager and main author is Denise Vaillancourt, who also researched and analyzed<sup>the special</sup> topics on poverty and quality. Other team members and their respective contributions include:<sup>Stacye Brown</sup> (review and analysis of operational statistics and trends), Rae Galloway (review of sector<sup>work and of policy,</sup> research and dissemination activities), Jane Nassim and Chantal Worzala (Population),<sup>and Leslie Elder</sup> (Nutrition). Chantal Worzala also prepared the Annex on Lessons Learned. Hoai Hong<sup>provided the team with</sup> ongoing secretarial and organizational assistance; and Christopher Wilson also provided<sup>graphics and word</sup> processing assistance in the preparation of this document for publication.
# EXECUTIVE SUMMARY

## _Lending_

1. The volume of Population, Health and Nutrition (PHN) lending decreased during FY92 from the record levels achieved in FY91, both in terms of lending amount and in terms of number of operations. Lending amounted to $961.6 million for 16 projects, compared with $1567.6 million for 28 projects in FY91. This dip in PHN lending is largely attributable to pipeline factors and is temporary. FY93 lending is projected to recapture if not exceed the record level achieved in FY91, and projections for the following two fiscal years indicate a continued increase in lending volume. Growth in the PHN sector has been significant during the past five years, stimulated by the Bank's renewed commitment to the reduction of poverty and its rapidly growing emphasis on human resource development.

2. Among the 16 operations included in this year's PHN portfolio are four social sector projects, with lending amounting to $51.0 million, or 5.3 percent of overall lending to the PHN sector. These operations, aimed at poverty alleviation, support activity in a variety of sectors. The PHN components of these projects amounted to $19.6 million or 38 percent of lending for that type of project. "Pure" PHN lending -- consisting of the 12 "pure" PHN projects and the PHN components of the four social sector projects -- amounted to $926.3 million in FY92, or 96 percent of officially reported lending to the PHN sector.

3. Since FY90, annual lending in the sector has remained above $900 million exceeding the target set by President Conable in November 1989 to increase PHN lending to $800 million annually during the period FY90-92. However, FY92 lending for PHN falls short of another goal set by Mr. Conable in September 1990 at the World Summit for Children: to increase lending for primary health care from three to five percent of overall Bank lending. In FY92 lending for primary health care accounted for 3.4 percent of the Bank's lending, largely a reflection of the overall temporary decrease in PHN lending this year. Nevertheless, the proportion of PHN lending for primary health care remains at roughly the same level as last year (78 percent) and the goal set by Mr. Conable will most likely be achieved again next year, as it was in FY91.

4. During FY92, the proportion of total Bank lending to the PHN sector decreased from 6.9 percent in FY91 to 4.4 percent, or from 5.7 percent to 4.3 percent if lending to non-PHN components is excluded. However, based on three-year moving averages, lending volume in the sector has been steadily increasing and is expected to continue to increase on average by 25 percent each year for the next three years.

_5._ The South Asia region accounted for the greatest proportion of lending volume ($377.5 million or 39 percent of total FY92 lending for the sector), while the Africa region processed the largest number of PHN operations (six projects or 38 percent of the FY92 portfolio). The proportion of PHN projects that receive IDA funds is larger than the Bank-wide average. Since 1990, IDA has accounted for a minimum of 43 percent of PHN lending, while accounting for a maximum of 30 percent of overall Bank lending during the same period. In FY92, IDA represented 68 percent of PHN lending and 30 percent of overall Bank lending. All lending to social sector projects was IDA-financed during FY92, as befits the important role of these projects in poverty alleviation.

6. During FY92, the number of cofinanced projects remained proportionally the same as in FY91. Every region except East Asia had at least one cofinanced project. However, the Bank leveraged fewer additional funds for its PHN and social sector projects in FY92 than in FY91. Social sector projects received more donor contributions than "pure" PHN projects. 7. Investment costs represented a smaller share of project costs in FY92 than in FY91 -- 59 percent versus 70 percent. The increase in the recurrent cost proportion of total project costs may reflect a growing appreciation of the high ratio of recurrent to investment costs characteristic of the human resources sectors and an increasing willingness on the part of the Bank to finance assistance of this type. Financial
**PHN 1992 Sector Review**

sustainability of PHN operations is ensured through sector reform and project conditionality aimed at mobilization of increased resources for the sector and at their more efficient allocation.

# _Sector Work_

8. 'Iwenty-five sector reports were completed in the PHN sector during FY92, a decline from the 33 reports produced in FY91. Five country-specific health sector reports, which reached grey cover in FY92, were reviewed to assess their usefulness for devising policies and programs to address poverty alleviation and the quality of PHN services. Collectively the reports cover the essential aspects of these issues: identification of poor and vulnerable groups, allocation of resources for health; mobilization of additional resources through increased public resources and/or greater role for private sector; decentralization of sector activity; and assessment of the demand for services. However, not all reports adequately covered all of these aspects. While financing issues were generally well addressed, the identification of poor groups and assessment of their demand and needs were not always carried out in sufficient depth. The review stresses that this element of sector work is necessary to influence and inform the design and targeting of Bank investments in the sector and makes suggestions for improved performance in these important areas.

# _Supervision_

9. During FY92, the PHN sector had 107 projects under supervision, representing commitments of $5.3 billion. Nineteen percent of PHN operations under supervision this year were categorized as problem projects. 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 reflect a greater use of local staff for supervision than the Bank average. 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 of the increasing attention to software components in PHN projects, which, while appropriate, tends to add to the complexity of operations.

10. Given the paucity of project completion reports (PCRs) completed during the year and the growing importance and interest attached to the lessons of implementation experience, this review provides: a brief overview of lessons learned from various sources; examples of good practices in Staff Appraisal Reports (SARs) for analyzing lessons and incorporating them into new project designs; a summary of PCR findings, and a compilation of lessons derived from the Seventeenth Annual Review of Implementation and Supervision (ARIS).

# _Policy, Pesearch and Dissemination_

11. The PHN Department l maintains a diverse work portfolio that includes: the carrying out of policy and program-relevant research; the dissemination of research findings drawing from work undertaken both inside and outside of the Bank; and the provision of direct support to operations. Specific operationally relevant research ongoing or completed in FY92 include: a Best Practices paper on Micronutrient Deficiency Disorders, a Best Practices paper on Women's Health and Nutrition; a paper on Effective Family Planning Programs, Guidelines on Safe Motherhood, and a study of the Economic Impact of Adult Mortality in Africa, focusing specifically on how households cope with illness and death of victims of Acquired Immunodeficiency Syndrome (AIDS).

12. Dissemination activities include the organization of 19 seminars attended by 363 Bank staff, on a variety of PHN topics; the publication of 19 Working Papers and a series of two-page "PHN Notes"; and the publication of three technical papers. PHRHN and the technical
**PHN** 1992 **Sector Review**

departments conducted training programs that aimed to inform Bank management and staff about key sector issues. Notable among FY92 training activities was a half-day seminar for senior Bank management, including the President of the World Bank, to discuss the implications of rapid population growth for economic development and poverty alleviation objectives of the Bank, followed by region-specific seminars for regional management teams. Other staff training included a successful five-day program on effective work in the health sector and a five half-day nutrition "best practices" seminar. In addition, the Population Working Group, Health Financing Working Group and AIDS Working Group each met regularly to facilitate discussion and dissemination of relevant technical issues and innovations. Finally, the startup of preparation for the 1993 World Development Report (WDR) on health generated a series of excellent technical seminars, which many Bank staff attended.

13. A major part of the work program of the PHN Department is to provide support to operations. In FY92 PHRHN provided 112 weeks of direct operational support to assist in sector analysis, lending and supervision. This was approximately 20 weeks in excess of planned support.

_Population, Health and Nutrition Content of Projects_ 14. _Population._ Ten projects in the FY92 PHN lending program provide assistance to family planning, two of which (Niger and Mauritania) also contain components that support the development of population policy and analytical capacity. One interesting aspect of the FY92 portfolio is its contribution to the geographical expansion of the Bank's population portfolio. The Niger Population project represents the Bank's first freestanding population project in the Sahel. Five other projects (Mauritania, Equatorial Guinea, Chile, Poland and Romania) are the first Bank lending operations in the PHN sector in those countries, with all but one providing direct support to family planning. (While not addressing family planning directly, the Chile project will support the design of a women's healthl program.) _15._ The volume of lending for population, at $103.2 million, represents a substantial drop from last year's total of $351 million, a drop that was forecast, but not expected to be quite so steep. The number of projects with a population component is also down from FY91's record level of 18, reflecting, in part, the drop in the number of PHN projects overall.

16. PHN sector work completed and ongoing in FY92 gave substantial attention to population issues. These studies also dealt with the themes of integration and decentralization of PHN projects, under the headings of improving the effectiveness of services delivered, the efficiency of resource allocation and utilization, and the equity of access. In addition, sector work examined the effect of population growth on other development activities -- in the provision of social services, and its impact on labor markets, in particular.

17. _Health._ The main thrust of health projects approved during the year is the provision of primary health care services to those most in need: largely the poor, women of child-bearing age and children under the age of five. Considerable emphasis is thus given to maternal and child health services. A fundamental objective of these interventions is to improve the quality, efficiency, and equity of basic services. As a complement to interventions at the service level, FY92-approved health operations also provide considerable support to building national capacity for policy formulation and sector management and to the field testing and eventual country-wide application of policy reforms, which aim for increased sector efficiency and equity.

18. Notable features of this year'sportfolio reveal two emerging trends in health sector lending: increasing attention to urban primary health care and to the hospital sector. FY92 health operations also targeted a number of priority diseases, notably AIDS, schistosomiasis, tuberculosis and malaria. A brief overview of projects' coverage of these aspects of health lending is provided in this review. Finally, two FY92 projects addressed the issue of an evolving epidemiological profile characterized by the
PHN 1992 Sector Review emergence of an aging population and chronic disease.

19. _Nutrition._ Nutrition lending in the Bank continues to grow. While the number of PHN projects with nutrition components decreased between FY91 and FY92 from 22 to 10 (reflecting the overall drop in the _total_ number of PHN projects in FY92), the allocation of total project resources for nutrition has continued to grow, rising from $49.3 million for FY87-89 to $893 million for FY90-92 to an estimated $1257 million for FY93-95. Attention to micronutrient deficiencies and long-term strategies for food fortification remain areas of emphasis in PHN projects.

20. Resources allocated for nutritionrelated activities outside the PHN portfolio increased significantly in agriculture, education and emergency relief operations. In addition, FY92 adjustment projects continue the trend of including nutrition conditionality, with 10 structural and sector adjustment operations addressing nutrition, including two that contain specific nutrition actions required for tranche release. In what is largely a new area of Bank lending, four adjustment operations contain sizable credits to address the impending starvation and food insecurity resulting from an unprecedented drought throughout southern Africa in FY92.

# _Poverty Content of PHN Operations_

21. PHN projects approved during FY92 have been responsive to the Bank's poverty alleviation objective, in terms of both content and focus. Every operation approved during the fiscal year addressed poverty issues in a significant way: twenty percent of the portfolio comprised multisectoral operations, whose major objective is the alleviation of poverty. The primary objective of thirty-five percent of operations is the provision of basic social services to the poor, responding to an important component of the poverty strategy recommended by WDR 90. And the balance of operations (seven projects or forty-five percent of the portfolio), while not addressing poverty alleviation as the primary objective, include interventions from which the poor should derive significant benefits. All operations addressed both short- and medium-/long-term interventions, combining support for improving quickly and directly the wellbeing of the poorest and most vulnerable of the groups with efforts to develop and strengthen national commitment and capacity to improve the economic and social wellbeing of the population.

22. Collectively, FY92 projects cover the essential features of good poverty work: poverty information and monitoring; understanding and responding to the needs of the poor; targeting assistance to those most in need; and reforms in policy, financing and organization. Although the coverage of these features is quite extensive, the depth and quality of each of these aspects of povertyworkvariesacrossprojects. Drawingfrom the good practices observed and lessons recorded in this year's portfolio, the review offers suggestions for further strengthening of PHN interventions aimed at poverty alleviation.

# _Quality Issues_

23. Overall, the PHN projects approved during the fiscal year cover fully the selected indicators of quality reviewed in this document (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 review suggests ways to improve work in this regard, drawing from particularly good project designs and documented lessons of experience.

24. Low quality of services is consistently raised and addressed in PHN operations across the board. However, for the most part, analyses and interventions focus on issues of technical quality and the need for strengthening outreach activities for promotional and preventive activities. Relatively little is done, however, to assess or address the more subjective and culturally charged
**PEN 1992 Sector Review**

dimensions of quality. Again, lessons of experience and innovative features of the FY92 portfolio are reviewed and offer some guidance in this regard.

# _Conclusion_

25. Health lending is now a decade old; and many innovations in PHN lending have emerged only recently -- over the past four or five years. Notable among these are multisectoral operations aimed at poverty alleviation objectives, and sector funds, which accommodate a decentralized, demand-driven approach to the provision of social services and social safety net assistance. Furthermore, fully one half of PHN projects approved since 1980 (or over the past 13 years) were approved only during the last _three_ years (FY92 included). Thus PHN experience in the Bank is very short and project designs are still somewhat experimental. PHN staff are, therefore, challenged to exploit lessons of experience and to develop innovative approaches to still new and emerging sector issues. This review has shown that there are indeed good practices and new and promising ideas scattered across PHNwork, which are well worth noting and emulating.

26. Overall, the thrust of PHN work is moving in the right direction and the quality of work is generally seen to be improving. Noteworthy and welcome trends include serious attention to the poorest and most vulnerable populations, growing consideration of the demand of target groups/beneficiaries and increased attention to monitoring and evaluation of sector performance. These trends should be encouraged and reinforced.

Prior to January **1,** 1993, **the** PHN Department was known as the Population, Health and Nutrition Division of the Population and Human Resources Department (PHRHN).
# CHAPTER **I.** INTRODUCTION: PURPOSE AND SCOPE OF REVIEW

1.1 The objectives of this Population, Health and Nutrition (PHN) Annual Sector Review (ASR) are: (a) to provide an overview of the FY92 work portfolio, including statistics on the volume and mix of lending and sector work and a brief discussion of salient features and trends; and (b) to address in some depth, as the special topic of this year's review, the contribution of PHN lending to the Bank's poverty alleviation objective.

This report did, however, take great care to review the lessons learned through implementation experience, as documented in the Seventeenth ARIS and in the Staff Appraisal Reports (SARs) and Projection Completion Reports (PCRs) produced for the PHN sector during the year. These lessons are compiled and discussed in a specially prepared annex to this report, and served to inform and inspire the approach to this review's special topic.

1.2 This report covers three components of the PHN work portfolio. First, the portfolio of FY92-approved _lending_ operations considered in this review comprises the sixteen projects officially categorized as PHN sector, including a number of multisectoral operations, aimed at poverty alleviation objectives that support, in some cases, relatively small PHN components. Second, the review provides statistics on _sector work_ and some analysis of sector reports' treatment of poverty and quality issues. Third, the coverage of the projects under _superviron,_ now numbering more than one hundred, is limited to some basic statistics on the size and composition of the supervision portfolio, on the proportion of problem projects, and on Bank staff resources devoted to supervision. The Eighteenth Annual Review of Implementation and Supervision (ARIS), provides a thorough review of supervision work.
# **CHAPTER II. OVERVIEW**

## A. **Lending**

_Figure 1: Lending for the Population, Health and Nutrition Sector, FY80-92_

### 1. _Trends in the Lending Portfolio_

2.1 The volume of PHN activities decreased during FY92 from the record levels achieved in FY91, both in terms of lending amount and in terms of number of operations. Lending amounted to $961.6 million for sixteen projects, compared with $1567.6 million for twenty-eight projects in FY91 (Figure 1). This dip in PHN lending is largely attributable to pipeline factors (both advancement of projects from FY92 to FY91 and slippage of others from FY92 to FY93) and poses no cause for concern. FY93 lending is projected at least to recapture and in all likelihood to exceed the record level achieved in FY91; and projections for FY94 and FY95, respectively, indicate a continued increase in lending volume. Growth in the PHN sector has been significant during the past five years, stimulated by the Bank's renewed commitment to the reduction of poverty and its rapidly growing emphasis on human resource development.

2.2 Since FY90, social sector projects (multi-sectoral operations aimed at poverty alleviation) have been a common feature of PHN work. In FY92 there were four, with lending amounting to $51.0 million, or 5.3 percent of overall lending to the PHN sector. PHN components of these four social sector projects amounted to $19.6 million or 38 percent of lending for that type of project. 'Pure" PHN lending--consisting of "pure" PHN projects and PHN components of social development projects-amounted to $926.3 million, or 96 percent of officially reported lending to the sector (Annex 1, Table 1).

2.3 In addition, in FY92 three social sector projects included in other categories of the Bank's lending provide substantial support to PHN sector activity. As shown in Table 1, PHN components of these projects are estimated at $81.6 million, which brings total lending for "pure" PHN in FY92 to just over $1 billion.

<!-- Start of picture text -->
-<br>U4.-<br>,,,  __<br>,14<br>,  _<br>P"<br>*m  pm.uci  ,  MA-  wOMea<br>-<br>.<br>..  . .<br>7*7  s<br>SI<br>0  *  m a a a a  a a a  M  1<br>*  -a0  ,<br>Table 1: Non -PHN Projects with PHN Components<br>(US$ Millions)<br>TaO  OfWlichi<br>Country  Projed  IBRD/MA  forPtW<br>C6k  d'lvelr  Hummn  Reoure<br>Dc.dopment  Promgsm  150.0  75.0<br>Gaimea-Wiasa.  Soc  Rdief<br>(Supplemental Credt)  2.9  00.6<br>da  Dmught Racoey  16.0  06.0<br>_  _-_<br>TOtal  166.9  81.6<br><!-- End of picture text -->

_Table 1: Non -PHN Projects with PHN Components_ (US$ Millions)
**PEIN 1992 Sector Review**

**4**

2.4 Many FY92-approved operations are multisectoral in nature. This reflects the poverty alleviation objectives of these operations, and efforts in some projects to stimulate demand for family planning services. Table 2 provides a breakdown of support to the various sectors under PHN projects for FY91 and FY92. For further reference, Annex 2 presents a summary description of each of the 16 PHN operations approved in FY92.

And the goal will most likely be achieved again next year, as it was in FY91.

2.6 During FY92, the proportion of total Bank lending to the PHN sector decreased from 6.9 percent in FY91 to 4.4 percent, or from 5.7 percent to 4.3 percent if lending to non-PHN components is excluded (Table 3). As explained in _Table 3: Trends in Lending to the PHN Sector by Region, FY90-92_ _Table 2: Composition of PHN ProjectsApproved in FY91 and FY92 (US $ million)_

|Seder|FY91||FY9|2|
|---|---|---|---|---|
||**S**|*****|$|%|
|**PHN**|1300.20|82.9|926.27|96.3|
|Infmstrucsure|110.20|**7.0**|16.40|**1.7**|
|Income|**89.30**|5.7|6.S0|0.7|
|Generaxion|||||
|Education|58.70|3.8|2.23|0.3|
|WAater|6.30|**0.4**|**3.30**|**0.3**|
|Agriculture|2.90|**0.2**|6.70|0.7|
|**Ibta**|1567.60|100.0|961.70|100.0|

2.5 One lending target for the PHN sector was exceeded in FY92, while another was not reached this year. In November 1989, President Conable pledged to increase PHN lending to $800 million annually during the period FY90-92. Since FY90, annual lending in the sector has remained above $900 million. In September 1990, Mr. Conable set a goal at the World Summit for Children of increasing lending for primary health care from three to five percent of overall Bank lending. In FY92, lending for primary health care accounted for 3.4 percent of the Bank's lending (Annex 1, Table 2). Lending falls short of this goal because of the overall, temporary decrease in PHN lending this year. The proportion of PHN lending for primary health care remains high, at 78 percent or roughly the same level as last year.

|**1-.PH**|**NLdti**<br>**Am**<br>**FY9**|**tinA****_(in_** <br>**0**|US**S milli_e**<br>_w9_<br>_v,_|**) and**N<br> <br>_a2_|_db_<br>of**Pr.J**|**ets**|
|---|---|---|---|---|---|---|
||**_A.-_**|**_N._**|**A.d**|NI|**_A.W_**|**N**.|
|AMe|232.7|**(3)**|**432.3**|(12)|14.3|**_(6)_**|
|**LAsia**|**0.0**|**(0)**|**140**|**(2)**|**1294**|(1)|
|S.**Asia**|**192.5**|(2)|**_311.5_**|(4)|**377.5**|(3)|
|ECA|**4.0**|**(0)**|**0.4**|**(0)**|**280.0**|(2)|
|_LAC_|379.2|**_(6)_**|337.3|**(5)**|**47.5**|(3)|
|MENA|**119.0**|(2)|**245.**|**(5)**|**26.3**|**(1)**|
|Totl|*73.4|(18)|W7|(29)|%1.7|(14)|
||**lb.**PHN**L.d**|**lag**_a_a|Po<br>**otT **|**otal****_Bak_**|1n_ift||
|**Reel..**|**FY9**|**0**|**ml**|**9**|**FM**|**9**|
||**Pm**<br>**PHN**|**TOW**<br>**PHN**|**Pm.**<br>**PHN**|**Total**<br>**PHN**|**Pn**<br>PHN|**Toa**<br>**PHN**|
|**LAsia**|**_OA._**|**1.1**|3.4|3.4|**2.3**|**2.3**|
|&**Asia**|**5.5**|**5.**|**_9.5_**|**10.**|**_12._**|**_12._**|
|ECA||**U..**.|U<br>**a**|A.|**_13.1_**|**_13.1_**|
|_LAC_|_S._|**.4**|**5.4**|**.4**|**0.6**|**0.9**|
|MENA|3.4|3.4|**4.0**|**2.1**|**L.**|**1.3**|
|NSod**lP**<br>**TotalPH**|ePHelp**ProA**<br>**Nmpsabal.**|**s.Nl**<br>**dleebr**|*****<br>nom**PUN**|**PUN**<br> **oodldm**|**dinga..PH**|**N**|
**_5_**

**PHN 1992 Sector** Review

para. 2.1, the lower lending levels achieved during FY92 represent a temporary glitch in PHN activity. Based on three year moving averages, lending volume in the sector has been steadily increasing and is expected to continue to increase on average by 25 percent each year for the next three years. (More detailed information on PHN lending is given in Annex 1, Table 3.) 2.7 Specific investment loans (SILs) were the major lending instrument utilized in the sector in FY92, accounting for 12 (or 75 percent) of the 16 approved projects (Table 4). The portfolio also includes one sector investment loan (SECIL) and three social investment funds (SIFs), the latter in support of sub-projects prepared in-country by communities, local governments, and NGOs, among others. These funds are managed by the _Table 4: Sectoral Composition and Funding Characteristics of PHN Portfolio, FY92_

||SIL<br>SECIL<br>SIF|
|---|---|
||(12)<br>(1)<br>(3)|
|PHN|EquatorialGuinea<br>Chile|
|(12)|Mauritania<br>Niger<br>China<br>Poland<br>Egypt<br>India (AIDS)<br>India (MCH)<br>India (Family Welfare)|
|PHN<br>and<br>Education<br>(l)|Sao Tome and Prindipe|
|PHR and<br>other|Rwanda<br>Honduras|
|sectors<br>(3)|Guyana|
|<br>Note: Figure|s in parenthesis represent the number of projects.|
|SIL<br>-<br>Spe|cific Investment L~oan|

borrower, which has responsibility for the solicitation, review, appraisal, approval and supervision of sub-projects. Moreover, some SILs/SECILs provide for sector funds to support innovative activities as a complement to other components. A list of all sector funds is provided in Annex 1, Table 4.

# 2. _Regional Distribution and IBRD/IDA Commitments_

2.8 The South Asia region accounted for the greatest proportion of lending volume, while the Africa region processed the largest number of PHN operations in FY92. Six projects supported PHN and social sector activities in Africa; and three projects were approved each in the Latin America and the Caribeen region (LAC) and in South Asia, two projects in Europe and Central Asia (ECA), and one each in Middle East and North Africa (MENA) and East Asia. Thirty-nine percent of loan and credit amounts were for projects in South Asia, 29 percent for ECA, 13 percent for East Asia, 10 percent for Africa, 5 percent for LAC and 3 percent for MENA (Figure 2). The average size of IBRD/IDA allocations for PHN operations in FY92 was $60 million. Lending amounts for projects in the Africa, LAC and MENA regions were lower than average. Loans/credits for projects in the Asia regions were larger than the average. The average size of loans/credits for PHN operations for each of the six regions was: $140 million for ECA, $129.6 million for East Asia, $125.8 million for South Asia, $26.8 million for MENA, $16.7 million for Africa, and $15.8 million for LAC.

2.9 The proportion of PHN projects that receive IDA funds is larger than the Bank-wide average. Since 1990, IDA has accounted for a minimum of 43 percent of PHN lending, while accounting for a maximum of 30 percent of overall Bank lending during the same period. In FY92, IDA represented 68 percent of PHN lending and 30 percent of overall Bank lending (see Annex 1, Table 5). IDA accounted for all lending to social sector projects during FY92, as
6

**PHN** 1992 **Sector Review**

befits the important role of these projects in poverty alleviation.

_Figure 2: Regional Distribution of PHN Lending,_ **_FMrV2_** <!-- Start of picture text --> Lending Amounts<br>(In US $ millions)<br>Africa $100.3 MENA S28.8<br>10%<br>E. Asria SI19 6, 1 /_<br>13X $280 : : _<br>29%<br>S. Asia v $47.5<br>397 t5<br><!-- End of picture text --> <!-- Start of picture text --> Number of Projects<br>Africa 6<br>38% ENA 1<br>6%<br>ECA 2<br>1 L | 2X<br>E. Asia I<br>6% X . 1 h . . : /<br>S. Asias 3 /LAC 3<br>19% 19%<br><!-- End of picture text -->

# 3. _Cofinancing_

2.10 During FY92, the number of cofinanced projects remained proportionally the same as in FY91. Every region except East Asia had at least one cofinanced project. All of the projects in the LAC and MENA regions were cofinanced, while half of the projects in the Africa rcgion were cofinanced (Table 5). The Bank leveraged fewer additional funds for its PHIN and social sector projects in FY92 than in FY91 accordinig to both measures of additionality--the amcunt donor cofinancing (not recipient governments) adds to the Bank lending for all PHN projects (overall

**ECA**

additionality), and the amount cofinancing adds only to those projects that are cofinanced.

2.11 Social sector projects received more donor contributions than "pure" PHN projects representing 54 percent of overall additionality, compared to 13 percent for PHN-only projects. In the cofinanced social sector projects, additionality was 60 percent; in the PHN-only projects it was 22 percent. Social sector projects offer an attractive means of combining assistance from donors, since they support a broad range of social investments. Most social sector projects support a portion of a larger country social program.

2.12 In-country cofinancers (excluding government counterpart funds) continue to remain a feature of PHN lending. In the East Asia and the ECA regions, one project included cofinancing from state governments and public agencies. Beneficiaries are contributing in one Africa project and two LAC projects. Amounts committed by in-country cofinancers tend to be small, since they are, in most cases, the municipalities, NGOs, and local groups that will be presenting proposals for project funding. In two projects, the beneficiaries' contribution matched at least half of the government's contribution. In the Guyana SIMAP/Health, Nutrition, Water and Sanitation project, the beneficiaries fully matched the amount committed by the government.

2.13 The Bank financed on average 62 percent of total project costs in the PHN sector during FY92. Average total projects costs in the "pure" PHN projects were higher than in the social sector projects--$117 million versus $34 million. Bank loans/credits on average were lower in social sector projects than in PHN-only projects--$13 million versus $79 million--due to the additional leverage gained in cofinancing from external sources in social sector projects.

4. _Project Funds by Expenditure Category_
**PHN 1992 Sector Review**

**7**

_Table 5: Cofinancing from Official Sources in P:'HN Projects, FY91 and FY92_ foi the private sector and non-governmental organizations (NGOs).

_Figure 3: Breakdown of Total Project Costs by Erpendizture Category_

|3at. Cofinarnce<br>_.............._|d Projects<br>_................_|_................_|_..............._|_........................._|<br>_............_<br>_Erpendizture Category_|
|---|---|---|---|---|---|
||FY91|-------------------|FY<br>-|92<br>I-------------------||
|Region|........................<br>No. of<br>Coftmnancd<br>Projects|....<br>Total No.<br>of PHN<br>**Projects**|..<br>.........<br>No. of<br>**Coflnance**<br>**Projecs**|..<br>**Tbtal**No.<br>**d**<br>ofPHN<br>Projects|Project<br>Cost Categories<br>(In U5 $mllions)|
|**Africa**|8|12|3|6||
|E.**Asia**|1|2|0|1||
|**S. Asia**|**3**|**4**|**2**|**3**|Vhce|
|**ECA**|**0**|**0**|**1**|**2Te**|Ast|
|_LAC_<br>MENA<br>AU Regions<br>3b. Additionali|3<br>2<br>....<br>17<br>ty(9b)R.cr|5<br>5<br>....<br>28|**3**<br>1<br>....<br>10<br>Det|3<br>1<br>....<br>16|_T-o3iSWdY_<br>_<br>fZM<br>/////<br>DIurgs4<br>**Iniest Costs**WK<br>Ewip!Furn<br>**91t**25<br>**404.9/5**<br>232.14<br>Pr~~~~~~~~~~~~~~~~~~4as<br>~e|
||**Oveall**<br>Addition|ality|Addition<br>Coftnance|ality in<br>a<br>d<br>Projects|<br> <br><br>14<br>Cm_ Wor|
|Region|FY91|FY92|FY91|FY92|76|
|.....................<br>Africa|......................<br>26.2|.....................<br>30.2|.....................<br>41.4|..............<br>57.8||
|E. Asia|12.9|n.a.|35.3|0.0||
|**S. Asia**|69.5|18.4|95.6|23.2||
|ECA|n.a.|10.0|n.a.|19.2||
|LAC|13.6|40.6|79.9|40.6|<br> <br> <br>|
|MENA|105.0|38.8|148.6|38.8|2.15<br>Project costs<br>allocated<br>to<br>drugs|
|**AU Regions**|**56.0**|**19.3**|**110.2**<br>.|**9.4**|(including<br>contraceptives<br>and<br>nutrition|

2.15 Project costs allocated to drugs (including contraceptives and nutrition supplements) increased significantly from 6 percent in FY91 to 26 percent in FY92. The "drugs" cost category is shown separately in the figure, since it has been categorized both as an investment and as a recurrent cost by different projects within and across regions. While drug costs are recurrent in nature, in that supplies need to be replenished on an ongoing basis, the purchase of an initial stock of drugs through a project, which will be replenished ultimately through cost recovery and/or by other means, is sometimes categorized by task managers as an investment cost.

2.14 Investment costs represented a smaller share of project costs in FY92 than in FY91--59 percent versus 70 percent (Figure 3). The greatest share of investment costs financed in FY92 projects was for equipment, furniture, supplies and civil works--70 percent. Recurrent costs, including drugs, contraceptives and nutrition supplements, accounted on average for 41 percent of total project cost, an increase over the 30 percent share in FY91. This increase in recurrent costs may reflect a growing appreciation of the high ratio of recurrent to investment costs characteristic of the human resources sectors and an increasing willingness to finance assistance of this type. Financial sustanability of FY92 operations is addressed through a combination of the following: Bank financing of recurrent costs on a gradually declining basis; and financial reforms to mobilize additional resources for PHN, including increased allocation of public funds for PHN, cost recovery schemes, and increased role

# B. Sector **Work**

2.16 TWenty-five sector reports were completed in the PHN sector during FY92, a decline from the 33 reports produced in FY91 (see Annex 1, Thbles 6 and 7). Of these, five reports were published in grey cover, eleven in green cover, and nine in yellow cover. Three reports focused mainly on population, 10 on health, and three on nutrition. One report covered
**PHN 1992 Sector Review**

8 population, health and nutrition and eight focused on the social sectors or poverty alleviation, but paid specific attention to the PHN sector.

2.17 In FY92, five country-specific health sector reports were published in grey cover (Nigeria: Health Care Cost, Financing and Utilization; Poland: Health System Reforms - Meeting the Challenge; Romania: Accelerating the T'ansition - Human Resource Strategies for the 1990s; Bra2il: Women's Reproductive Health; and Yemen: Human Development - Societal Needs and Human Capital Response). In this section, these reports are examined to assess their usefulness for devising policies and programs to address poverty alleviation and the quality of PHN services in developing countries (A review of population sector work is provided in paras. 2.412.42).

2.18 A first step in making use of limited resources to alleviate poverty is to identify the poor and vulnerable groups. The strongest reports classified the poor by gender, geographic area, income, nutritional level, and educational level, among other indicators. However, several reports did not provide data on who the poor are and where they reside. The Romania Human Resources Strategies Report did make the case that the country should conduct an assessment of the needs of poor and vulnerable groups in the country. The identification of poor and vulnerable groups and the assessment of their needs and demand for basic health services is an essential component of general health sector work. Chapter V of this report stresses this message and offers guidance in this regard.

2.19 A key barrier to poverty alleviation mentioned in most reports is the misallocation of health resources. Many countries spend the majority of their health resources on costly curative care, and, consequently, most reports stressed the importance of redirecting funds from curative care to primary health care activities for the general population. The Brazil Women's Reproductive Health Report goes a step further by recommending that women, in particular, be targeted to benefit from basic health services, since they currently benefit from a disproportionately smaller share of available health resources. However, several reports also make the point that in order to reach the poor and vulnerable groups, reallocation of public health expenditures will not be enough; actual spending must increase if needs are to be met.

2.20 While increasing resources for public health services is important for poverty alleviation, the best reports stressed that countries need to find a way to pay for this increase. The Poland Health Systems Reform Report emphasizes the need to diversify sources of funding. Several reports recommend giving greater support and encouragement to the private sector (including NGOs) to deliver health services. Increased government recognition of the private sector is important since private sector providers offer a complement of services to those provided by the government thus expanding service availability overall; and the quality of private services is often relatively high. The Nigeria Health Care Cost, Financing and Utilization Report emphasizes the need to encourage the "complementary role" of the private sector to provide services, especially to higher income groups. This report suggests that in order to ensure that access and quality are maintained or improved, the government may need to provide incentives to the health sector and regulate it through education programs targeted to providers. The Romania Human Resource Strategies Report suggests that granting more autonomy to private sector providers may be an effective incentive for encouraging their growth.

2.21 A number of reports recommend decentralization as a way to increase access to and quality of health services; however, several reports warn that there should be simultaneous efforts to improve management and financing at decentralized levels. In the Republic of Yemen Human Development Report, training of female health workers in rural areas is recommended as a means to improve the access to and quality of health care, especially for women.
**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
**PHN 1992 Sector Review**

10 program include women's health, micronutrient malnutrition, health economics, AIDS, hospital financing and costing, worldwide demographic estimates and projections, family planning, and health management.

2.29 Awareness raising involves meeting with other donor agencies and development organizations to discuss and promote salient topics in the PHN sector. In FY92 PHRHN continued its involvement in several inter-agency task forces, including the Task Force for Child Survival and the Inter-Agency Group on Safe Motherhood and Better Health Through Family Planning, and participated in preliminary meetings for the International Conference on Nutrition that was held in Rome in December 1992. PHRHN was also involved in inter-agency discussions on micronutrient malnutrition and co-sponsored an international conference in Montreal on the subject.

2.30 To raise awareness and share information within the Bank, the PHN Department sponsors seminars; publishes a Working Paper Series and PHN notes on current topics; organizes and conducts training courses; and prepares a series of best practices and other papers aimed at helping Bank staff in operations develop and implement more effective Bank projects. During FY92, PHRHN provided new information to Bank staff working in operations by sponsoring 19 seminars, attended by a total of 363 Bank staff, on a variety of PHN topics. PHRHN also published 19 Working Papers and a series of two-page PHN notes, and assisted with the publi^cation of three technical papers.

2.31 PHRHN and the technical departments conducted training programs that aimed to inform Bank management and staff about key sector issues. The most significant of these programs was a half-day seminar for senior Bank management including the President of the World Bank, managing directors, several vice presidents, and about thirty department directors. Its purpose was to consider the implications of rapid population growth for economic development and poverty-alleviation objectives of the Bank.

Outside experts reviewed the current state of our knowledge about the consequences of population growth and the efficacy of family planning services as a means to improve reproductive health and help families achieve their fertility and family-size goals. The seminar was followed by regionspecific seminars for regional management teams and the task managers of population projects; that series will be ongoing throughout FY93.

2.32 Other staff training included a successful five-day program on effective work in the health sector; a five half-day nutrition seminar that disseminated best practice among nutrition specialists; a monthly series of technical seminars for the Population Working Group; a brown-bag luncheon series that focused on current issues in health-care financing; and periodic meetings of an AIDS Working Group, all these organized by PHRHN. The technical departments offered a number of region-specific programs, including migration issues in the Middle East and North Africa; nutrition, decentralization and AIDS, in the Asia region; and poverty analyses, including the impact of targeted nutrition assistance, in the LAC region. In addition, the startup of preparation for the 1993 World Development Report (WDR) on health generated a series of excellent technical seminars, which many Bank staff attended.

2.33 The Bank's Economic Development Institute (EDI) organized seminars in the LAC region on public budgeting for PHN, including the issues of public finance for social security and health care; in Eastern Europe on health care and public social spending; and in Asia on health. In all these seminars, Bank staff played significant roles in the dissemination of experience with Bank projects and ongoing research.

2.34 Staff in the PHN sector grew from about 310 to about 360 during the course of FY92, as a result of some new hires and transfers from other sectors. PHRHN found, through two questionnaires sent to staff, that training on health insurance and health-care financing, as well as best practice exchange-of-information in all areas of population, health, and nutrition project
11 PHN 1992 Sector Renew formulation, have highest priority among Bank staff for their immediate training needs. There is also considerable interest in the use of study tours to learn about current practice in the more successful OECD countries that have been able to moderate the high costs of health care services while assuring quality and broad coverage. Maintaining and enhancing staff skills through training will continue to be a major sector challenge.

2.35 Specific, operations-relevant research undertaken by PHRHN included preliminary research on Best Practices papers on Micronutrient Deficiency Disorders and on Women's Health and Nutrition; publication of a paper on Effective Family Planning Programs and Guidelines on Safe Motherhood; an ongoing study of the Economic Impact of Adult Mortality in Africa, specifically focusing on how households cope with illness and death of AIDS victims; and continuing work on costing and financing issues for hospitals. This work synthesizes lessons learned from the experience of countries and donors, and explores cost-effective strategies for combatting major health problems in the world.

2.36 A major part of the work program of the PHN Department is to provide support to operations. In FY92 PHRHN provided 112 weeks of direct operational support to help staff in operations conduct sector work and identify, prepare, appraise, supervise and evaluate Bank projects. This was approximately 20 weeks in excess of planned support.

# E. Population, Health and Nutrition Content **of Projects.**

# 1. _Population_

2.37 Ten projects in the FY92 PHN lending program provide assistance to family planning, two of wh,ch (Niger and Mauritania) also contain components that support the development of population policy and analytical capacity. One interesting aspect of the FY92 population lending program is its contribution to the geographical expansion of the Bank's population portfolio. The Niger Population project, for example, represents the Bank's first freestanding population project in the Sahel. Five other projects (Mauritania, Equatorial Guinea, Chile, Poland, and Romania) are the first Bank lending operations in the PHN sector in those countries; all but one of these provide direct support to family planning (the Chile Technical Assistance and Hospital Rehabilitation project does not address family planning directly, although it does have a subcomponent that will fund the design of a women's health program).

2.38 The volume of lending for population, at $103.2 million, represents a substantial drop from last year's total of $351 million, a drop that was forecast, but not expected to be quite so steep (Annex 1, Tables 9 and 10 provide more detail). The number of projects with a population component is also down from FY91's record level of 18, reflecting, in part, the drop in the number of PHN projects overall. Slippage from FY92 to FY93 provides additional explanation. TWo projects committing substantial resources to population - Ethiopia Population and Nepal Population and Health, together amounting to $76.0 million - are now expected to go to the Board in FY93. Both the volume of population lending and the number of projects are expected to increase next year, and be maintained in FY94. (Annex 1, Figure 2 provides more detail). Bank support for population projects benefitted substantially from IDA funding, as it has in the past. Eight of the 10 population projects are IDAsupported, to the value of $80.8 million, or 80 percent of population lending. In comparison (as noted above in para. 2.9), 68 percent of PHN lending in FY92 is IDA-financed. For Bank lending as a whole, the proportion financed by IDA is 30 percent.

2.39 One relatively minor reason for FY92's low population lending figure is an accounting change, which allocates the reinforcing subcomponents of a population project to the relevant subsector in recognition of the increasingly integrated nature of population and PHN projects. (Based on the definition previously
**PHN 1992 Sector Review**

**12**

used, FY92's total would have been $125 million.) This change has been introduced as part of the effort to track the subsectoral thrust of human resource lending, which increasingly integrates activities in several sectors into one project. Thus, the loan amount for a population project with maternal and child health (MCH) or women in development (WID) components is no longer quantified as 100 percent population. The increasingly diverse nature of Bank population projects reflects the effort to address not only the unmet need for contraception that exists in most countries, but to stimulate the demand for family planning that derives from better infant, child and maternal health, and from improved women's status. Programs that used primarily to provide family planning services are moving to provide maternal and child health, including nutrition interventions (India Family Welfare) and WID components (Mauritania and Niger projects). Often projects involve local communities or NGOs in these activities. Indeed, moves towards including NGOs and the private sector in general, and towards decentralizing control in public programs, are frequently features of current population and PHN projects, reflecting the search for ways to improve access of vulnerable groups.

2.40 The Niger Population project, for example, establishes a Population Fund to finance private sector, NGO, and community involvement in service delivery and information, education and communication (IEC) activities. In addition, the India Family Welfare project will put forth "concerted effort" to include private voluntary organizations (PVOs) and private medical practitioners (PMPs) in the delivery of services and IEC. The Innovative Schemes component of this project establishes a revolving fund used to finance PVOs and PMPs. They will compete for the funds, proposing new interventions that involve the community directly. Suggested projects include creche programs, nutrition and environmental sanitation projects, and fermale education and training activities. This project targets involvement of PVOs because "PVOs generally take up innovative programs by adopting strategies and methodologies which are aimed at fostering social transformations, thereby generating attitudinal changes and improving quality of life of women in particular (SAR, p. 21)." 2.41 PHN sector work completed and ongoing in FY92 gave substantial attention to population issues. These studies also dealt with the themes of integration and decentralization of PHN projects, under the headings of improving the effectiveness of services delivered, the efficiency of resource allocation, and the equity of access. In addition, sector work examined the effect of population growth on other development activities - in the provision of social services, and its impact on labor markets in particular. The FY92 reports for IDA countries focussed on countries with rapid rates of population growth - in the majority of cases over 3 percent per annum, or only reduced below this level by high mortality (e.g. Guinea Bissau). Four PHN reports reached grey cover for countries in eastern Europe and the former Soviet Union, but only one, Romania, deals with population and family planning issues in any detail, although the Poland study takes up the issue of family planning's role in improving maternal and child health.

2.42 A sector report on _New Directions in the Philippines Family Planning Program_ quantified the health benefits of family planning to women and children, and its message is being increasingly noted and quoted in the Philippines. The report's key finding is that "...preliminary analyses of available data indicate that if pregnancy were avoided by women under the age of 20, over 35, with four or more children, and less than 15 months post-partum, both the infant and child mortality rates would decline by almost 25 percent and the number of infant and child deaths would decline by 35 to 50 percent.

# 2. _Health_

2.43 The main thrust of health projects approved during the year is the provision of primary health care services to those most in need: largely the poor, women of child-bearing
PHN **1992** Sector **Review** 13 age and children under the age of five. Considerable emphasis is thus given to maternal and child health services. A fundamental objective of these interventions is to improve the quality, efficiency, and equity of basic services. Quality issues are primarily addressed through interventions to: upgrade physical facilities, upgrade the technical and outreach skills of personnel, ensure the availability and affordability of essential drugs and adequate recurrent financing, and involve communities in the design and management of sector activity. (See Chapter IV for a fuller discussion of quality issues).

2.44 As a complement to interventions at the service level, FY92-approved health operations provide considerable support to building national capacity for policy formulation and sector management and to the field testing and eventual country-wide application of policy reforms, which aim for increased sector efficiency and equity. T-hese objectives are largely realized through financing and institutional reforms such as: the mobilization of additional resources through cost recovery and increasing health's share of the public budget; reallocation of the public budget for health in favor of basic services for the poor and underserved; more financial autonomy for hospitals and increased private sector activity thus liberating public funds for basic services for the poor; decentralization; and increased involvement of NGOs and communities in health sector activity. Section E of Chapter III provides a more detailed analysis of project support in this regard.

2.45 Notable features of this year's portfolio reveal two emerging trends in health sector lending: increasing attention to urban primary health care and to the hospital sector. In support of urban health services, the Kenya Health Rehabilitation project will support the development and initial implementation of a strategic plan for health services in the Nairobi areas; the Mauritania Health and Population project will strengthen basic health services in three regions including Nouakchott; and the India Family Welfare project will improve the supply and management of family welfare services for poor urban populations.

2.46 Assistance to the hospital sector will be provided through a number of health operations. The Chile Technical Assistance and Hospital Rehabilitation project will initiate improvement in the quality of hospital services in Santiago through the support of subprojects to rehabilitate hospitals to be designed and implemented by hospital staff and local health authorities. The Equatorial Guinea Health Improvement project will support key reforms in the management of two national hospitals, in Malabo and Bata, including progressive management and financial autonomy, the selective application of the fee-for-service policy, and the strengthening of accounting and administrative controls. Under the Kenya Health Rehabilitation project, the Kenyatta National Hospital will be rehabilitated and its organization and management strengthened.

2.47 Health operations also targeted a number of priority diseases. This year the Bank's second ever freestanding AIDS project was approved for India (the first being for Zaire in FY89). AIDS is also addressed through projects in Romania (safer blood products and AIDS testing), China (surveillance of STDs and AIDS), Kenya (HIV/AIDS-related supplies for hospital workers to avoid inadvertent transmission), and Rwanda (targeting of emergency assistance to AIDS-afflicted families and orphans). In addition, the Equatorial Guinea project will help establish a sexually transmitted diseases (STD) program in the Ministry of Health. Malaria is a primary target of both the Equatorial Guinea and Sao Tome and Principe projects. Schistomiaisis is the sole target of a project in Egypt and one of two targets in the China project, the other being tuberculosis.

# 3. _Nutrition_

2.48 Nutrition lending in the Bank continues to grow. While the number of PHN projects with nutrition components decreased between FY91 and FY92 from 22 to 10 (reflecting the overall drop in the total number of PHN projects in FY92), the estimated allocation of total project resources for nutrition in the three-year period
**14**

**PHN 1992 Sector Review**

FY93-95 continues the strong climb upwards, rising from $49.3 million for FY87-89 to $893.9 million for FY90-92 to $1257 million for FY93-95 (Annex 1, Table 11 and Figure 3).

2.49 In addition to PHN activity, resources allocated for nutrition-related activity outside the PHN portfolio increased significantly in agriculture, education and emergency relief, among others. The Emergency Drought Recovery and Mitigation Project in Zimbabwe includes nearly $21 million for a child supplementary feeding program. Within agriculture projects, both the Ghana National Agriculture Extension Services project and the Chile Small Farmer Services project finance expanded extension services to women with a strong emphasis on nutrition. A $15.3 million school feeding component in Chile's Primary Education Improvement project also adds to the total project resources for nutrition represented in Bank projects for FY92 (Annex 1, Table 12).

2.50 Attention to micronutrient deficiencies and long-term strategies for food fortification remain areas of emphasis in PHN projects with nutrition components. Several projects under preparation, including the FY94 Pakistan Nutrition project, are exploring potential vehicles such as sugar, for the iron fortification necessary to make a sustained impact on the widespread iron deficiency anemia found in so many lower income countries. Under the Bank's Special Grant program on micronutrients, financial support for the development of a ten-year action plan to combat global iron deficiency anemia has gone to the International Nutrition Foundation for Developing Countries and work continues on a best practices paper on micronutrients.

2.51 The nutrition component in Poland's Health Services Development project represents a shift away from the traditional attention to undernutrition found in most Bank projects. Its focus on preventive counseling and education is aimed at addressing unhealthy dietary practices leading to high levels of mortality due to cardiovascular disease and cancers found in Poland. This new direction in nutrition programming will be repeated in upcoming PHN projects in several of the countries of eastern Europe and central Asia.

2.52 FY92 adjustment projects continue the trend toward inclusion of nutrition conditionality, with 10 structural and sector adjustment operations addressing nutrition, including two that contain specific nutrition actions required for tranche release (Annex 1, Table 13). In what is largely a new area of Bank lending, four adjustment operations contain sizable credits to address the impending starvation and food insecurity resulting from an unprecedented drought throughout southern Africa in 1992. The Malawi Entrepreneurship Development and Drought Recovery Program disbursed $50 million of the $120 million Credit in the first tranche for the purchase of maize imports, while $10 million under Mozambique's Economic Recovery credit will assist with emergency import of seeds, farming equipment and food. Zambia and Zimbabwe's FY92 adjustment operations also include IDA credit for drought-relief importation of agriculture inputs and food grain.

2.53 In spite of the addition of several technical nutrition specialists to the Bank's staff this year, the rapid escalation of nutrition operations in the Bank's pipeline and the increased demand for direct operational support from the PHN Department, forces the continued reliance on outside consultants. Further augmentation of the Bank's technical nutrition capacity is necessary to support adequately the growth in this sector.

# --------------------------

> l Prior to January 1, 1993, the PHN Department was known as the Population, Health and Nutrition Division of the Population and Iluman Resources Department (PHRHIN).
SPECIAL TOPIC: **PHNIS** CONTRIBUTION TO THE BANK'S POVERTY ALLEVIATION OBJECTIVE

# CHAPTER III:

## A. **Background**

3.1 The 1990 World Development Report (WDR) documents the extent and impact of poverty around the world, and, drawing on the Bank's own experience of the last three decades, emphasizes that economic growth alone is not a sufficient development objective or adequate measure of success. It argues convincingly that investments in human resources contribute to increasing incomes and to the reduction of poverty. As time goes by, the real success of this WDR lies less in the documentation, dissemination and reanimation of this very important message and more in the significant way it has influenced and continues to influence both the content and approach of the Bank's work.

content of the sixteen operations approved in FY92.

## B. **Context**

3.3 The Bank's contribution to poverty alleviation efforts through its PHN sector must be evaluated in the proper context. The following section thus sketches out in a country setting: _what_ are the essential activities for successful and sustainable poverty alleviation, _who_ should be responsible for carrying out these activities, and _how_ these activities should be carried out. Only when these three elements are clearly laid out does the optimal role for the Bank begin to emerge.

### 1. _W7zat._

3.2 The 1990 WDR reaffirmed the Bank's commitment to poverty reduction as its fundamental objective, and was followed by a series of operational documents, which provide practical guidance in strengthening the focus on poverty reduction in Bank operations. The policy paper, _Assistance Strategies to Reduce Poverty,_ articulates a two-pronged strategy for sustainable poverty reduction: (1) the generation of incomeearning opportunities for the poor; and (2) the provision of basic social services to the poor to enable them to seize those opportunities. The strategy also calls for providing a social safety net for vulnerable groups during periods of adjustment. The _Poverty Reduction Handbook_ demonstrates good-practice analytical and operational work. Operational Directive 4.15 on _Poverty Reduction_ summarizes Bank procedures and guidelines for operational work on poverty reduction, emphasizing the importance of assessing country policies, reviewing public expenditures, and strengthening institutions in achieving that objective. This chapter will demonstrate just how well and to what extent PHN operations respond to the Bank's poverty alleviation objective, by analyzing the design and 3.4 In order to address and resolve poverty issues, a country needs to carry out four crucial and complementary activities. First, _information collection and analysis_ permits the identification of poor and vulnerable groups and provides essential information on their location(s), needs, constraints, demands and on why their needs and demand for basic social services are not being met. Second, a country's _policies, strategies and reform measures_ can be instrumental in reaching the poor and are a reflection of political commitment to poverty alleviation. Wellarticulated macro- economic and multisectoral policies that are oriented toward growth with poverty reduction will provide the framework needed to carry out poverty alleviation activity both within and outside of the PHN sector. The impact on the poor of PHN policies and priorities needs to be well understood by planners and policy makers. A re-examination and reform of PHN policies, financing and institutions in light of their impact on poor and vulnerable groups will permit improvements in access, quality, affordability, efficiency and effectiveness of PHN services, which will benefit poor and vulnerable groups.
PHN 1992 Sector Review 16 3.5 The _translation of policy into practice_ is a third essential ingredient for successful and sustainable poverty reduction. It involves the planning and programming of resources and design of activities for the optimal benefit of the poor. Particularly challenging in this regard (both technically and politically) are: (1) the review and reallocation of public investment and recurrent budgets for PHN away from the development of more sophisticated services and the support of an excessively curative orientation, characteristic of many current allocative patterns, towards more basic curat-ve, preventive and promotional activities; and (2) the targeting of groups most in need, both to ensure the availability of basic services and to ensure their affordability. Finally, _implementation_ of poverty alleviation activities requires good organization and sound management of human, financial and physical resources, a reliable monitoring and evaluation system for early detection of implementation issues, and the flexibility to fine-tune design and objectives to overcome these issues rapidly. In addition to tracking the implementation process, monitoring and evaluation should assess the impact on the poor of program or project interventions, and should inform policy analysis and formulation.

# _2. Wo._

3.6 Both L. _Salmen'sInstitutional Dimensions of Poverty Reduction_ (WPS No. 411) and the FY91 Annual PHN Sector Review (WPS No. 890) stress the importance of using optimally the numerous and various potential actors and institutions in the sector -- both public and private -- according to their comparative advantages. Salmen argues that the understanding, development and use of local and informal institutions in the design, promotion and delivery of basic services for the poor is likely to result in an intervention which is highly cognizant of and responsive to demand and, therefore, more likely to result in the success and sustainability of such interventions. The FY91 ASR, which addressed "Institutional Development in Support of a Poverty Focus for the PHN Sectors', argues that significant gains in quality and efficiency could be realized if the private commercial sector, NGOs, community organizations, universities, national and regional institutions specializing in training, consulting and research and other groups outside the public sector, were encouraged to work in partnership with government -- both centralized and decentralized -- to address and resolve sector issues.

# 3. _How._

3.7 How best to address the poverty problem is a question which has not been fully answered. This is due in part to the need to tailor interventions to a particular country context, thus indicating an "it depends" answer. It is also due in part to the fact that lessons from experience have not been sufficiently analyzed, exploited or widely disseminated and that much more pilot testing, operational research, and monitoring, and evaluation of poverty initiatives need to be carried out in order to fine-tune efforts to alleviate poverty and provide basic social services to the poor.

3.8 There does exist, however, some guidance in this regard. The operational guidelines emanating from the 1990 WDR, the FY91 PHN ASR and L. Salmen's _Institutional Dimensions of Poverty Reduction_ all stress the importance of the following three conditions for successful and sustainable poverty alleviation interventions:

- (a) A full _understanding_ of the extent of the poverty issue at all levels of government (particularly the highest), which would provide the basis for a firm _commitment_ to address the issue and more _transparency_ in policy formulation.

- (b) The reorientation of poverty interventions (including basic social services) to be more
**PEN 1992 Sector Review**

**17**

knowledgeable and accommodating of the locations, problems, needs and perspectives of poor clients. According to Salmen, experience suggests that poverty reduction efforts would be more successful if they were energized more by _demand_ than supply.

- (c) _National capacily_ to carry out the four essential activities outlined above (i.e., information collection and analysis: policy analysis and formulation; planning, programming,budgetingandtargeting;and management, monitoring and evaluation of implementation), and to mobilize and coordinate the optimal contributions of partners in carrying out those four activities, including clients or target groups, NGOs, private sector, community groups, government (centralized and decentralized, across sectors).

sustainability of poverty interventions over the medium- to long-term. It should assist in developing and strengthening, where needed and appropriate, a country's commitment and capacity to address and resolve its own poverty-related issues and problems, with the full involvement of those who have much to gain from and contribute to the process: the poor.

# D. Evaluation **of FY92 Portfolio of PHN Projects: An Overview**

3.10 PHN projects approved during FY92 have been responsive to the Bank's poverty alleviation objective and have addressed both short- and medium-term issues. The following sections of this chapter will provide an overview of the poverty content of these projects and analyze special features of these interventions. For reference, the Credit and Project Summaries for each of the sixteen projects, as presented in the respective SARs, are reproduced in Annex 2.

# C. **The Bank's Role**

3.9 Invaryingdegreesandpatterns,thethree above-mentioned conditions for successful and sustainable poverty alleviation are not at present being effectively met in most of the Bank's client countries. These will take time to be fulfilled, and yet the needs of the poor and vulnerable are urgent in many of these countries and must be addressed immediately. Appropriate Bank intervention should ideally address both the short and medium-term issues. In order to prevent poor and vulnerable groups from slipping through the social safety net, particularly during periods of economic hardship and adjustment, the Bank should invest in activities to improve quickly and directly the food security and social welfare of the poorest and most vulnerable population groups. However, short-term,emergency-typeinvestments aimed at reducing poverty do not constitute by themselves a sufficient response to the Bank's poverty alleviation objective. The Bank needs also to focus on a crucial medium-term objective: that of stimulating and encouraging the three abovementioned conditions for success and 3.11 All sixteen PHN projects approved this year will, in various ways, benefit poor and vulnerable segments of national populations. This portfolio of projects can be subdivided into three categories in terms of how their design and objectives are geared towards poverty alleviation. The classification of the sixteen projects is presented in Table 6 and discussed below.

3.12 _Category I: MultisectoralInterventionsfor PovertyAlleviation (Poverty Projects)._ The primary objective of these projects is the provision of short-term emergency assistance to address the basic needs of groups most affected by a country's economic adjustment process, while also building national capacity to monitor and alleviate poverty in the medium- and long-term. Three of the sixteen PHN projects (or about 20 percent of the FY92 portfolio) fall into this category: Rwanda Food Security and Social Action, Guyana SIMAP/Health, Nutrition, Water and Sanitation, and Honduras Second Social Investment Fund. Short-term assistance provided through these projects is channeled to target groups in a
18 PHN **1992** Sector Review decentralized and demand-driven manner, and includes: credits to small business/entrepreneurs, provision of basic social services (food aid, primary health care, day care centers), and income generation opportunities/temporary employment on public works activities to develop social and economic infrastructure at the local level. Medium-term components of these projects include efforts to increase national capacity to monitor living standards and basic needs of populations and to reform policies and develop and implement strategies (both inter- and intrasectoral) to climinate poverty.

3.13 _Category 2: Provision of Basic Social Services to the Poor as Primary Objective._ As an important complement to broadly-based economic growth to generate income earning opportunities for the poor, the WDR 1990 emphasized the direct improvement of the welfare of the poor through the provision of basic social services. This category of projects, of which there are six (or about 35 percent of the FY92 portfolio) focuses on that aspect of the Bank's poverty reduction strategy as the primary objective. These projects target poor populations, and within those populations, particularly disadvantaged and vulnerable groups (mostly mothers and children). All of these projects include both short-term assistance, aimed at improving the quality and accessibility of basic social services, and medium/long-term assistance aimed at developing national commitment and capacity to reform, implement and monitor sector policy with a view to improving the social welfare of poor and vulnerable groups. Of the six projects included in this category, four are in the Africa region (Equatorial Guinea Health Improvement, Mauritania Health and Population, Niger Population, and Sao Tome and Principe Health and Educaton), and two are in India (Child Survival and Safe Motherhood, and Family Welfare [Urban Slums]).

3.14 _Category 3. PHN Interventions Whose Benefits to PoorAre Important But Not the Primary Objective._ Projects in this third category (totaling seven, or about 45 percent of the FY92 protfolio) do not set poverty alleviation as their primary objective, but support strategic sectoral interventions, which will in fact benefit poor and vulnerable groups both directly and indirectly. Four of these projects (Kenya Health Rehabilitation, Poland Health Services Development, Romania Health Rehabilitation, and Chile Technical Assistance and Hospital Rehabilitation) are supporting policy, institutional and operational reforms from which the poor should derive significant benefits. Such reforms include: (a) increased attention and resources for prevention and promotional activities (vs. curative); (b) increased financial and managerial autonomy for higher levels of health care and greater private sector involvement, both of which should liberate public funds for basic services; (c) regulation of drug production, procurement, distribution and prescription for better quality and greater affordability of health services; (d) development and expansion of the institutional framework for health (private sector involvement, decentralization of authority and responsibility, community involvement), which should provide the poor with "exit" and 'voice" options; and (e) mobilization of resources through cost recovery with a social safety net for the poor.

_3.15_ In addition to medium-term interventions focussed on sector reforms, these projects also include components which are more clearly and directly focussed on poverty issues -- both short- and medium-term. The Chile project will improve health service provision to a majority of the poor population of metropolitan Santiago by upgrading the dilapidated capital stock of seventeen hospitals that cater to the ambulatory and tertiary care needs of the city's semi-rural and marginal peri-urban areas. The Kenya Health Rehabilitation project will support the establishment of a National Household Welfare Monitoring and Evaluation System to monitor trends in poverty and evaluate impact of policies on household welfare. The Poland and Romania projects provide for more effective targeting of poor and vulnerable populations.
**PHN 1992 Sector Review**

19 _Table 6: Classification of FY92 PHN Projects by Poverty Objectives_ **_and_** _Content_

||Category I|Cateory 2|Category 3|
|---|---|---|---|
|REGION|Multisectoral<br>Interventions for Poverty<br>Alleviation|Provision of Basic Social<br>Services to Poor and Vlnerable<br>Groups as Primary Objective|PHN Sector Interventions<br>Whose Benefits to Poor Are<br>Important, But Not Primary<br>Objective|
|AFRICA|Rwanda|Equatorial Guinea<br>Mauritania<br>Niger<br>| Sao Tome|Kenya|
||EASTASIA|II||China|
|ECA<br>l<br>_<br>_<br>_<br>__<br>_<br>_|1<br>ll<br>_<br>_<br>_<br>_<br>_<br>_<br>_<br>_|<br>l__<br>_<br>_<br>_<br>_<br>_<br>__<br>_<br>_<br>_<br>_<br>_<br>_<br>i~~~~~~~~~~~~~~i|||Poland<br>|i_<br>R om ania|
|LAC|Guyana<br>Hondurasl||Chile|
|MENA|l||Egypt|
|SOUTH ASIA||India Safe Motherhood and<br>Child<br>Survival<br>India Family Welfare (Urban<br>Slums)|India AIDS Prevention<br>Control|

3.16 The three remaining projects in this category target diseases which afflict the poor. The Egypt and China projects are supporting major programs for the control of schistosomiasis, targeting mainly rural and lower income and less educated segments of the population. The China project will also support a major reform in that country's approach to tuberculosis. The new control strategy emphasizes treatment of _all_ detected cases to reduce infection rates rapidly, rather than searching for new cases and treating only these who can afford to pay, which had been the practice. This will lead to increased effectiveness, accountability and _equity_ in the control of that disease, and will help alleviate the immediate, often financially devastating impact of the disease on the patients and their families.

3.17 The India AIDS project will benefit poor segments of the population and migrant labor. As a part of project preparation the impact of HIV/AIDS at the household level in India was assessed and found to have devastating effects on the social and economic welfare of the victims and their families, such as loss of economic security, potential loss of land and other assets, reduced remittances to family and friends, reduced capacity to finance education, orphans (young and old), not to mention the high costs of medical care and funerals. This project's success in reducing the incidence of HIVlAIDS will thus contribute to poverty alleviation in an important way.
**PHN 1992 Sector Review**

**20**

## **E. Special Features of Poverty Interventions in the FY92 Portfolio**

3.18 This section selectively highlights design features of poverty interventions included in PHN's FY92 portfolio of projects. While it is premature to call them 'best practices", these components of poverty work in the Bank generally reflect careful consideration and incorporation of lessons of experience and as such hold promise for success and sustainability of investments. This section is by no means an exhaustive inventory or comprehensive analysis of the coverage and treatment of each of these special features. Rather, it provides an overview of the poverty content and a flavor of the design and approaches of this year's crop of PHN projects. The special features reviewed in this section are: (1) poverty information and monitoring; (2) understanding and responding to the needs and demand of the poor; (3) targeting; and (4) reforms in policy, financing and management/organization of activities. The last category covers the three key areas of Bank intervention in poverty alleviation as set out in the recently distributed OD 4.15 on _Poverty Reduction:_ assessment of country policies; review of public expenditure; and reform of institutions.

_1. Poverty Information and Monitoring_ 3.19 A general objective of the Rwanda Food Security and Social Action Project is to increase government capacity to monitor the living standards of the population. This project will thus support the development of a system to trace the evolution of selected determinants of welfare and welfare outcomes at the levels of the household and the individual, in the context of the country's adjustment process. This system is comprised of a combination of integrated surveys (which observe the income generation and expenditure processes and basic needs achievements) and priority surveys (which provide for the rapid identification and monitoring of a wide range of welfare indicators of policy target groups). Thbe design of this welfare monitoring system will **integrate** data collection and processing, on the one hand, with policy relevant analysis, on the other.

3.20 The Kenya Health Rehabilitation Project is supporting a component to develop within the Ministry of Planning and National Development (MPND), the establishment of a National Household Welfare Monitoring and Evaluation System for monitoring trends in poverty and evaluating the impact of policies on household welfare. The project will develop permanent capacity to carry out national household surveys on an annual basis and to analyze data collected as a basis for providing advice to MPND and social sector ministries in policy design.

3.21 In order to improve knowledge about the extent of poverty and the determinants of living standards, the Guyana SIMAP/Health, Nutrition, Water and Sanitation Project includes a component to strengthen that country's data collection capacity. It will support the development of a methodology for a Living Standards Measurement Survey (LSMS), the execution of field work, and the analysis of results. The LSMS will be implemented in conjunction with U.NIDP's Income and Expenditure Survey (IES). Selected LSMS modules with particular focus on social sectors data will be added to the IES in its second survey round. Survey rounds for the LSMS will be undertaken on three separate occasions, the last of which is expected to be completed in mid-FY93.

# _2. Understanding and Responding to the Veeds and Demands of the Poor_

3.22 A review of PHN projects over the past five years reveals a notable trend of increased importance attached to the demand and perspectives of beneficiaries in project design and development. This is reflected in increased involvement of NGOs, other local organizations, and beneficiaries in the assessment of needs and in the design, implementation and evaluation of
21

**PHN** 1992 Sector Review

interventions. It is also reflected in the emergence of a number of more carefully conceived, culturally appropriate and better targeted programs aimed at encouraging the poor to seize opportunities to participate in their own development and at stimulating among this group latent demand for basic social services. The following paragraphs give examples of how some projects have done this.

3.23 _Involvement of Beneficiaries, NGOs and Other Grassroots Organizations in Program Design and Implementation._ By design, two Sector Funds approved during the year (Honduras and Guyana) are largely demand-driven interventions. These funds, intended to address the basic needs of the poor, finance subprojects which are designed, developed and implemented by NGOs, community groups, and/or local government agencies. A national agency is given responsibility to manage the funds, to solicit proposals for subprojects, and to appraise, approve, supervise and evaluate them. The labor-based public works component of the Rwanda Food Security and Social Action project has a similar design, whereby communes (local administrative units) are invited to submit proposals for small public works subprojects, which would provide temporary income-earning opportunities for the poor.

3.24 Over and above the special demanddriven design of social funds, virtually all FY92 projects provide for the participation of the poor in some form. One particularly good example of thoughtful, well-designed and extensive participation is the India Family Welfare (Urban Slums) project. A major activity of this project is to increase the participation of urban slum communities in the design, implementation and supervision of the family welfare services being provided to these communities. Under this project community groups will undertake and/or participate extensively in beneficiary/needs assessmentsinitiatedbyeachmunicipalitytargeted for project assistance. In order to elicit and encourage community inputs to project design, as a part of project preparation each municipality undertook a series of workshops during which participants, drawn directly from the targeted slum communities, commented on and recommended changes to project design.

3.25 Four methods for community participation will be employed under this project: (a) the establishment of neighborhood communities; (b) the promotion of PVO partnerships; (c) the organization of supplementary health support schemes such as sanitation and nutrition awareness; and (d) the support of community-initiated ideas with financial, material and staff resources. And six community involvement strategies have been identified: persuasion, education, information feedback, consultation, joint planning of design, and delegated authority.

3.26 A plan for operationalizing community participation was prepared by each municipality. The plan itemizes for each of the six strategies: implementation methods; government inputs; community inputs; joint management structures; associated problems/issues risks; requirements to increase demand; expected benefits; evaluation indicators; and additional funding required. This project may provide a good model for other PHN operations striving to initiate and institutionalize community participation in the design and implementation of basic social services, particularly in an urban setting.

3.27 The following are yet other examples of community participation initiatives included in FY92 projects. Promoting regular consultations with beneficiaries is a general objective of the Equatorial Guinea Health Improvement project; management of a new pilot drug system, supported under this project, will involve community participation through facility-level management committees comprising representatives of the beneficiaries. The Sao Tome and Principe Health and Education project will finance a study on community involvement in the social sectors as well as an IEC campaign to stimulate community participation in malaria
PHN 1992 Sector Review 22 control activities. A portion of the Population Fund under the Niger Population project will be allocated to subprojects designed by beneficiaries, which would support activities in the promotion and provision of family planning services and basic primary health care. To minimize the risk of inefficient management of the Rwanda Food Security and Social Action Project, beneficiaries will be involved in the monitoring process.

3.28 Agreement was reached during negotiation of the Romania Health Rehabilitation Project that the Government would prepare for Bank review a development plan for health promotion and public participation for the period 1992-94, which would include training of district health education workers and involvement of NGOs. The India Child Survival and Safe Motherhood Project will support the design and development of a number of community participation strategies and the implementation of district planning including community participation based on Ministry of Health and Family Welfare (MOHFW) guidelines.

3.29 _Raising Awareness and Stimnulating Demand._ In addition to eliciting and responding to the perspectives and demands of communities/ beneficiaries, FY92 projects also devote significant resources and effort to the stimulation of latent demand for basic social services and to raising awareness about the value of preventive activities. As for the provision of services supported by FY92 projects, the preponderance of IEC activities are targeted to poor and vulnerable segments of the population as a complementary means of improving their social welfare. This activity poses a significant challenge, given that poor groups are the most difficult to reach and influence. Not only will such activity encourage these groups to adopt behaviors to improve their own health, it will better equip them to fulfill the r role as participants in the design, nionitor.ng a.od evaluation of basic social services for th.. communities. Both the Poland Health Scr,!:` Development Project and the Romania H 2 '!ta Rehabilitation project will support li 't promotion and preventive activities as an important part of the health reform to be implemented under those projects. The Niger Population project will develop a nationwide IEC program to promote family welfare and women's status. Major activities of the program include: (a) expanding mass media communication; (b) strengthening inter-personal communication; (c) organizing listeners' groups at the village level; and (d) expanding IEC activities of voluntary associations such as woman's associations and youth groups, and other community action groups including NGOs and the private sector.

3.30 All three India projects approved during FY92 include well designed and targeted IEC programs. Notable among them is the India National AIDS Control Project, which is supporting an extensive program to raise public awareness and increase community involvement. The program's strategy has two main components: (1) mass media for creating a favorable environment for prevention across the whole social fabric; and (2) focused, inter-personal communication and interventions targeted at four risk groups: commercial sex workers; intravenous drug users and sexually transmitted disease patients; persons who engage in high risk behavior such as migrant workers, truck drivers, and adolescents; and persons who cannot control their high risk (e.g., mothers and patients needing blood or blood products). An important and innovative feature of this component is the sensitization and mobilization of political and social leaders in addressing this issue.

# _3. Targeting_

3.31 Targeting methodologies employed in FY92 projects tend to vary by type of project and objective. The three operations which aim to alleviate poverty through multisectoral interventions (identified as Category 1 projects in JTble 6) appear to use the most elaborate methodologies. The Guyana project targets the urban and rural poor, in particular women of child-bearing age and children under five years of
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**PHN** 1992 Sector Review

age. The project employs a poverty targeting methodology developed with UNDP support, which permits the assessment of poverty through the analysis of key indicators: health, education, housing, and employment. Prior to appraisal each subproject will be screened two times: first its geographical location will be evaluated against regional level poverty maps, and second its specific location will be considered and evaluated against indicators available at the village level, tailored, where possible, to the type of subproject proposed. During the subproject appraisal visit, SIMAP staff will verify the level of need of the population as well as the fit between SIMAP's targeting criteria and intended beneficiaries. The Guyana SAR notes a lesson of experience which calls for a modification of the demand-driven format of social fund projects and greater care in targeting investments to those in greatest need. Guided by regional and village level indicators, SIMAP's promotional strategy to stimulate demand and determine priorities will accommodate that lesson.

3.32 That same lesson is also emphasized and reflected in the Honduras Second Social Investment Fund project. Sixty percent of the funds of the first project, which targeted its subprojects based on a poverty map, went to poor regions, falling short of its initial target of 73 percent. Experience has shown that, for a number of reasons, it is difficult to ensure that a sufficient proportion of social funds are allocated to the poorest. Where targeting is not used, larger proportions of funds will in all likelihood be absorbed by wealthier municipalities with larger demand for projects and greater capacity to prepare proposals. NGO-sponsored projects tend to be developed in more advantageous municipalities. Furthermore, promotional activities have been insufficient in poorer municipalities and subprojects are usually smaller in poorer areas. To ensure that subprojects would be more accurately targeted, therefore, the second project will: increase promotional activity; pay subproject-related wages aligned with the market rate for unskilled labor to ensure participation of 'he lowest deciles of the income scale; allocate funds on the basis of a poverty map and a departmental/ municipal index of poverty; ensure that social services subprojects receive at least 20 percent of overall program funds; make more funds available to finance projects most demanded by the poor; and give priority to high social returns projects.

3.33 The Rwanda Food Security and Social Action project has clearly defined but varied target groups reflecting the diversity of interventions supported by that project. Target groups include: (a) individuals with insufficient earning capability (landless farmers, poor femaleheaded households, AIDS-afflicted families, orphans); (b) farmers faced with acute food insecurity; (c) farmers with land less than 0.2 hectare needing off-farm employment to survive; and (d) micro-entrepreneurs. For the labor-based works component, the forty-three poorest communes were selected using an index of vulnerability, which ranks communes on the basis of indicators/needs in terms of poverty alleviation and which will be reviewed at the project's midpoint.

3.34 Category 2 projects, aimed at the provision of basic services to poor and vulnerable segments of national populations, target the poor using geographic criteria. A number of these projects target particularly vulnerable groups within those populations, notably women of childbearing age and children under five years of age. They reach these groups through well-targeted IEC programs to stimulate demand and by strengthening the services tailored to the specific needs of those groups.

# _4. Reforms in Policy, Financing and Organization_

3.35 A number of projects will develop capacity and support initiatives to monitor social poverty indicators and the impact on those indicators of policies and strategies of a _macroeconomic or multisectoral_ nature. The social
PHN **1992** Sector Review 24 survey component of the Rwanda Food Security and Social Action project will strengthen government capacity to monitor the living standards of the population through socioeconomic surveys and studies, which will provide the foundation for the development of a long-term poverty alleviation strategy and for the development of a national food policy, both of which are important objectives of the project. The development of a National Household Welfare Monitoring and Evaluation System supported under the Kenya project will provide a better information base for the design of social policies.

3.36 Significant reform of _PHN_ policies and strategies are encouraged and supported through the great majority of PHN projects approved during the fiscal year. These reforms largely support a reorientation of priorities and refinement in strategies, the aim of which is to increase the quality, efficiency and equity of health care services and thus benefit the poor and vulnerable both directly and indirectly. New or reaffirmed priorities support, _inter alia,_ an increased emphasis on primary health care (prevention and health promotion, in particular) on selected diseases (e.g., malaria, schistosomiasis, tuberculosis, and AIDS) and health problems (e.g., high infant, child and maternal mortality), and on selected groups with acute needs (e.g. poor, underserved populations, women of childbearing age and children under five).

3.37 In order to address these priorities more effectively and efficiently, Ministries of Health with project support are testing and implementing institutional and financial reforms. While not always done exclusively for reasons of poverty alleviation, these reforms should facilitate achievement of that objective.

# 4.a _Institutional Reforns._

3.38 Institutional reforms supported by FY92 projects include efforts to embrace and use more rationally the potential of various actors in sector activity. Under these projects, decentralization policies will be implemented, the role and responsibilities of central ministries will be redefined and strengthened, private sector and NGO activity will be encouraged and supported, and community participation will be institutionalized. These reforms are likely to give the poor increased opportunity to participate in sector activity, and to have their concerns and problems addressed at the local level, where they would most likely be better understood. They could also improve the availability and affordability of basic social services. A number of community participation initiatives have already been described in section E. 2 above. The following paragraphs will describe selectively project support of decentralization and private sector development.

3.39 _Decentralization._ Virtually all FY92approved projects support decentralization of health sector activity. The Mauritania Health and Population Project supports the governments' strategy to decentralize service delivery. The government has already defined structural, administrative and staffing norms for regional services. The project will assist in strengthening regions' capacity to assume newly decentralized responsibilities by (1) developing training programs for regional personnel; (2) developing a maintenance system for vehicles, equipment and infrastructure; (3) strengthening financial management; and (4) strengthening health service delivery in three regions. The Chile Technical Assistance and Hospital Rehabilitation project will facilitate decentralization of decision-making and resource management, by delegating needs analysis and the design and implementation of hospital rehabilitation subprojects to Health Service Areas and hospital managers and staff. With assistance from the Equatorial Guinea project, decentralization of decision-makingwould be achieved though greater delegation of authority to the district level on use of approved budgets, personnel management, drug distribution, and management of revenues for drug supply and
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maintenance. The Niger Population project will strengthen departmental and district capacity in sector management, planning, monitoring and evaluation.

3.40 Both Poland and Romania will pilot tcst, with project assistance, decentralization of health sector policy making, planning, management and evaluation in three to four subregions in each of these countries, with the intention of eventually decentralizing on a country-wide basis. An interesting and innovative feature of both of these projects is that pilot subregions were chosen to participate in the projects based on a nation-wide competition initiated by those governments inviting proposals from regions/districts. All three India projects support decentralization activities: the AIDS project will strengthen central and state management capabilities; the Safe Motherhood and Child Survival project will improve management information systems, supervision, planning, logistics management and maintenance at the central, state and district levels. The Family Welfare (Urban Slums) project will improve management and administration of municipal health departments and support municipalities in the preparation and implementation of City Health Plans.

3.41 There is conventional, but unproven wisdom on the topic of decentralization. It should not be seen as a panacea. While it is likely to make services more responsive to clients, it may be, in some instances, less efficient and costeffective than more centralized services, and may also invite central governments to decentralize too rapidly financial andorganizational responsibilities to state and local governments, which are at present incapable of assuming them.

3.42 _Private Sector Development._ An important objective of the Kenya Health Rehabilitation project is to rehabilitate the Kenyatta National Hospital (KNH) to reduce its burden on the overall public budget and permit an increase in expenditures on preventive and primary health care. In support of the KNH Private Practice Plan, the Kenya project will support the rehabilitation and expansion of a private wing of that hospital and the construction of high quality office space for rental by KNH doctors for their private practices. The four objectives of this plan are to: provide KNH doctors with the opportunity to see and treat private patients on the hospital premises and thus ensure their continuous presence; run the private wing as a model institution to inspire and motivate the public sector; elevate KNH's image and reputation; and increase profit and augment KNH revenues. Over and above this initiative, KNH has become a parastatal and is thus expected to cover an increasing share of expenditures from its direct revenues. The Chile Technical Assistance and Hospital Rehabilitation project is financing a feasibility study for a private hospital project in Santiago.

# 4.b _Financial Reforms_

3.43 Financial reforms encouraged and supported under FY92 projects comprise a number of initiatives and activities that should significantly improve the quality and access of health services for the poor. They include: the mobilization of additional financial resources through cost recovery (fees for service and health insurance); increasing the social sectors' share of the public budget; reallocation of resources within social sector budgets in favor of basic services for the poor and underserved; more financial autonomy for hospitals and increased private sector activity, thus releasing public funds for basic services for the poor.

3.44 Most FY92 projects are supporting the implementation of a combination of these reforms to achieve greater efficiency and equity in the delivery of PHN services. Because of its leverage and comparative advantage in financial issues, the Bank is monitoring scrupulously project performance in this regard. Some examples of Bank involvement of this type are provided below. The government of Mauritania has developed a financing plan which provides for a gradual
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PHN **1992** Sector Review increase in the Ministry of Public Health's (MOPH's) share of the general recurrent budget during the course of project implementation. MOPH share will grow to 5.5 percent in 1992 and by additional increments of _0.5_ percent annually until it reaches a level of 7.5 percent in 1996. The plan also ensures that budget allocations for the 13 regions combined will total at least UM60 million for drugs and UM90 million for other operating costs and that allocations will be maintained in real terms at 1991 prices up to the end of 1996. The Bank will review annually during the course of project implementation the draft recurrent budget for health for the following fiscal year and the draft three-year investment budget for health. This project will also support the introduction of cost recovery activity in three regions, which will be organized and managed through local health communities, and which will raise revenues principally through the sale of drugs. Because of its pilot nature, this cost recovery system will be introduced gradually over the first three years of the project. All health centers and one-third of the health posts will implement the initiative in the project's first year; all regional hospitals and another third of the health posts will join the initiative during the second year of the project, and in the project's third year the balance of health posts will be brought into the experiment.

3.45 The Rwanda Food Security and Social Action Project was prepared and is being implemented in close coordination with the ongoing Structural Adjustment Program. During the course of the design and development of both of these operations, the government, with Bank assistance, prepared a social action program which aims to (a) establish a social safety net including core social sector programs and a national social action program targeted to the poor; (b) mobilize resources to ensure adequate funding of this core social expenditure program; and (c) monitor closely the financial and physical implementation of the social expenditure program. The programming process for social sector public expenditures has been integrated into the Structural Adjustment Program as part of the component aimed at imlproving public sector resource management. This process has two main elements: (a) a review of the public investment program to eliminate all investments inconsistent with sectoral policies and/or that are economically or financially inefficient; and (b) adequate budgetary allocations to cover the operational costs of essential development programs such as the social safety net. In order to avoid underfunding of social programs, the annual review of social sector public expenditure programs is a covenant of the Food Security and Social Action Operation.

3.46 Both the Poland Health Services Development project and the Romania Health Rehabilitation project will assist efforts on the part of those governments to diversify sources of health care financing and thus lessen total dependence on the public budget, which is under pressure from rising costs and demand for health care. The Poland project will finance feasibility studies on (a) the introduction of contributory health insurance; (b) cost recovery; (c) private sector health services; and (d) preparation of draft legislation on health financing. The decentralization pilot supported under the Romania project will allow field testing and experimentation with financial decentralization and autonomy, and new financing schemes. The Poland project will also support efforts to develop a more efficient and equitable basis for budget preparation, based on criteria such as demography, morbidity, socioeconomic factors, and existing resources.

3.47 The Equatorial Guinea Health Improvement project will support the implementation of key financial reforms in the hospital sector. These include financial and managerial autonomy for the country's two major hospitals; stricter enforcement of the fee collection policy by targeting exemptions more narrowly; elimination of transfer to the Public Treasury of funds collected by hospitals; and the strengthening of financial management and
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**PHN 1992 Sector Review**

control systems. The hospital fee policy will be reviewed one year into the project's implementation with a view to refining and expanding it to other facilities.

3.48 Municipalities participating in the India Family Welfare (Urban Slums) project must generate resources from direct beneficiaries of the facilities and programs being developed under the project, in order to support a portion of operating and maintenance costs of those activities. City Health Plans, to be developed by those municipalities, will thus set out financing plans, a regime of fees, and plans for insurance and subsidization. During the course of the design and development of the India AIDS project, the Bank and MOHFW initiated a collaborative study on health financing to identify gaps in financing of sectoral interventions and how they can be effectively met in light of the escalating costs of caring for AIDS patients. Under the India Safe Motherhood and Child Survival project, the government has committed itself to maintain levels of planned budgetary allocations for the national MCH program for fiscal years 91-95, as agreed with the Bank.

reflects on this achievement, notes some areas of relative weakness in poverty-related work of the PHN sector, and suggests ways of further strengthening this aspect of PHN work, based on some of the better designs of this year's projects and on implementation experience and lessons learned, documented during the year.

3.49 Currently available data, which are sparse and somewhat unreliable, indicate a drastic reduction in social sector public expenditure in Sao Tome and Principe over the past decade or so. As a part of the Health and Education project, the government will prepare a report, based on more reliable data, on social sector allocation and expenditures from 1987 to the present. For each of the subsequent fiscal years, the government will present to IDA and discuss the adequacy of future budgets. The government, having recently adopted an essential drugs policy, will also initiate with project assistance cost recovery from the sale of drugs, which should also assist in generating increased resources for health.

_3.50_ This chapter shows that the Bank's PHN sector operations have been responsive to the Bank's restated emphasis on poverty alleviation as a fundamental development objective. Chapter V
# CHAPITER IV: A BRIEF LOOK AT QUALITY

4.1 Quality in PHN projects can be analyzed from two perspectives: the quality of the projects, themselves, and the quality of PHN services delivered through those projects. This chapter will provide a brief assessment of the FY92 portfolio of projects from both of these perspectives.

III). The strategic nature of these projects go well beyond that one feature of their design, however. Most projects are conceived as one in a series of interventions aimed at sector reform. Sector work sets the stage for project assistance and each operation builds on the previous one and prepares for the next. A few illustrations of the strategic nature of FY92 operations are provided below.

## A. **Quality of PHN Projects**

4.2 What are the characteristics of a high quality PHN project? Drawing from lessons of experience documented during the year (see Annex 3), a sound and appropriate Bank investment in the PHN sector should address both short-term needs (the provision of basic services and other emergency assistance to poor and vulnerable groups) and medium- /long-term needs (the development of national commitment and capacity to identify, address, and resolve sector issues and problems). Interventions should be cost effective, strategic, and flexible to accommodatelearningduringimplementationand to incorporate lessons of experience. The impact of operations should be closely monitored and evaluated, calling for a good information base and carefully selected indicators of success. Project management arrangements should provide for efficient execution of activities while contributing to long-term capacity building objectives. This section selectively reviews the following features of FY92-approved PHN lending, which provide some indication of the quality of these operations: strategic nature of operations; flexibility/opportunities for learning and finetuning; project management arrangements; and monitoring and evaluation.

_1. Strategy. Addressing Both Short-and Long-term Needs_ 4.3 This year's projects address both shortterm and medium- long-term needs (see Chapter 4.4 The Chile project was designed as a preparation phase for a subsequent health sector reform project. As such, one of its intermediate objectives is to create a receptive environment for the implementation of some of the difficult policy and institutional reforms envisaged under a planned second operation. The Kenya project is also being used as an opportunity to prepare for future policy and managerial reform to be supported under a health sector adjustment operation planned for FY94. The recently completed sector report, _Poland: Health System Reformn,_ provided an important input into the formulation by that government of a strategic framework for fundamental systemic reform in the health sector. The introduction and testing of this reform program is now being supported by an FY92 operation in that country. The Romania project is designed to provide immediate assistance for critically neglected parts of the health sector (primary health care) while at the same time building the institutional base for meaningful reform. It will thus support the introduction of reform while ensuring maintenance and improvement of basic services. The India AIDS project is seen as the first critical step in dealing with HIV. Under this project, the government will prepare a strategic plan for the next phase of the program. The India Family Welfare project will support detailed preparation and project launch activities for another fifteen designated cities to be financed under a future project. It will also assist the government to refine further its Urban Revamping Scheme to
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develop operational models for nation-wide replication.

# _2. Flexibility/Opportunitiesfor Learning and Fine-tuning_

_4.5_ As an extension of their strategic nature and long-term vision, FY92 projects for the most part demonstrate considerable flexibility to accommodate learningduringimplementation and consequent refinement of project activities and sector strategy. The Chile project will assist in the development, pilot testing and initiation of key reform measures through the undertaking of twelve policy/institutional reform studies and the pilot testing and start-up of recommendations for implementation. The project features built-in flexibility to adapt, as appropriate, recommendations of the reform studies: a $1.4 million fund under the project will finance their pilot testing. The Equatorial Guinea project will support the development and pilot-testing of efficient procedures for the procurement, distribution and management of essential drugs in public facilities. Under the Rwanda project, the component to develop micro-enterprise activity is experimental in nature. Operational research on this component will provide feedback and guidance to government and development agencies on ways off-farm employment can be developed in that country.

4.6 An essential drugs program pilot-tested under a first project in Sao Tome and Principe in FY90 introduced policy reform measures including: (a) preparation of a national essential drugs list; (b) preparation of guidelines for distribution and prescription; (c) improvements in drug procurement; and (d) introduction of cost recovery measures. The second (FY92-approved) project would help institutionalize and implement policy reforms initiated under the first project. The China project will research, deve!op and disseminate cost-effective methods and matcrials for further improving disease controi strategics and programs and sustaining progress made.

Operational research planned under the India AIDS project will assess and allow for adaptations in control interventions before replicating them in other areas. Under the India Family Welfare (Urban Slums) project, small-scale process and impact evaluation activities would be conducted to help adjust and shift the IEC program as needed. The findings of such research and feedback would be incorporated into program plans, which would be developed on an annual basis.

# _3. Project Management_

4.7 Project management arrangements for all FY92-approved projects are intended to strengthen the capacity of concerned ministries and institutions to manage sector activity over the medium- to long-term. In fact the great majority of projects are designed so that the implementation responsibility rests with appropriate, responsible units within government, both at the center and the periphery. Projects which work with a number of line ministries (e.g., Rwanda, Niger, and India AIDS) have placed project management responsibilities in Plan ministries and established inter-ministerial technical coordination committees. The two sector funds (Guyana and Honduras) are managed by agencies specially set up to handle these emergency operations. These agencies are largely autonomous, although they do coordinate with line ministries and are viewed as temporary institutions, whose purpose is to complement line ministries during a period of adjustment. The project management unit under the Rwanda operation was also set up to have as much operational autonomy as possible, separating program and financial management from technical management.

4.8 How the responsibilities of these more autonomous agencies will be gradually phased out and permanently integrated into concerned line ministries is not yet clearly set out, though this is a stated intention of those projects. A pattern of project management arrangements is detected in
PHN 1992 Sector Review 31 the FY92 portfolio that favors a more autonomous agency for multisectoral and/or emergency-type operations. Those multisectoral projects that rely on line ministries and other already existing agencies to implement them make for rather complex operations. The various arrangements for project management and implementation included in FY92 projects reveal somewhat of a tension between smooth and successful project implementation (assured by a more autonomous project management and implementation entity), on the one hand, and institutional development (which occurs when existing, but weak, units within government are responsible for project management and implementation), on the other. An increasing number of project management entities are largely independent from central administrations. This autonomy has many positive aspects with regard to project performance but its institutional implications in the long run should be assessed.

# _4. Monitoring and Evaluation_

4.9 Considerable attention has been paid by the majority of FY92-approved operations to the development of a good information base and to monitoring and evaluation. And that attention has been, in some cases, thoughtful and thorough, focussing not only on tracking the project's success, but also on developing national capacity for improved inforrration collection, analysis and management and for monitoring and evaluation of sector activity more broadly. All of the FY92 projects support improvements in the collection, analysis and management of sector information. And all FY92 operations provide for a mid-term review in order to take a thorough look at project progress and impact and to adjust and refine the operation accordingly. In addition, significant provision has been made in many projects to monitor progress and evaluate impact on an ongoing basis. Examples follow.

4.10 Under the Chile project a study will be undertaken to develop methods for monitoring z,c: projCct component and for evaluating costs and b)enclits of the investment. The study will recommend appropriate methodologies for monitoring and evaluating for efficiency, equity and quality of care and for financial effectiveness. Technical assistance will be used under the Guyana project to carry out an external evaluation of SIMAP's impact and to improve the internal monitoring of the project cycle and evaluate the implementation of food supplementation activities. Indicators are process-oriented, but will be complemented by a series of studies to assess the quality and impact of various categories of subprojects. The mid-term review for the Honduras project will focus on targeting, quality, impact, administrative efficiency and financial soundness, prospects for the future of the Honduras Social Investment Fund, and how to strengthen line ministries based on lessons of experience from this project. The Rwanda project has compiled a list of project indicators to evaluate each component, which are process oriented. As a necessary complement to these indicators, the project's impact at the family and community level will be assessed through the LSMS component as well as other social studies.

4.11 Malaria targets established under the Sao Tome and Principe project are very explicit: decrease the parasite index by 50 percent from 410 cases/10,000 to 200; decrease malaria mortality in children under five by 80 percent from 65/10,000 to 13; and decrease malaria mortality in the general population by 85 percent from 20/10,000 to 3. These indicators will permit effective project monitoring and evaluation. The project will support the maintenance of efficient epidemiological surveillance and regular evaluation of the malaria control program. Key indicators to measure program performance, agreed with the government, will provide for simple, practical and timely information; they include both operational indicators and epidemiological indicators. The China project will support operational research on management, economic, social and epidemiological factors to
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improve tuberculosis control in different settings in China. It will improve the disease surveillance system to adjust and target control activities appropriately and will improve monitoring and evaluation systems at all levels. In addition, this project will finance research into alternatives for improving surveillance and control of other key infectious diseases. Indicators will permit the tracking of project inputs, process steps, and epidemiological and output measures. Process indicators will clearly show whether and where project objectives are being achieved and will be sufficiently specific to highlight non-performing subregions, permitting quick intervention on the part of MOPH and IDA.

4.12 Indicators for the Romania project will provide for very extensive review of both process and output. An important objective of the India AIDS project is to monitor the development of the HIV/AIDS epidemic in the country. It will, in this regard, finance operational research and social/behavioral studies and epidemiological and intervention studies to fine-tune the program approach. It will also support the collection of baseline information for planning and programming, measuring changes in behavior and in process and outcome indicators, assessing mass awareness campaigns, and providing quality control. Process indicators have been established and agreed with the Government; impact indicators include World Health Organization (WHO) indicators for evaluating the AIDS strategy world-wide. Other impact indicators have been established to complement those of WHO and will be tracked through operational research supported under the project.

4.13 The India Safe Motherhood and Child Survival project is supporting the development of an enhanced management information system (MIS) designed to upgrade the monitoring and evaluation function. Key performance indicators have been discussed with the government and are process-oriented, focussing on quantity of services delivered and coverage level achieved. Impact heing more difficult to evaluate, studies and operational research will be undertaken to determine whether objectives are being achieved. The India Family Welfare project has compiled a set of indicators of progress and targets that will facilitate close tracking of that project. It itemizes by city: the objectives and components; indicators of project progress (number and proportion of couples effectively protected due to family planning methods; mortality figures in different age groups); and project targets and process indicators.

# B. **Quality of PHN Services**

4.14 Virtually all SARs for FY92 operations discuss the issue of low quality of services. Low quality is attributed to some combination of the following factors: state of disrepair of infrastructure and equipment; unreliable supply of essential drugs; poor performance of personnel, due to insufficient technical and outreach skills and low motivation; unresponsiveness of services to client demand; and inadequate financing of essential operating costs. Project efforts to address the issue of low service quality, consequently, aim to upgrade physical facilities and equipment; ensure an adequate and affordable supply of essential drugs; upgrade the skills and motivation of personnel; elicit and consider the demand of the client in service design and delivery; and ensure adequate recurrent financing through cost recovery, mobilization of more public funds for the social sectors, and/or reallocation of the public budget for social sectors in favor of basic services. All of these interventions are, without question, essential to improving the quality of services; and they are provided for in virtually all FY92-approved operations.

4.15 However, more can and should be done to improve the quality of services. While greater attention is being paid to demand, it is addressed in terms of the type and mix of services desired and not in terms of the compassion, care and
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empathy with which those services are delivered. Two initiatives undertaken during FY92 address the issue of quality in much more depth than the typical PHN activity and are highlighted here for the consideration others.

# _1. India AIDS Project_

4.16 The government of India has stated its unequivocal support for the policy of humane treatment of persons affected by HIV/AIDS, as articulated in Resolution WHA41.24 of the World Health Assembly. This decision is in recognition that programs for the prevention and control of AIDS should be planned and implemented in a manner that ensures the humane treatment of affected persons, which is an essential prerequisite for an effective long-term policy for the prevention and control of AIDS. Accordingly, the India AIDS project would assist the government in creating a framework for the provision of health, psychological and social support to HIVinfected persons and AIDS patients. The aim would be to: foster the spirit of understanding and compassion for HIV-infected persons; protect the rights and dignity of HIV-infected persons; avoid discriminatory action against and stigmatization of HIV-infected persons; ensure the confidentiality of HIV test results and case reports; and promote the availability of social services including confidential counseling.

4.17 Counseling services would be available to the affected individuals and their families on their request and would not be imposed on them. The purpose of counseling support for persons with HIV and AIDS would be to : offer explanation and help get the individual to understand the significance of having HIV or AIDS, motivate the infected individual to minimize the risk of transmitting the infection through the use of condoms, and assist in meeting the psychosocial needs of the individual and his/her family, including guidance on lifestyle, adjustment and maintenance of good health for as long as possible. The govemment has established

**a** Technical Advisory Subcommittee on Social, Ethical and Legal Issues, which will put in place and monitor the operation of effective procedures through which affected persons can express grievances and seek resolution of concerns.

4.18 This concept could be applied in other PHN programs as they impinge so intimately on the personal choices, values and lives of individuals, households and communities. Evaluating and addressing quality of services on technical grounds alone will not ensure that services will be valued by clients.

# 2. _Sector Report on Quality of Health Care in C6te d'Ivoire_

4.19 Both the approach to the subject matter as well as the subject matter, itself, are unique features of this piece of sector work. Rather than the Bank taking the lead in addressing this topic, some aspects of which are subjective and cultturally charged, a national team was assembled to assess quality of services in Cote d'Ivoire. This team visited a large number of facilities throughout the country and observed and assessed the quality of care provided at every level of service. The findings of this study are thoughtprovoking and highly attuned to the cultural context, revealing important and pervasive deficiencies in the quality of health services in that country. The exercise so motivated this national team to address the issue of low quality of services that they compiled its findings and produced a well conceived, feasible (both technically and financially) and comprehensive plan of action in the space of a few months, on which they received strong national consensus. While it had initially been envisaged that a project would be developed to finance recommendations emanating from that sector work, in actual fact, the plan of action was developed and approved so rapidly and government commitment to address the issue was so high that funds from the ongoing Human Resources Development project were earmarked
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to permit immediate implementation of recommendations.

4.20 With the exception of the two tasks highlighted here, PHN project and sector work have addressed quality largely from the technical perspective. Chapter V offers a number of suggestions on how to address, as well, the human dimension of quality issues.
# CHAPTER **V. PROSPECTUS**

### A. **Future Work Portfolio**

5.1 The future lending program looks quite strong. Both the number of projects and lending amount projected for FY93 are nearly double the levels achieved in FY92 and, even when discounting for the pipeline factor, are estimated to equal, if not exceed, record levels attained in FY91. Lending volume is expected to continue to grow and to remain above $2 billion over the next three years.

5.2 Sector work output is projected to increase to about forty reports in FY93. Over half of the sector work scheduled for the next two years will focus on countries in the Africa region.

## **B. Conclusions and Recommendations**

## _1. Poverty_

_5.3_ PHN operations approved during the fiscal year have been responsive to the Bank's poverty alleviation objective, in terms of both content and focus. Every operation approved during the fiscal year addressed poverty issues in a significant way: twenty percent of the portfolio comprised multisectoral operations, whose major objective is the alleviation of poverty. The primary objective of thirty-five percent of operations is the provision of basic social services to the poor, responding to an important component of the poverty strategy recommended by WDR 90. And the balance of operations (seven projects or forty-five percent of the portfolio),whilenotaddressingpovertyalleviation as the primary objective, include interventions from which the poor should derive significant benefits. All operations provide for both shortand long-term interventions, combining support for the basic PHN and other social needs of the poorest and most vulnerable of national populations with efforts to develop and strengthen national commitment and capacity to improve the economic and social well-being of the population.

5.4 Collectively, FY92 projects cover the essential features of good poverty work: poverty information and monitoring; understanding and responding to the needs of the poor; targeting assistance to those most in need; and reforms in policy, financing and organization. Although the coverage of these features is quite extensive, the depth and quality of each of these aspects of povertywork varies across projects. Drawing from the good practices observed and lessons recorded in this year's portfolio, the ASR offers the following suggestions for further strengthening of PHN interventions aimed at poverty alleviation:

- Poverty information and monitoring must be accompanied by dissemination and sensitization activities to strengthen national understanding of poverty-related issues, and commitment to resolving them, and deliberately linked to the policy process.

- Involvement of communities in project design and development will significantly improve prospects for success and sustainability but require clearly defined and carefully designed institutional and procedural mechanisms and a concerted effort to make them work.

- **0** Targeting beneficiaries is essential to the fulfillment of poverty alleviation objectives but must be done with great care and flexibility. Even the most demand-driven project designs aimed explicitly at clearly and accurately identified poverty groups must be accompanied by promotional activities to ensure that these groups both participate in and benefit from project initiatives.

- The identification of poor and vulnerable groups and the assessment
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
**PHN 1992 Sector Review**

**37**

- quality,which are generally adequately covered, but the human factor as well. A more holistic approach to health care should be evident not only in the empathy and bedside manner of the technical staff, but should also be a fundamental objective of policies and programs.

- Cultural sensitivity enhances project success. Interventions should be designed with a view to the likelihood of beneficiary acceptance.

# _4. Overview_

5.7 Health lending is now a decade old; and many innovations in PHN lending have emerged over the past four or five years. Notable among these are multisectoral operations aimed at poverty alleviation objectives, and sector funds, which accommodate a decentralized, demanddriven approach to the provision of social services and social safety net assistance. Furthermore, fully one half of PHN projects approved since 1980 (or over the past 13 years) were approved during the last _three_ years (FY92 included). Thus PHN experience in the Bank is very short and project designs are still somewhat experimental. PHN staff are, therefore, challenged to exploit lessons of experience and to develop innovative approaches to still new and emerging sector issues. This ASR has shown that there are indeed good practices and new and promising ideas scattered across PHN work, which are well worth noting and emulating. The Chile Technical Assistance and Hospital Rehabilitation project devoted considerable time to analyzing lessons of experience, reviewing 34 Bank-financed health operations, as well as lessons learned by other development organizations and empirical studies inside and outside the Bank. This effort has resulted in a very well-designed project.

recommendations emanating from the analysis, while directly addressing those issues in particular, should serve more broadly to improve the impact of Bank PHN interventions on the general health and well-being of a country's population. The evaluation of the impact and effectiveness of PHN sector activity, be it from the Bank or a country's perspective, is difficult and could benefit from a clearly defined and common framework for analysis. This need is being addressed through a number of ongoing efforts including the WDR 93 on health; AFTPN's draft paper "Better Health in Africa"; and LATHR's initiative to develop a set of mutually agreed PHN performance indicators. In the meantime, it can be said that the overall thrust of the Bank's PHN work is moving in the right direction and that the quality of this work is generally seen to be improving. Noteworthy and welcome trends include serious attention to the poorest and most vulnerable populations, and growing consideration of the demand and perspectives of those groups. These trends should be encouraged and reinforced.

5.8 The focus of this review has been on poverty and quality issues. However, the