metadata: authors: 0: author: Vaillancourt, Denise
1: author: Nassim, Janet
2: author: Brown, Stacye
docna: 0: docna: Population, health, and nutrition : fiscal
            1991 sector review
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Nutrition,Social Development & Poverty,Inequality
teratopic: Poverty Reduction
abstracts: cdata!: The theme of this year's annual
            sector review blends two special topics: poverty alleviation
            and the development of management and institutional
            capacity. Based on a review of project experience, both
            within and outside of the population, health and nutrition
            (PHN) sector, this report distills lessons that should
            assist task managers in the design and implementation of
            interventions to develop poverty-sensitive management and
            institutional capacity in the PHN sector. The Bank's
            ability to strengthen institutions, especially those needed
            to alleviate poverty, are constrained by the number and the
            skills mix of PHN staff, by the absence of standards and
            guidelines for analyzing and addressing institutional and
            management issues, and by too little time to spend on
            institutional and management issues. Therefore, the sector
            review recommends : a) improving the sector staff not only
            in numbers but in access to guidelines and training; b)
            revising Bank priorities and practices to ensure that enough
            time is spent on supervision and on upstream diagnostic
            work; c) grounding PHN policies in a macroeconomic and
            multisectoral framework oriented toward growth with poverty
            reduction, together with a sound strategy for building
            institutions and the capacity to implement and manage
            policy; and d) seeking more creative use of Bank instruments
            through a review and assessment of the best use of lending
            instruments for PHN sector interventions.
repnme: repnme: Population, health, and nutrition : fiscal
            1991 sector review
display_title: Population, health, and nutrition :
            fiscal 1991 sector review
listing_relative_url: /research/1992/04/699708/population-health-nutrition-fiscal-1991-sector-review
topicv3: Poverty m1326687 695,Nutrition m1326779 644,Social Development m1327660 134,Health, Nutrition and Population m1327755 621,Health m1504661 3480
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Poverty Reduction
origu: Pop & Human Resources Department
no_of_pages: 70
model_extractions: **Policy Research**

**Populatlon, Health, and Nutrition I**

# **WPS** 890

- This paper a product of the Population, Health, and Nutrition Division, Population and Human Resources - Department is part of a larger effort in the department to address management and institutional issues in the PHN sector. Copies of the paperare available free from the World Bank, 1818 H Street NW, Washington, DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (April 1992, 65 pages).

Growth in both number of projects and amount of lending has been a notable feature of the Bank's support to the population, health, and nutrition (PHN) sector since fiscal 1981, when the Bank first began lending for health. The proportion of total Bank lending to the sector increased from 4.5 percent in fiscal 1990 to 6.9 percent in fiscal 1991 (from 4.1 percent to 5.8 percent, if lending to non-PHN cornponents is excluded), surpassing targets set by the Bank's senior management for growth in the sector.

In September 1990, President Conable expressed the Bank's determination to provide greater support - for primary health care and set a goal of increasing lending for primary health care from about 3 percent to about 5 percent of total Bank lending in the next three to four years. This goal was exceeded fiscal 1991: lending to primary health care for that year amounted to US$1,220 million, or 5.4 percent of total Bank lending.

The momentum in actual and forecasted growth in PHN lending is attributable to several factors, including the high priority assigned to human resource development (as a key component of economic reform and development objectives) and the Bank's strong commitment to the alleviation of poverty, which requires providing basic social services to the poor.

The theme of this year's annual sector review blends two special topics: poverty alleviation and the development of management and .nstitutional capacity. Based on a review of project experience, both within and outside of the PHN sector, this report distills lessons that should assist lask managers in the design and implementation of interventions to develop poverty-sensitivc management and institutional capacity in the PHN sector.

The Bank's ability to strengthen institution5s. especially those nceded to alleviate poverty, are constrained by the number and the skills mix of PHN staff, by the absence of standards and guidelines for analyzing and addressing institutional and management issues, and by too little timc to spend on institutional and management issues. Therzfore, the sector review recommends: Improving the sector staff not only in numbers but in access to guidelines and training; making more use of in-housc management and institutional development expertise; using more consulting specialists; and increasing **thc** number of management and institutional development experts in divisions working on the PHN sector.

* Revising Bank priorities and practices to cnsure that enough time is spent on supervision and on upstream diagnostic work, and that management rigorously reviews the management and institutional development content of lending and sector work.

> * Grounding PHN policies in a macroeconomic and multisectoral framework oriented toward growth with poverty reduction, together with a sound strategy for building institutions and the capacity to implement and manage policy. This means country operations divisions have a critical role in helping key national decisionmakers understand and internalize objectives of poverty alleviafion and institution building.

o Seeking more creativc use of Bank instruments through a review and assessment of the best use of lending instruments for PHN sector interventions; more innovative identification and financing of local expertise; and greater effort to encouragc the exchange of experience and ideas among devcloping countries.

ThePolicy Research Working Paper Sericsdisseminates thc findings of work under way in the Bank. An objective of the scrics is to get these fimdings out quickly, even if presentations are less than fully polished. The findings, interpretations, and i conclusions in these papers do not necessarily represent official Bank policy.

Produced by the Policy Research Dissemination Centcr
page

# CONTENTS

|EXECU<br>1.INT|TIVE SUMMARY<br>_...................._<br>_,_<br>RODUCTION: PURPOSE AND SCOPE OF REVIEW|i<br>1.|
|---|---|---|
|II. OV|ERVIEW.........................................|......<br>,,.<br>.3|
|A.|Lending .<br>|3<br>|
||1. Growth in the Lending Portfolio .<br>|3<br>|
||2. Regional Distribution and IBRD/lDA Commitments ....<br>|**S**................<br>|
||3. Cofinancing .<br>|6<br>|
||4. Project Funds by Expenditure Category .........<br>|7<br>|
|B.<br>|Sector Work .<br>|7<br>|
|C<br>|Supervision and Project Evaluation .<br>|8<br>|
|D.|Population, Health and Nutrition Content of Projects .|8|

# III. SPECIAL THEME: INSTITUTIONAL DEVELOPMENT IN SUPPORT OF A POVERTY FOCUS FOR PHN SECTORS .11

|A. Introduction .11<br>|
|---|
|1. Poverty .11<br>|
|2. Management and Intitutional Development .11<br>|
|3. Choice of and Approach to Special lbpic .11|
|B. Lessons Learned .12<br>|
|1. Lessons of Substance .12|
|2. Lessons of Design and Process and Some Useful Tbols .16|
|<br>_C._Evaluation of FY91-Approved PHN Operations Against Lessons Learned .18<br>1. Overview .18|
|2. Innovative Categories of PHN Operations .19<br>3. Issues .20|
|IV. PROSPECTUS .23|
|A. Future Work Portfolio .23|
|B. Conclusions and Recommendations<br>..<br>23|
|1. Expanding Bank Expertise in Institutional Development .23|
|2. Changing Priorities and Practices in the Bank .24|
|<br>3. Expanding the Role of Country Operations Divisions .25|
|<br>4. Making Creative Use of Bank hIstruments and Resources .25|
|5. Other Recommendations .26|

a
Page

# CONTENTS (Contd)

# TEXT TABLES:

1. BIends in Lending to the PHN Sector, FY89-91<sup>................................</sup> 4 2. Sectoral Composition and Funding Characteristics<sup>of PHN Portfolio, FY91</sup> .... ....... _5_ 3. Cofinancing from Official Sources in PHN Projects,<sup>FY90 and FY91 .....</sup> ........... 6

# TEXT FIGURES:

1. Lending for the Population, Health and Nutrition Sector,<sup>FY80-91 .....</sup> ............ 3 2. Sectoral Compostion of PHN Projects Approved in FY91<sup>.........................</sup> 4 3. Regional Distribution of PHN Lending, FY91 ................................. 5 4. Breakdown of Tbtal Project Costs by Expeneiture<sup>Category ........................</sup> 7

# ANNEXES:

1. Statistical Annex . 29

- TIbles: 1. FY91 PHN Portfolio by Sectoral Compostion .31 2. Primary Health Care Component of PHN Lending, FY91<sup>.32</sup> 3. PHN Lending Volume, FY80-91 .33 4. FY91-Approved PHN Projects: Funds Components<sup>.34</sup> _5._ PHN Sector Reports Completed by Region, FY82-91<sup>.35</sup> 6. PHN Sector Reports Completed in FY91 .36 7. OED Reports on PHN Sector, FY91 .38 8. Lending for Population Projects and Components by<sup>Region, FY86-91 .39</sup> 9. PHN Projects with Population Components, FY91<sup>.40</sup> 10. Nutrition Components in Structural and Agricultural<sup>Adjustment Operations,</sup> FY91 .41

# Figures:

1. PHN Projects under Supervision .43 2. Total Project Resources for Nutrition in Bank-Assisted<sup>Operations, FY81-91 .</sup> 44 3. The Bank's Nutrition Lending, FY81-91 .44 4. World Bank Lending for Population, FY80-91 .45

2. Lo3n and Credit Summaries of FY91-Approved<sup>PHN Operations .47</sup> 3. Bibliography ....... 61
# AbbrevlatPons and Acrotms

|AF2PH|East Africa Department, Population and Human Resources Operations<br>Division<br>|
|---|---|
|AFIPN<br>|Africa lechnical Department, Population, Health and Nutrition Division<br>|
|AFISP<br>|Africa lIchnical Department, Poverty and Social Policy Division<br>|
|AIDS<br>|Acquired Immune Deficiency Syndrome<br>|
|ARIS<br>|Annual Review of Implementation and Supervision<br>|
|ASR|Annual Sector Review<br>|
|COD|Country Operations Division<br>|
|EDI|Economic Development Institute<br>|
|EM3|Europe, Middle East and Nonh Africa Country Department III<br>|
|EMENA|Europe, Middle East and North Africa Region<br>|
|EXTIE<br>|International Economic Relations Division<br>|
|IBRD<br>|International Bank for Reconstruction and Development<br>|
|**IDA**|International Development Association<br>|
|IEC|Information, Education and Communication<br>|
|LAC|Latin America and the Caribbean Region<br>|
|MIS<br>|Management Information System<br>|
|NGO<br>|Non-governmental Organization<br>|
|OED|Operations Evaluation Department<br>|
|PCR|Project Completion Report<br>|
|PER|Public Expenditure Review<br>|
|PHN<br>|Population, Health and Nutrition<br>|
|PHR|Populalion and Human Resources Department<br>|
|PHRHN|Population, Health and Nutrition Division of the Population and Human<br>|
||Resources Department<br>|
|**PIR**|Public Investment Review<br>|
|PIU|Prcject Implementation Unit<br>|
|PRE|Policy, Research and External Affairs<br>|
|PRS|Sector Policy and Research<br>|
|PRSVP|Office of the Vice-President for Sector Policy and Research|
|SAR|Staff Appraisal Report|
|SOD|Sector Operations Division|
|TD|Tbchnical Division<br>|
|WDR|World Development Report<br>|
|WID|Women in Development|
# EXECUTIVE SUMMARY

## _Overview olFY91 Sector Operations_

1. The volume of lending in the Povulation, Health and Nutrition (PHN) sector showed continued and significant growth in FY91. Lending to twenty-eight projects totaled $1567.6 million, compared with commitments of $933.4 to eighteen projects in FY90, which, in turn marked a substantial increase in both number of projects and lending volume over FY89. In fact, growth both in number of projects aind amount of lending has been a notable feature of the Bank's support to PHN since FY81, when the Bank first began lending for health (Figure 1).

Figure 1: Lending for the Population, Health and Nutrition Sector, FY80-91 2. Of the twenty-eight projects approved during the fiscal year, eighteen are "pure" PHN projects and ten are social development projects -- multisectoral operations encompassing the PHN and education sectors and, in some cases, other sectors, as well, s-ch as agriculture, water supply and sanitation, other basic infrastructure and income generation activites for the poor. The ten social development projects received $464.8 million of IBRD/IDA support (30 percent of overall PHN lending) of which an estimated $207.4 million wil support PHN components. Lending for "pure" PHN projects and for the PHN components of the social development projects amounts to $1.3 bitlion, or 83 percent of overall lending to the sector.

<!-- Start of picture text --> 30Number o Pojects<br>30 28<br>2 6<br>20E la<br>20 t8 g<br>1. 1*<br>10. 7 7<br>a<br>4 4 2 m E<br>o-<br>80 81 82 83 84 86 80 87 88 8e 90 91<br>Fs8cal Year<br>- PHN PROJECTS EMSOCIAL DEV. PROJECTS<br>1800 Mill lons of USS<br>1600 166<br>1400<br>1200<br>1000 934<br>800i<br>eoo- 420 660<br>400 244193 304<br>200 143 120 3<br>o- 0 36 I 8"<br>S0 8t 82 83 84 88 S0 87 88 89 90 es<br>Fiscal Year<br>_PHN PROJECT8 80CIAL OEV. PROJECTS<br><!-- End of picture text --> 3. The growth in PHN lending has surpassed targets set by the Bank's senior management on a number of occasions. In November 1989, President Conable, in an address to the Annual Meeting of the International Planned Parenthood Federation, pledged to increase PHN lending to $800 million annually during the period FY90-92; lending for the total PHN sector and for "pure" PHN reached $933.4 milion and $845.1, respectively, in FY90, and $1567.6 and $1,300.2 respectively in FY91. The Bank's 1990 "Review of World Bank Programs and FY91 Budgets' estimated that PHN lending would increase from an average of 3 percent of Bank lending in FY89-90 to 4 percent in FY91. The proportion of total Bank lending to the sector increased considerably -- trum 4.5 percent in FY90 to 6.9 percent in FY91, or from 4.1 percent to 5.8 percent, if lending to non-PHN components is excluded. More recently, on the occasion of the World Summit for Children in September 1990, President Conable expressed hBank's determination to provide greater support for primary health care and set a goal of increasing lending for primary. health care from about 3 percent to about 5 percent of total lending within the next three to four years. InFY91,some90percentof "pure" PHNallocations, or $1220 million, supported primary health care, accounting for 5.4 percent of total Bank lending.
ii PHN 1991 Sector Review 4. The future PHN lending program looks strong. The large Increase achieved in FY91 probably will be followed by a decline in FY92 in the number of projects and the volume of lending. Projected FY92 levels, however, still exceed those achieved in FY90, both in terms of the number of operations and the volume of lending. Furthermore, these levels would surpass senior management's target of $800 million in lending to the PHN sectors. Continued growth is projected for FY93 and FY94.

5. The momentum in actual and forecasted growth in PHN lending is attributable to a number of factors. Human resource development is accorded very high priority, in the context of overall economic reform and development objectives, by both the Bank and national policymakers. Furthermore, the World Development Report (WDR) 1990 and subsequent operational strategies reflect the Bank's strong commitment to the alleviation of poverty, a key component of which emphasizes the provision of basic social services to the poor.

6. PHN lending and sector work undertaken during the year has been responsive to the Bank's emphasis on human resource development and on poverty. Highlights follow: _7. Diversity in sectoral content and lending instruments._ In addition to the increasingly multisectoral nature of PHN operations, discussed briefly above, diversity is evident in the funding mechanisms employed in FY91-approved operations. Seven (or 25 percent) of the twenty-eight operations are designed as sector funds, wiiich support subprojects prepared in-country by communities, local governments and non-governmental organizations (NGOs), among others. These funds are managed by the Borrower, which has primary responsibility for the solicitation, review, appraisal, approval and supervision of subprojects. In addition, the first-ever PHN sectoral adjustment operation (Togo Population and Health) was approved this year, along with one emergency recovery operation (Yemen) prepared In response to urgent social sector needs generated by the Gulf crisis.

# _8. Cofinancing._ The Bank's leveraging of

additional funds for its PHN and social development projects was sigr.ificantly higher in FY91 than in FY90. In FY91, cofinancing more than doubled the resources available to those PHN projects that were cofinanced. The proportion of PHN sector projects receiving cofinancing from official sources (61 percent) was higher than the overall Bank share (53 percent); in FY90, the shares were equal (56 percent). Social development projects attracted more cofinancing than those projects focussing exclusively on the PHN sectors. In addition to official cofinancing arrangements, Staff Appraisal Reports (SARs) document increasing coordination with donors overall.

_9. Integrated Strategies._ The increasing integration of PHN into country strategies, noted in the FY90 sector review, has continued. A growing number of projects address PHN and other components together, and sector work is preparing the ground for dialogue and operations in integrated human resource and social sector activities. Many projects now involve multiple line ministries and require significant coordination among the different parts of the governm-nt. While these projects maybe more complex, they promise long-term payoffs. The involvement of central ministries, such as planning and finance, seems to elicit from those ministries an improved appreciation of and, consequently, stronger commitment to social programs.

_10. NGOs._ The involvement of NGOs in the design aLd implementation of PHN operations is on the increase. In nearly all 28 of the PHN operat:ns approved during the fiscal year, NGOs are assuming important roles in prceect implementation. 'lb a lesser but still significant extent, NOOs are participating in the design of projects.

_11. Health._ The main thrust of health operations has been on extending access to quality primary health care. Within the primary health care objective there has been considerable emphasis on maternal and child health services as well as on the Acquired Immune Deficiency Syndrome (AIDS) pandemic. Nutrition and population projects also support important components of primary health care.
iii PHN 1991 Sector Review _12 Populaton._ Thirteen projects in the<sup>FY91</sup> lending program provide direct support<sup>to family</sup> platnirtg -- up from eight last year.<sup>Lending volume</sup> rose as well, doubling from $169.3<sup>million in FY90</sup> to $340.3 million in FY91, with much<sup>of that in-</sup> crease attributable to the Bangladesh project,<sup>which</sup> was. advanced from FY92 during<sup>the fiscal year. The</sup> $340.3 million is a conservative estimate<sup>of direct</sup> lending to population, and represents<sup>about 25</sup> percent of the S1.3 billion committed<sup>to "pure' PHN</sup> projects and components. In addition<sup>to the provi-</sup> sion of family planning services and<sup>their integration</sup> into basic health services, support is<sup>also provided to</sup> policy and program development with<sup>a strong</sup> emphasis on building national capacities<sup>in these</sup> areas.

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

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

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

16. _Lessons of Substance._ Both the institutional and organizational framework and the<sup>capacity for</sup> policy formulation and implementation<sup>need to be</sup> strengthened for more effective and efficient<sup>PHN</sup> activity. In summary, six dimensions of<sup>institutional</sup> strengthening should be considered when<sup>developing</sup> and implementing a PHN operation, particularly<sup>one</sup> with a poverty focus: (1) optimal use<sup>of institutional</sup> resources; (2) forming and strengthening<sup>local</sup> organizations; (3) intersectoral coordination<sup>between</sup> poverty-oriented institutions; (4) appropriate<sup>decen-</sup> tralization of health sector authority and responsibility, (5) sound organization of service delivery<sup>and</sup> promotional activities; and (6) strengthening<sup>of key</sup> components of the institutional frameworkl<sup>The</sup> following dimensions of management capacity<sup>for</sup>
PHN 1991 Sector Review iv policy analysis and implementation need to be strengthened: (1) qualitv and availability of information; (2) skill in policymaking, planning, programming, and budgeting to ensure the translation<sup>of</sup> well-articulated, appropriate policy into .implementable programs and projects; (3) the availability, distribution and management of resources (physical, human and financial); and (4) sound project<sup>and</sup> program management.

17. Attention to the following process factors should increase the effectiveness and efficiency<sup>of</sup> efforts in the PHN sector to improve the promotion and delivery of basic services to poor and vulnerable groups and to develop inLstitutional and management capacity in support of that objective: (1) sufficient analysis of institutional, organizational and socioeconomic culture preceding project preparation; (2) flexibility in project design and implementation; (3) deliberate attention to political, institutional and financial sustainability at all stages of a project; (4) project management arrangements that ensure smooth implementation and encourage institution building and sustainability; (5) improvements in the quality of supervision work; (6) increased use of qualified local expertise in all aspects of the Bank's wek; (7) greater community participation; and (8) improved planning and management of technical assistance.

_1& Overview._ The FY91-approved portfolio of PHN operations has.a strongpoveny focus: twenty-six of the twenth-eight projects support the provision of basic services to targeted poor and vulnerable segments of the population. The two remaining projects, which support the hospital sector in countries where access to basic services is universal, emphasize efficiency and equity issues. Vitually all FY91 operations support _sist4ution development_ and improvements in _management_ capacity. A predominant feature of such assistance is support of decentralization policy in the PHN sector by strengthening lower-level planning, decisionmaking and financial management; encouraging community participation; and redefining and limiting the role of central government. Four innovative categories of PHN operations were evaluated against these lessons<sup>and</sup> found to be quite responsive in various ways:<sup>(1)</sup> sector funds; (2) social swetor operations; (3) sector adjustment operations; and (4) emergency recovery operations. Their comparative advantages are discussed in the review.

19. _Issues._ While the FY91 portfolio of PHN projects pays great attention to poverty and institutional issres--many with ingenuity and creativity--it still reveals some variance in the depth, breadth, and quality of PHN analysis and interventions aimed<sup>at</sup> strengthening institutions and management capacity. The notably increased policy orientation of<sup>PHN</sup> operations is not always accompanied by fully adequate capacity building efforts to permit national institutions to assume responsibi!ities and implement activities generated by such operations. The ASR has distilled a wide array of documented experience and wisdom in the Bank into a matrix of lessons or principles, which give direction in this regard. The quality and effectiveness of Bank efforts to strengthen institutions, particularly with a view to facilitating the achievement of poverty-alleviation objectives is constrained by three major issues:

- (a) number and skills mix of PHN Staff; (b) absence of standards and guidelines for analyzing and addressing institutional and management issues; and

- (c) lack of suffcient time to spend on institutional and management issues.

_Recommendations_ 20. These constraints can be significantly alleviated by implementing the following suggestions. First, Bank expertise in institutional development should be expanded by: (1) improving the capacity of<sup>exist-</sup> ing sector staff (increasing not only their numbers but their access to guidelines and training); (2) increasing the use of in-house management<sup>and</sup> institutional development expertise; (3) increasing the use of consultant specialists in this area; and (4) increasing the number of management and institutional development experts in divisions working<sup>on</sup> the PHN sector. Second, priorities and practices in the Bank should be revised to ensure adequate<sup>time</sup> spent on supervision and on upstream diagnostic work, and to ensure a rigorous review by management of the management/institutional development content of lending and sector work.
PHN 1991 Sector Review v 2i. Third, the full potential of PHN policies and Interventions to contribute to institution building and poverty alleviation can be realized only when policies are grounded in a macroeconomic and multisectoral policy framework oriented towards growth with poverty reduction, accompanted by a sound strategy for building institutions and the capacity to manage and implement policy. This means that countly operations divisions have a critical role in assisting cey national decisionmakers to understand and internalize poverty alleviation and institution-building objectives and to plan and prioritize sector interventions and allocate resources accordingly.

22. Fourth, more creative use of Bank instruments and resources should be sought through: (1) a review and assessment of the optimal use of lending instruments for PHN sector interventions; (2) increased innovation in the identification and financing of local expertise; and (3) increased efforts to encourage the exchange of experience and ideas among developing countries, over and above the notable efforts of the World Bank's Economic Development Insititute (EDI).
CHAPTER I. INTRODUCrION: 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 overvlLt of the FY91 work portfoIio, including ,tistics 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 the special topic of institutioial development for poverty alleviation.*

agreed with Operations colleagues that the issue would be dropped from this years sector review in favor of a more tncused exercise.

1.2 This report covers three components of the PHN work portfolio. First, the vortfolio of FY91approved _knding_ opelations considered in this review comprises the twenty-eight projects officially categorized as PHN sector, including a number of multisectoral operations that include relatively small PHN components. While the PHN secor lending work undertaken during FY91 actually encompasses a larger sampling of projects (i.e., those at the preparation, appraisal, and negotiation stages at the end of the fisal year), resources did not permit a rigorous review of all projects developed during the fiscal year. Second, the review provides statistics on _sector work,_ but no critical analysis; such a review is under consideration. Third, the coverage of the ninety-seven projects under _supervision_ is limited to some basic statistics on the size and composition of the supervision portfolio. The Seventeenth Annual Review of Implementation and Supervision (ARIS), currently underway, will provide a thorough review of supervision work This report did, however, take great care to incorporate into the lessons learned matrix the findings of the Sixteenth ARIS and of all seven Project Completion Reports (PCRs) produced during FY91.

1.3 r.. years Annual Sector Review guidelines, prepared oy the Office of the Vice-President for Sector Policy and Research (PRSVP), explicitly noted that reviews of _research and poly work_ were not to be included, as had been the case in the past. Such a review is being considered as a separate eercise and would, more appropriately, be undertaken by Operations. Also, while the _teholg topic_ proposed in the PRSVP guidelines was widely considered to be important, it was discussed and

* The review team (Denise Villancourt, Jane Nassim, and Stacy. Brown, PHRHN) consulted about forty operations staff on the process and substance of this exercls. These consultations heavily influenced the choice of the special theme as well as the overal approach to the review.
# CHAPTER It. OVERVIEW

### A. Lending

Figure 1: Lending for the P^;sulatlon, Healah and A4utrition Sector, FY80-91

## _1. Growth in the Lending Portoli__

2.1 FY-I saw continued growth in the PHN activities of the World Bank. Lending to twenty-eight projects totaled $1567.6 million, compared with commitments of $933.4 to eighteen projets in FY90, which, in turn, marked a substantial increase in both numbnr of projects and lending volume over FY89. In fact, growth in both number of projects and amount of cnd.ng has been a notable feature of the Bank's support to PHN since FY81, when the Bank first began lending for health (Text Figure 1). The Bank's restated commitment to the reduction of povertyandits rapidly growingemphasison human resource development have stimulated this growth, which has been particularly marked in the past four to rive years. In addition, the 1987 reorganization of the Bank, which combined PHN with education in integated Population and Human Resource (PHR) divisions, also led to expansion in PHN operations and In social development projects that include PN and education sector components and, in many cases, others as well. Annex 1, Ibble 1 lists the twenty-eight PHN projects approved during FY91 ..nd provides a breakdown of IBRD/IDA amounts by sector--PHN, Education, and others--which highlights the multisectoral nature of the social development procs^.

<!-- Start of picture text --> 3 Number of Project*<br>30 24<br>2 6 -<br>2 18<br>11 1E<br>so r 8 8<br>6 , 2<br>o<br>80 SI 8 83 84 86 86 87 88 8a9 90 G<br>Fiscal Year<br>PHN PROJECTS i0OCIAL DEV. PROJECTS<br>Milli10 f Use<br>180G -<br>10 0 . .66<br>1400*<br>1200<br>18000- t34<br>600 e -o<br>400 244420 304<br>200 143 t20 64<br>o868<br>F38cal Year<br>MrHM PACE? M3OCIAL 0EV. PROJECTS<br><!-- End of picture text --> <!-- Start of picture text --> __<br><!-- End of picture text --> 2.2 Social development projects arose as a distinct feature of PHN work in FY90 when there were six such projects. In FY91 there were ten, with lending amounting to $464.8 million, or 30 percent of overall lending to the PHN sector. The review team estimated the value of the PHN components of social development projects at $207.4 million, representing 45 percent of loans and credits for that type of project. Lending for 'pure' PHN projects and for the PHN components of the social development projects mounted to $1.3 billion, or 83 percent of overall lending to the sector (Annex 1, lable 1).

Figure 2 gives an overview of the sectoral composition of the FY91 PHN projects.

2.3 The proportion of total Bank lending to the PHN sector increased considerably in FY91--from 4.5 percent in FY90 to 6.9 percent in FY91, or from 4.1 percent to 5.8 percent if knding to non-PHN components is excluded (Ilx lIble 1). PHN lending has grown in both absolute and relative terms, in response to senior management's commitment. to increase PHN activities. This commitment has been expressed on several occasions. In November 1989, President Conable, in an addtess to the Annual Meeting of the Internationai Planned Parenthood
PHN 1991 Sector Review 4 Federation, pledged to increase PHN lending<sup>to $800</sup> million annually during the period FY9O-92.<sup>The</sup> Bank's 1990 "Review of World Bank<sup>Progms and</sup> FY91 Budgets' stated that it expected PHN lending to increase from an average of 3 percent of Bank Figure 2: Sectoral Composition of PHN Projects Approved in FY91 <!-- Start of picture text --> . , .<br>PHN 1300.2<br>EDUCATION 58.7<br>INFRASTRUCTURE 110.2<br>'MTER 6.3<br>INCOME GEN. 8Q.3<br>AGRICULTURE 2.9<br>- - - - - -<br>TOTAL 1567.6<br>AgrIc~ulturo 0.2'b_ PHN a2 9$<br>lntragtruCturO 7.0$ $<br>Education 3.7%<br>Income 5.7%<br>Water 0.4%<br>(In USS millions)<br><!-- End of picture text --> lending in FY89-90 to 4 percent in FY91. Both<sup>of</sup> these targets have been exceeded. More recently,<sup>on</sup> ihe occaslon of the World Summit for Children<sup>in</sup> September 1990, President Conable expressed<sup>the</sup> Bank's determination to provide greater support<sup>for</sup> primay health care and set a goal of increasing lending for primary health care from about 3 percent to about _5_ percent of total lending within the<sup>next</sup> three to four years. Some 90 percent of "pure" PHN allocations, or $1220 mllion, supported primary health care in FY91, acoounting for 5.4 percent<sup>of</sup> total Bank lending (see Annex 1, ibble 2 for detalls). PHN p-o,ts approved during the year have also been found to be highly responsive to the Bank's poverty alleviation objective (see Chapter III). (More detailed information on the growth of the sector<sup>is</sup> given in Annex 1, lhble 3.) lhble 1: lVends in Lending to the PHN Sector, FY89-91 <!-- Start of picture text --> ls. 2MSLRidll Aemots in S Hi<br>Regon r089 FY90 FY91<br>~~~~~~~~~~~~~~~~~~~~~~~~~~............... ......... I..... ........... I........<br>SEACt No. APaW. No. Rount No.<br>AFRICA III.0 1'.) 732.7 (8) 432.8 (12)<br>ASA 80.0 (4) 192.5 ? 507.5 (5)<br>fICECA s0.0 (2) 119.0 (2) 2?0.0 (6)<br>SAc 99.0 (1) 389.2 (6) 337.3 si)<br>TOTAL 530.0 (11) 033.4 (18) 1567.6 (a8)<br>lb. PHt Ledirng as a Percent of Totat Rank Ltiring<br>ltegion .. o . . rYb FY89 . . FY90 rY9;FY91<br>Pure Totes Pure Total Pure Totat<br>_PN PHt Po pit PNY PKM<br>AFRICA kASIA 2.1 3.7 2.1 3.7 4.3 3.0 5.9 3.0 12.3 6.3 12.86.8<br>fIEUA 2.1 2.1 2.7 2.7 1.9 4.4<br>LAC I.r 1.7 6.1 6.5 5.6 8.4<br>................................................<br>TOtAL 2.6 ?.6 4.1 4.5 5.8 6.9<br>Note: QPur* PNe- reters to PHU only Projects and PHU ctmpnents<br>of Social Dovelopomnt Projects.<br>Total PuN emooseg (l lling for rttro PtU sector,<br>i.e. incuding non-PHoI contonta.<br><!-- End of picture text --> 2.4 The portfolio of FY91-approved operations, reveals increasing divetsity in both the sectoral content and the lending instrument used (lbx<sup>'able</sup> 2). Eighteen of the twenty-eight projects (64 percent) are devoted entirely to the PHN sector, of<sup>the</sup> remaining ten social development projects, four<sup>(14</sup> percent) support PHN and education sectors<sup>only</sup> and six (22 percent) support PHR and other sectors as well, such as agriculture, water supply and<sup>sanita-</sup> tion, other rural infrastructure, and income generation activities for the poor. Diversity is evident<sup>as</sup> well in the funding mechanisms employed. Seven<sup>of</sup> this yeares operations (25 percent) are in the<sup>form of</sup> sector funds, which support subprojects prepared<sup>in-</sup> country by communities, local governments and<sup>non-</sup> gwrernmental organizations (NMOs), among<sup>othes</sup>
_5_ PHN 1991 Sector Review These fuads are managed by the borrower which has FY91 projects supported PHN and socal developresponsibility for the solicitation, review, apprisal, ment activitdes In Africa; six projects were approved approval and supervision of subprojecs. In additon, in the Europe, Middle East and North Africa a number of other traditional projecs provide for (ENENA) region and five each in the Asia and the small sector funds to support such Innovative activity Latin America and Carlbbean (LAC) regions. In which serves as a complemen **t** o other components. terms of loan and credit amounts, 32 percent<sup>of total</sup> A list of all sector funds is provided In Annex 1, PHN sector lending was committed to Asia, 28 Ibble 4. In aiditlon, one project (rogo), represent. percent to Africa, 22 percent to LAC and 18 percent ing the flrst-ever PHN sectoral adjustmt operation, to EMENA (lbxt Figure 3). In FY90, sodal developwill provide balance of payments support In three ment projects were a feature of the lending programs tranches in fulfMllment of a number of sectoral inAfrlmaandLAConWlInFY9lallregions hadat reform measures. Ths year's portfolio also includes least one such project: four in LAC, three in Africa, one emergency recovery operation (Yemen) In two in EMENA, and one in Asia. response to urgent social sector needs generated by the Gulf crisis. The comparative advantages of the variety of sectoral and financing characteristics of Figure 3: Regional Distribution of PHN Lending, this years portfolio of projects are discussed in some FY91 detail in Chapter Hm detail in Chapter Hm AFRICA 12 Ikbie 2: leczoral Composition and Funding r43W% **Characteristics** of PHN Portfolio, FY91 ASIA 6 <!-- Start of picture text --> AFRICA 12<br>ASIA 6<br>18% LAG<br>18%<br>2 1% 8<br>Number of t'rojbcts<br>ASIA 607.6 _ _ AFRICA 432.828%<br>32%<br>22%<br>EEA<br>E Amounts------<br>Lending Amounts<br>(In US$ Millons)<br><!-- End of picture text --> <!-- Start of picture text --> _ _ .. _____ __ _EMENA ......<br>?rSdleloauL sector naa ot,.r<br>._N,L-qa,r, !} .;- -- _. "'' ._<br>aoly Xad4q9ccr-SIL NIgeria P.-ZtL<br>(i) NSI*VL- SIN<br>RZntL<br>UmIabJt-t<br>Saaqlad.sh-StL<br>madla-SIL<br>IWlOMOLOI-SZL<br>Tun&*A& (R@apOI -tL9<br>Neaaco-SIL .<br>... _ CL __...... SeLas014-fSL _ _------<br>PX1 VtmSIMU-S.. L ;;<br>_ ~~~~. ...... ............ .............. ......<br>erstw SA Sctr uxaafi, S<br>S tOd Or tsri M_tOW Iinn Laon -<br>taL l= e uaLoan<br>. . . . . . .<br><!-- End of picture text --> Afmha n project laqe than S100 mflon, ~~~~wherma thtee of the five Asia projects were larger than trat, as were two of the **re ee** LAC projects, and one of the six in ENA. These large projects ac counted for 57 percent of PHN lemding volume. **ee** _aveage size of_ IBRD/IDA allocations for PHN operaSot in FY91 **r** $56 millon; for the four regions the averagd size p p s l1are5 thla on for Asia, S67.5 mionforAcut for for PHN mlning lme A,EpCe

# _2ReDianadl RDM 4CoMM i_

2.5 'Me Atifca Region developed the lugt regions the averagd size p p number of projects in FY91, though lending volume S67.5 mionforAcut for for was greatest in Asia. 'Nelve of the twenty-eight and $36.1 mfllon for Africa
PHN 1991 Sector Review 6 2.6 The proportion of PHN projects that receive IDA funds is larger than the Bank-wide average. Overall, 59 percent of the total amount of Bank lending to PHN operations in FY91 was comprised of IDA funds, compared with 28 percent for all<sup>Bank</sup> projects. The proportion was greater for<sup>social</sup> development projects (73 percent) thdn for "pure' PHN projects (53 percent), as befits the former projects' important role in poverty reduction. (Annex 1, Ibble 1 itemizes the IBRD/IDA allocations.)

# _3. Coflnanc_

2.7 In FY91 the number of cofinanced projects increased with the overall growth in the number<sup>of</sup> PHN sector projects, though the proportions remained the same as in FY90. The regional distribution of cofinanced projects ums, however, more balanced in FY91. Every region had some cofinanced projects in FY91, whereas in FY90, Asia<sup>and</sup> EMENA had no cofinanced projects (Text Tble 3). The Bank's leveraging of additional funds for its PHN and social development projects was significantly higher in FY91 than in FY90 according to both measures of additionality--the amount donor cofinancing (not recipient governments) adds to the Bank's lending .'or all PHN projects (overali additionality) and the amount cofinancing adds<sup>only</sup> to the projects that are cofinanced. In FY91 cofinancing more than doubled the resources available to the cofinanced projects. The proportion of PHN sector projects receiving cofinancing from official sources (61 percent) was higher than the overall Bank share (53 percent); in FY90 the shares were equal (56 percent).

2.8 Other donors contribute more to the financing of social development projects than to 'pure' PHN projects: overall additionality is 113 percent in social development projects and 33 percent in PHN-only projects. IX the cofinanced social development projects, additionality is 153 percent; in the PHNonly projects it is 83 percent. The social development projects, supporting a broad range of social investments, appear to offer an attractive means of combining assistance. Official cofinancing of Bankassisted PHN and social development projects reveals only part of the growing collaboration between the Bank and other agencies in the official donor community, however. The social development project appraisal reports, in particular, refer to coordination in support of larger country social programs, of which the Bank project often constitutes only a part.

Tible 3: Cofinancing from Official Sources in PHN Projects, FY90 and FY91

|3s. Cotfirn|ed<br>Projects<br>FY|FY91|
|---|---|---|
||90||
||_................_<br> f<br>Total<br>N0|_........._<br>Nof<br>Total<br>LO|
||go.o<br> <br>.|o. <br> <br>.<br> <br>|
||Coflraced<br>of PHU|Cofinared<br>of P,Ig|
|Region|Projects<br>Projects|Projects<br>Projecto|
||8FRICA<br>7<br>a|<br>9<br>12|
|ENEA|0<br>2|**3**<br>**6**|
|**LAC**|**3**<br>6|**3**<br>5|
||..<br>....<br> <br> <br>|...<br>....<br> <br>|
|AllR8gior|<br>10<br>18|17<br>28<br>|
|..........|...........|28|
|3b.Addition|<br>ity<br>Ovrall;|Additionetity<br>In Cofmr4oed<br> <br>|
||Additloo<br>lity|Projects<br>**18)**|
|Regio|F90<br>FY91|F;90<br>FY91|
|<br>.-.-.-.-.<br>AFRICA|-.-.-.<br>42?<br>393|<br>l<br>603<br>S91|
|<br>ASIA|..<br>.<br>07<br>S|.<br>.<br>0.0<br>112.0<br>|
|EIEUA|0.0<br>1380|040<br>1<br>89<br>1|
||<br>4||
||.<br>..<br> <br>|.........|
||<br>|<br>|
|Allee|o1S.4<br>**36.0**|**S6.?**<br>**110.2**|

2.9 An interesting feature of the FY91 lending program is the involvement of in-countrycofinanciers in addition to central government or, in one or two cases, in place of central government. In three of the Africa projects and in one Asia project, state governments and public agencies are cofinancders. In many projects the beneficiaries are also contributing: this is occurring in six Africa projects, two LAC projects and one Asia project In the Korea Health Technology I project, the private hospitals that are the project beneficiaries are financing 26 percent of total project costs while the government is making no financial contribution. In all other projects the amounts committed by the beneficiaries are quite small, since they are, in most cases, the municipalities, NGOs,
7 PHN 1991 Sector Review and local groups that will be presenting proposals for project funding. In general the contributions are in the form of matching grants, and their significance lies less in their size than in their implications for greater local involvement in project design, implementation, and sustainabDlity.

2.10 On average for FY91, the Bank is financing 46 percent of total project costs in the PHN sector. Average project costs were higher in the socdal development projects than in the "pure" PHN projects--$131 million versus $119 million--though Bank loans were lower on average to social development projects--$46 million versus $61 million--another indication of the additional leverage gained in cofinancing from all sources in the social development projects.

# _4. Project Funds by Expenditure Catezorv_

2.11 As shown in Figure 4, investment costs weie 70 percent of total projea costs, and recurrent costs were 30 percent, including the costs of drugs, contraceptives and therapeutic nutrition. The greatest share (about two-thirds) of investments financed under FY91 projects was **fcr** equipment, furniture, supplies, and civil works. While not calculated in detail by the ASR team, a large proportion of these investment costs are for the rehabilitation of existing facilities and for replacement of equipment which have been allowed to deteriorate. This phenomenon is reflective not only of the need for improved management of maintenance activities but also of the lack of recurrent financing to support such activity. Securing adequate levels of recurrent financing for proper maintenance of buildings, vehides and equipment is surely a more cost effective alternative for providing needed inrastructure for the promotion and delivery of health services. The Bank, both in its policy on recurrent cost financing and in its PHN project designs, should be more supportive in providing needed assistance in this regard.

2.12 Three-quarters of the non-drug recurrent cost component, which represented 24 percent of total project costs, was for salaries and allowances. The "drugs" cost category, which includes drugs, contraceptives and therapeutic nutrition, made up 6 percent of total project costs; it is accounted for separately in this analysis because it has been categorized both as an investment and as a recufrent cost by different projecs within and across regions. While drugs are recurrent In natu:e, 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 other means nationally, is sometimes categorized by task managers as an investment cost.

Figure 4: Breakdown of ibtal Project Costs by Expenditure Category <!-- Start of picture text --> Project Cost Categories<br>Summary Accounts<br>. S<br>402<br>_Dev. j<br>33.1<br>I9C.2a 74074 SI'.<br>............... v<br>117.9 ., 7i7<br>. U9<br>8&6<br>(in US$ millions)<br><!-- End of picture text --> Note: Data derived from 19 of the 28 FY91-ap proved PHN projects for which detailed break down of total project cost was available (18 "pure" PHN projects and the Mali Health and Water project).

## B. **Sector Work**

2.13 Thirty-threc pieces of sector work reached at least the white-oover report stage in FY91, the same level of output as in FY90 (Annex 1, lhble 5). TWelve of these reports were completed in final greyor red-cover form. (Annex 1, bkble 6, provides details.) lWenty-four of the reports were produced by the PHR divisions, the balance by the country divisions, a few other sector divisions and one by the
8 PHN 1991 Sector Review TIbchnical Cooperation Unit of the Europe, Middle East and North Africa Country Department m (EM3), which reviewed the organization and functoning of the Ministry of Health of Saudi Arabia. About half the reports treat PHN in the context of broader human resource, poverty alleviation, and social sector issues or, particularly in Africa, in relation to women in development issues.

2.14 The reviews, which focused exclusively on the PHN sector (or subsectors), were undertaken most often in countries where the Bank is at an early stage of involvement (e.g., the PHN sector report in Lao PDR), or where it has had to adapt to changing govermnent policy (e.g., the *New Directions in Family Planningf report in the Philippines). In health, several reports dealt in some detail with the technical issues of health financing and health planning, questions of growing concern. In nutrition, an increasing number of reports assessed needs and interventions in the broader context of food secuity concerns. IWo important areas of population sector work were (a) policy development and the institutional framework necessary for program implementation, and (b) the use of alternative channels for bmily planning services-- NGOs and, to some extent, the commercial sector. Secor work will remain at much the same level of activity in FY92 and FY93.

# C Supelion and Project Evaluatlon

2.15 The PHR divisions are currently responsible for a heavy supervision workload (Annex 1, Figure 1). Ninety-seven projects, representing commitments of nearly $4.5 billion, are being implemented. Nearly half these projects are in the Africa Region. (The implications of this workload are discussed in more detail in Chapter IV.) 2.16 Seven project completion and audit reports were produced during FY91 (Annex 1, Ihble 7). Several of them--the ibmil Nadu Integrated Nutrition Project, in particular-distill the lessons of experience in ways that have wide applicability. These completion reports were used by the Operations Evaluations Department (OED) in its 1990 _Reiew of Project Performance Results: Human Rsources Pojets._ Although the unsatisfactory rating for achievement of original objectives for three of the five projects reviewed in this exerc aises con cern, four of thowe projects were considered to be sustainable. The projects were among the first health and nutrition operations of the Bank; and the process of their review and evaluation has indicated that a review of criteria for rating success of PHR projects may be in order.

2.17 One OED report issued in FY90 with important implications for Operations was the review of the Bankes work to date on population, based on eight country case studies. The report found justification for the Banks greater focus (since its reorganization) on coherent macroeconomic and multisectoral strategies at the country level and for the poverty focus of its worL Although several of the famly planning programs studied were able to raise contraceptive prevalence levels even under unfavorable socioeconomic conditions, the report stresses the limits to such an approach. It argues that project impact would have been greater had family planning programs been developed in combination with reinforcing social programs that produce conditions favoring the emergence of preferences for smaller family size. The report cites the ase of Indonesia, where parallel investments in education helped to create the condidons for fertility decline and the increased demand for family planning services. Another important conclusion of the OED report Is that greater financial resources from the Bank would not necessarily have Improved the programs' impact; rather, non-financial assistance in the form of more sector work, more focus on software than hardware, a more pro-active role in some countries, and more collaboration and coordination with other donors, would have been useful oDmplements. Operations is already moving in the dections, and the report confirms the soundness of these approaches.

# D. PopulatIon, Health and Nutrulton Content of Projec

2.18 The increasing integration of PHN into country strategies, which was noted in the FY90 sector review, has continued, and the Staff Appraisal Reports (SARs) document increasing coordination with other donors as welL A growing number of projects address PHN and other components together, and sector work is preparing the ground for
9 PHN 1991 Sector Review dialogue and operations in integrated human resource and social sector activities. Many projects now involve multiple line ministries and require significant coordination between the different parts of government (see Chapter 111). While these projects may be more complex and risky, they promise longterm payoffs as previously excluded ministries, particularly central ministries, such as planning and financing, are drawn toward a stronger commitment to social programs. The involvement of NGOs is on the increase. In nearly all twenty-eight of the PHN operations approved during the fiscal year, NGOs are assuming important roles in project implementation. lb a lesser, but still significant extent, NOOs are participating in the design of projects, as well (Ghana, Pakistan, Venezuela, for example). NGO involvement is particularly significant in projects with sector funds, where their role in eliciting from communities and in preparing, themselves, subproject proposals is certain to result in the design and support of PHN activity which is responsive to the needs of local populations and which is likely to be sustained.

2.19 The integration of PHN into broader human resource operations, was a welcome development, but not all projects need be multisectoral though planning must take place in a broader context. Indeed, as the sectors mature, specialized projects addressing specific needs may become increasingly important.

2.20 _Health._ In health there were three such specialized projects in FY9': the Korea Health Technology project, which seeks to expand the diagnostic and treatment capabilities of hospitals by upgrading equipment; the Algeria Pilot Public Health Management Project, which tests management tools for replicability nationwide; and the linisia Hospital Restructuring Support Project, which addresses issues of management capacity and service quality in the context of policy reform in the sector. The main thrust of health operations in FY91, however, has been on extending access to primary health care services in the context of poverty reduction.

2.21 Within primary health care, there has been considerable emphasis on maternal and child health services as well as on the Acquired Immune Deficiency Syndrc-Ae (AIDS) pandemic. Nutrition and population projects support important components of primary health care, and, so, share that emphasis, seeking to address the needs of young children and women and to integrate ard coordinate those services with other basic health services for greater efficiency and effectiveness. Thus the Bangladesh, Indonesia, and Pakistan projects aim at more effective integration of family planning with maternal child and health services than has previously been the case. The India Integrated Child Development project is strongly focused on nutrition, the Sri Lanka Poverty Alleviation project includes a nutrition fund aimed at improving the health of mothers and children, and the Honduras social development project includes pilot nutrition activities.

_2.22 Population._ Thirteen projects in the FY91 lending program provide direct support to family planning--up from eight last year. Lending volume rose as well, a doubling from $169.3 million in FY90 to $351.0 million (Annex 1 Tbble 8 and Figure 4). Most of the increase comes from the Bangladesh project ($61.5 million for population), advanced from the FY92 program; next year's program will be correspondingly reduced. Attribution of commitments to population in Bank PHN projects has always been difficult, but it has become increasingly so with the integration of PHN and other components. The $351.0 million FY91 total is a conservative estimate of direct lending and represents about 25 percent of the $1.3 billion committed to "pure" PHN projects and PHN components of social development projects, and over 50 percent of lending in PHN projects that include Bank assistance to population (Annex 1, Tbbles 8 and 9).

2.23 Cofinancing also made important contributions to family planning projects. The Bank made no direct contribution to family planning in the Zimbabwe Family Health project, but raised $17.7 million for population from other donors. In the Bangladesh family planning program, the Bank's allocation of $61.5 million of its assistance to family planning represents 34 percent of the IDA credit, but the total project ($600 million), commits over 60 percent to population. The Nigeria Population project will do much to promote a strong institutional framework for policy and program development, at both national and local levels, while building national consensus on the importance of reduced fertility for national and individual progress. The Pakistan Family Health
10 PHN 1991 Sector Review nation of the country's program and uncertain government commitment. There, too, integration of fimify planning into a broader array of serices designed to inprove health is seen as the most effective way to stimulate the demand for family planing that provides the long-term conditions for program success.

2.24 _Nutn._ Bank support of nutridon is clearly manifest mx the large growth in number of operadons, which support nutrition activity--from thirteen in FY89 to eighteen in FY90 and twenty-eight In FY91, and in lending for nutrition (including PHN, education, Women in Development (WID) and food security operatlons)--from $33 million in FY89 to $200.9 million in FY90 and $252.7 million in FY91. Estimates of overall project resources for Bankassisted nutrition activities have risen in three years from $54.8 million to $337.7 million to $470.4 million (Annex 1, Figures 2 and 3). As with population, the Bank may sometimes finance only a modest share of total project resources for nutrition while raising substantially more funds from other agencies. (For example, because of the nature of nutrition operations, large portions of overall project costs are sometimes met by food aid agencies).

micronutrient components, including the pioneering Mali project for Iodizing water by equipping pumps with an iodine module. 'he Bankes support for micronutrient projects has grown considerabl, projecs under preparation demonstrate Bank interest in fortfication programs. Although there were additions to the technical nutriton staff this year to handle the grwng nutridon programs, the Bank continues to rely heavily on consultants for fieldwork assinments. The Bank needs to increase institudonal capacty to respond adequately to growing demands and opportunities for Bank-assisted nutrition operations.

2.25 These figures for nutrition do not reflect adjustment operations, which gave considerably more attention to nutrition in FY91. Venezuela's targeted food and nutrition progams went up more than sevenfold in conjunction with adjustment operations--from $102. million in 1989 to $761 million in 1991. And a significant portion of the Agrficultural Adjustment Project for Mexico ($400 millon loan plus $200 millon from the Inter-American Development Bank was directed to nutridon. Overall, nine of sixteen adjustment loans approved in FY91 address nutrition; four include specific nutrition actions as conditions for tranche release and three led to sizeable sodal funds to improve nutrition conditions. Three of the four agriculture sector adjustment operations include nutrition activities, and in two of them nutrition actions are a condition for tranche release (Annex 1, 'bble 10). Projections for FY9294 lending for nutrition projects and projects with significant nutrition components point to a continuadon in growth.
# CHAPTER HI. SPECIAL THEME: INSTlTUTIONAL<sup>DEVELOPMENT IN</sup> SUPPORT OF A POVERTY FOCUS<sup>FOR PHN SECTORS</sup>

### _A_ Introducwn

3.1 7Wo special topics were selected for this yeares sector review: (1) poverty, chosen by PRSVP<sup>for</sup> inclusion in al FY91 sector reviews and<sup>(2) manage-</sup> mentAnstitutlonal dwelopment, chosen<sup>by PHRHN</sup> in close consultation with PHN colleagues<sup>in opera-</sup> dons. A brief overview of each topic and<sup>its rele-</sup> vance to the PHN sector is presented<sup>here, followed</sup> by an introduction of this report's<sup>chosen theme,</sup> which blends the two special topics.

tions departments) and In the counuries (planning and finance ministres and heads<sup>of state). All</sup> sectoral interventions need to be prioritzed within<sup>a</sup> well-arIculated set of macroeconomic and multisectoral polcies that are oriented toward<sup>growth with</sup> poverty reductlon Without this kind of<sup>framework,</sup> the potential of the PHN sector (and<sup>others) to</sup> contribute effectively to poverty alleviation<sup>will not</sup> be fully realized.

## 2. _Manawment and Instiutdonal Development_

### 1. &env

3.2 The World Development Report (WDR) 1990 reflects the Bank's strong commitment to<sup>the allevia-</sup> tion of poverty as a central development<sup>objective</sup> and top priority. _RDR 1990,_ and<sup>the subsequent</sup> policy paper, *Assistance Strategies<sup>to Reduce</sup> Poverty," articulate a two-pronged<sup>strategy for</sup> sustainable poverty reduction: (1) the<sup>generation of</sup> income-earning opportunities for the<sup>poor, and (2)</sup> the provision of basic social services<sup>to the poor to</sup> enable them to seize those opportunities The strategy also calls for providing a social<sup>safety net for</sup> vulnerable groups who are unable to take<sup>advantage</sup> of income earning opportunides. Tbis<sup>strategy</sup> intensifies the emphasis on PHR sector activities<sup>as</sup> key investments in the development<sup>of any country</sup> and presents further challenges to the<sup>PHN sector.</sup> 3.3 Addressing poverty through PHN interventions certainly means expanding<sup>access to basic</sup> services and targeting programs<sup>for the poor and</sup> vulnerable groups, in particular. It also means addressing broader sectoral issues--improving<sup>the</sup> quality and efficency of services, reallocating<sup>public</sup> expenditure,decentralzingdecision-makingresponsibility, encouraging greater NOO and<sup>community</sup> involvement, and exploiting the role<sup>of the private</sup> sector to liberate public resources for basic<sup>and</sup> preventive serices and carefully designed cost-<sup>recov-</sup> ery programs.

3.4 The objective of poverty alleviation must<sup>be</sup> understood and internalized at the country<sup>(macro-</sup> economic) level-both in the Bank (country<sup>opera-</sup> 3.5 There is a strong, well-documented, positive correlation between project sustainability<sup>and institu-</sup> tional development. The FY90 PHN sector<sup>review</sup> noted an increasing appreciation in Bank<sup>investments</sup> in PHN of the importance of developing<sup>institutional</sup> capacity and management skills and<sup>practices, but</sup> some variance in the effectiveness with<sup>which differ-</sup> ent operations have addressd this issue.<sup>The need</sup> for strengthening Institutions and<sup>management</sup> capacity Is espedally acute when poverty<sup>and equity</sup> issues and objectives are addressed<sup>through PHN</sup> sector actvtities. To meet the PHN needs<sup>of poor and</sup> vulnerable groups, developing country<sup>institutions</sup> must be capable of: cross-sectoral and<sup>inter-agency</sup> communication and collaboration; more<sup>effective</sup> targeting, monitoring, and evaluation, which<sup>require</sup> a strong Management Information System<sup>(MIS) and</sup> research capadty, understanding and<sup>responding to</sup> the demands of the poor, and greater<sup>community</sup> involvement, to name only a few priorities.

## 3. _Choice f and ADporah to Special_<sup>_Topic_</sup>

3.6 Thespedaitheme,"Institutional Development in Support of a Poverty Focus for the PHN<sup>Sectors,"</sup> touches on issues of concern to all of<sup>the Bank's</sup> regions. In its treatment of this theme,<sup>this review</sup> emphasizes popular partidpation in the<sup>desig and</sup> Implementation of PHN activities, as a<sup>key to suc-</sup> vessfully providing basic servces to the poor.

3.7 One overwhelming message received from Operations during the consultative process<sup>of this</sup> exercise was the need to take better stock<sup>of lessons</sup> learned to enlighten the design of future<sup>operations.</sup>
PHN 1991 Sector Review 12 Section B of this chapter provides a distillation of lessons learned from myriad Bank reviews (see bibliography in Annex 3), from seven PCRs and other reviews of PHN program experience undertaken during FY91 (Annex 1, lhble 7), and from the insights of task managers of FY91-approv,-4 operations. Section C reviews FY91-approved PHN operations as they relate to those lessons learned. While the ASR team reviewed many documents in preparing this sector review, time did not permit a comprehensive review and analysis of Bank experience relevant to PHN sectors.

# B. Lessons Learned

3.8 The review of PHN project experience (Annex 1, Thble 7), two OED studies (1985 and 1989) on project sustainability, and the Sixteenth ARIS, reveals four conditions that have a strong influence on the sucoess and sustainability of PHN operations: _*Enabling policy and political environment,_ which includes (1) macroeconomic and muitisectoral pollcies that are oriented toward growth with poverty reduction; (2) strong political commitment to poverty programs despite the weak political and economic position of the poor, (3) policies that encourage private sector development, decentralization, institutional pluralism, and popular participation; and (4) PHN policies that emphasize the provision of basic services to the poor and vulnerable segments of national populations.

_eSound organiutonal stucture,_ which would encourage the involvement of the many institutions, agencies, and community groups that could participate in PHN sector development.

_*Adequate management capacity_ of all contributors to PHN sector development, which would permit appropriate planning, programming, design, implementation, nmonitoring, and evaluation of sector activity, as well as the optimal use of human, financial and capital resources.

_eAdequate and reliable finandng_ of esntial sector activities over the long term, which would be aehieved through investment and recurrent budget allocations that are filly reflective of sound policy and strong political support, adequate and equitably designed cost-recovery programs, and improved availability, coordination, and use of external aid.

This section provides insight based on lessons learned as to what managementfinstitutional Lssues PHN sector operations must focus on in order to assist national governments to bring about these four conditions for successful and sustainable activity In the PHN se vs. These lessons are drawn largely from the I _et. implentation eapeince,_ particularly but nt ;xclusively in the PHN sectors, as documented in the in-house reviews cited earlier. They also reflect the experience and perspectives<sup>of</sup> Bank staff consulted during the ASR exercise. Where available and appropriate, references are made to documents, which would provide furnher guidelines and/or insight on how to approach these issues.

3.9 Section B.1, below, presents some lessons of substance, which give some indication of _what_ to do about thee various components of management/institutional development issues. Section B.2, which immediately follows, presents a number of lessons of design and process and notes some useful tools, al of which might give some guidance on _how_ to address management/institutional development issues more effectively. These sections certainly do not provide a complete set of guidelines for task managers and management. Rather, they are an initial attempt to address a difficult yet crucial dimension of PHN work, which has thus far received little attention. PHRHN is considering, however, developing the preliminary work undertaken in this ASR into a more thorough review and analysis of management/nstitutional development experience<sup>in</sup> PHN, both inside and outside of the Bank, which would eventually culminate in the production of such guidance.

1. _Lessons of Substance_

3.10 Tne lessons of substance presented here are organized around two main categories: institutional and organizational framework, and management capacity for policy formulation and implementation.
PHN 1991 Sector Review 13

# _a. Insitutional and Organzanonal Framewwork_

3.11 A sound institutional framework is critical to the efficient functioning of PHN sector activity. The following six dimensions of institutional strengthening should be considered when developing and implementir.g a PHN operation, particularly one with a poverty focus.

3.12 _Ophimal Use of Instituond Zrsouces._ The institutional framework for In-country PHN activity should encourage involvement of the various potential actors in the sector according to their comparative advantages. While there are notable exceptions, in many developing countries the public sector carries out the planning, financing and delivery of PHN services. Significant gains in quality and efflciency could be realized if the private commercial sector, NGOs, oDmmunity organizations, universities, national and regional institutions specializing in training, consulting, aud research, and other groups outside the public sector were encouraged to engage in sectoral activities. The audit report on the Philippines Second Population Project recommends greater reliance on NGOs and the private sector for undertaking health sector activity. According to the Sixteenth ARIS, the sucoful emergence of institutional pluralism should be accompanied by a reduction in size and a redefinition of the role of the public sector in PHN. Such a redefinition should preserve and, where appropriate, promote preventive health activity.

_3.13 Forming and Strengthewning of Local Organfzadons._ 7he evidence is overwhelming that the particpation of well-functioning local community -oups in the design and implementation oi PHN sector activity has a strong influence on project success and sustainability. OED's two reports on project sustainabilHey reveal that within the right institutional framework, beneficiaries can be mobilized to particpate in a wide range of activides: needs identification; project design; adaptation of project acivities and technologies to local needs; information collection, monitoring, and evaluation; management of activities on a local level promotion of services; and maintenance of Infrastructure. These groups offer communities a way to make decisions that will improve their lives, a power many of them would not otherwise have, especially those such as women and the poor, whose disadvantages have made them virtually powerless to improve their situations. PHN experience corroborates these findings: according to review work undertaken during the year, US the achievements of Indonesia's population program and India's lkmil Nadu Nutrition project are largely attributable to well-organized community involvement in promoting and managing basic services.

3.14 _Intsectwal Cordinon Between Povety. OMknted Instauion&_ Intersectoral coordination Is crucial to the efflciency of PHN sector actviy, but achieving it is a formidable management challenge. Strate4les for population, health, nutrition, and poverty alleviation each require the input of a number of line ministries. OED's review of Bank population assistance in eight countries$ cautions that such essential contributions will not be forthcoming unless deliberate efforts are made to ensure coordination, collaboration, and accountability. One need is for a well-articulated and politically endorsed macroeconomic and multisectoral policy. Also important are clearly defined responsibilities for the various ministries and agencies and a high-level, politically stable and capable agency to coordinate, promote, and monitor activity. The audit report for the Philippines Second Population project recommends assigning principal responsibility for family planning to the one agency that is the least politically vulnerable among reasonable candidates. This same recsamendation is made for the iutrition sector, based on lessons of experience6. The linisia Health and Population PCR noted that the institutional rivalry that interfered with the smooth implementation of that project might have been avoided had collaborative arrangements been better. The report further recommends that the Bank needs to be ready to intervene and help resolve interagency disputes.

3.15 _Decenralfiawon._ The extent to which health sector authority and responsibilities can and should be decentralized is a matter of some debate; there is no one correct solution to this issue, which would be applicable and equally appropriate in all countries. The definition of roles and the distribution of responsibilities across the various levels of government should be done with a view to achieving the appropriate and optimal contnbutions of each of those levels together and separately.
PHN 1991 Sector Review 14 3.16 Many, if not most, developing countries view the decentralization of sector activities as a viable means of achieving greater effectiveness and efficiency in health sector activity and thus strive for greater decentralization. Realization of this objective, however, has been elusive. The Indonesia Provincial Health PCR notes a failure to decentralize health services effectively despite the government's stated objective and the project's Intention to support this effort At the end of the project, major decisionmaking, financial control, and other administrative responsibilities remained overly centralized.

3.17 More rigorous efforts should be made at the country and regional levels by Sector Operations Divisions (SODs) and Tbchnical Divisions (TDs), respectively, and eventually at the global level by PHRHN, to study and test both the means and the end of decentralization of decision-maldng and management authority to the provincial, district, and lower levels of government. This task may provide a good opportunity to implement the recommendation made in Chapter IV that PHN staff draw on the expertise of in-house management and institutional development staff working on publc sector management issues across sectors. Experience gained thus far strongly indicates that success requires clear delineation of responsibilities at each leveL mechanisms for communication and coordination among the various levels, sufficient management training to enable ful assumption of decentralized responsibilities, and a redefinition of the central government's role that would limit it to policymaking and coordination, regulation, flnancing (in part), and supel sion of sector activity. Useful insight on how to accomplish this is provided in the proceedings of an Economic Development Institute (EDI) policy seminar on Strengthening of Local Governments in Sub-Saharan Africa<sup>7</sup> A recent paper produced by the Poverty and Social Policy Division of the Africa lbchnical Department (AF1SP) on the poverty orientation of public expenditure<sup>6</sup> argues that efficiency gains in resource allocation can be realized from the decentralization of financial decisionmaking responsibilities to allow local and community groups a greater role in choosing, designing, and providing core services.

3.18 _OrgankationofServiceDeivery.Thedesirabili-_ ty of providing PHN services through a referral system based on a pyramid of services is well accepted in principle, but needs to be established in practice. Many developing countries continue to use expensive, higher-level facilities to provide primary ealth care, whether because of a shortage of lowerlevel facilides or because such facilities are inadequate or perceived to be so. And even when lowerlevel facilities are consulted, they do not always refer patients up the health services pyramid when they should because of inadequate training and guidelines, lack of equipment, such as ambulances and radios, and failure in the referral system itself--no coordination, communication, support, or follow-up between the various levels. A strengthening of the referral system improves resource use and makes health services more available and responsive, especia;ly to the needs of the poor and vulnerable groups. What is needed, among other things, is a clear definition of the pyramid of services, the range and sophistication of services to be provided at each level, and the roles and responsibilities of staff at each level with respect to referral and operational norms. Also important are staff training, mechanisms to facilitate communication among various service levels, adequate equipment, and a strengthening of basic health services. Sometimes different price structures are helpful in discouraging consultation at unnecessarily high levels of services. Any effort to strengthen or expand the pyramid of services should cover an service providers, public and private. A study prepared by the Population, Health and Nutrition Division of the Africa Tbchnical Department (AFTPN) on the Health Center in Sub-Saharan Africa, provides practical guidelines and insight on how to address these issues.<sup>9</sup> _3.19 Srengthening of Key Components of the Insiidonal Framework._ All institutions and actors that influence the PHN sector need to be well organized and effectively managed, with adequate legal frameworks, in order to maximize their contribution to sector activity. Any weak links in this institutional framework must be identified and strengthened through internal organization and management changes or a change in legal status. These efforts should focus on skills, functions, systems, and structure. PCRs on the Indonesia Provincial Health, Pakistan Population, and linisia Health and Population projects all conclude that early and rigorous assessments of the institutiuns involved in project
15 PHN 1991 Sector Review implementation would have had a positive<sup>impact on</sup> the success and sustainability of those<sup>projects. A</sup> review of institutional development<sup>in World Bank</sup> operations entitled, Institutional<sup>Development in</sup> World Bank Projects: A Cross-Sectoral<sup>ReviewVl,</sup> provides a useful matrix of analytical<sup>frameworks for</sup> institutional analysis, along with a critique<sup>of Bank's</sup> performance to date in undertaking<sup>such work,</sup>

# _b. Management Capacilyfor Policy_<sup>_Analysis and_</sup> _Implementation_

3.20 We have already noted the importance<sup>of a</sup> macroeconomic and multisectoral policy<sup>framework</sup> and transparency in the policymaking process<sup>to the</sup> capacity of countries to develop and<sup>refine their</sup> PHN policy and ensure its effective<sup>implementation.</sup> As imnportant are the quality and<sup>availability of</sup> _information;_ skills in _planning and_<sup>_programming and_</sup> _budgeting_ to ensure the translation of appropriate, well-articulated policy into implementable<sup>projects</sup> and programs; the availability, distribution,<sup>and man-</sup> agement of sector _resources;_ and<sup>sound</sup><sup>_project and_</sup> _program management._ _3.21 Infonmation._ Almost every PHN<sup>PCR pro-</sup> duced this year highlights the need for<sup>improving</sup> information, both for evaluating Bank-supported operations and for enabling governments<sup>to assess</sup> the needs of the PHN sector and to<sup>monitor and</sup> evaluate performance with a view to refining<sup>policy.</sup> The Indonesia Provincial Health PCR states<sup>that a</sup> simple monitoring system is more effective<sup>than a</sup> complex one collecting large amounts of<sup>data. The</sup> monitoring and evaluation system, envisaged<sup>under</sup> the Malawi Health project, was never put<sup>into place</sup> because it was accorded low priority<sup>by both the</sup> Bank and the government. The PCR on<sup>the Yemen</sup> First Health project, notes that lack of<sup>an evaluation</sup> plan and of any evaluation activities<sup>may have</sup> compromised the success of project activities.<sup>The</sup> Tunisian Government, as documented in the<sup>PCR on</sup> the Health and Population project, judged<sup>the MIS</sup> to be overambitious and problematic. The<sup>PCRs on</sup> 'Inisia and Indonesia both noted that research activities had been neglected.

3.22 The above and other experience reveals<sup>a need</sup> for increased attention to the quality and<sup>availability</sup> of information and countries' capacity<sup>to use it.</sup> Countries need to have at their disposal<sup>both quanti-</sup> tative and qualitative information on<sup>the population</sup> (PHN status, needs--both perceived<sup>and real-</sup> socioeconomic status, traditions, cultures)<sup>and on</sup> PHN services (coverage, performance,<sup>quantity,</sup> quality, efficiency, mix). Such information<sup>should be</sup> sufficiently disaggregated (e.g., by geographic<sup>region,</sup> socioeconomic group, gender, age<sup>group) to permit</sup> the development of differentiated information, education and communication (IEC)<sup>activities and</sup> strategies for their delivery. Information<sup>should be</sup> gathered by various agencies and through<sup>several</sup> channels, e.g., research, surveys, beneficiary<sup>assess-</sup> ments, and monitoring and evaluation.

3.23 Management information systems<sup>are often</sup> too complex and camberseme, in many<sup>cases because</sup> they were designed to meet the needs<sup>of various</sup> donor programs rather than to monitor<sup>and evaluate</sup> PHN policies and services countrywide. Operational research and evaluation activities<sup>are frequently</sup> underdeveloped and underutilized. Efforts<sup>to im-</sup> prove information collection and analysis<sup>must focus</sup> on the development of a streamlined MIS,<sup>designed</sup> to meet the carefully defined information<sup>needs of</sup> the country rather than those of donors. The<sup>capacity</sup> to undertake needs assessment, operational<sup>research,</sup> survey work, data processing, and<sup>monitoring and</sup> evdluation (including the encouragement<sup>and orches-</sup> tration of local input)--al of which<sup>have been ne-</sup> glected--must be developed.

3.24 _Plannng, Programming and Budgetig._<sup>Capac-</sup> ities must also be developed for using<sup>information</sup> appropriately to ensure that PHN seetors<sup>articulate</sup> and effectively re-pond to issues and<sup>needs. Skills</sup> need to be developed and methodologies<sup>identified</sup> for targeting, priority setting, policy<sup>formulation,</sup> testing and experimentation, implementation<sup>and</sup> evaluation. Policy statements need to<sup>be translated</sup> into implementable activities through<sup>the formula-</sup> tion of an operational strategy with<sup>medium-term</sup> targets and specific plans for priority<sup>programs, as</sup> well as an action plan with key indicators<sup>for success-</sup> ful and monitorable implementation.<sup>Skills in plan-</sup> ning, programming and budgeting need<sup>to be devel-</sup> oped, with a bottom-up emphasis on nlanning<sup>so that</sup> local government and community groups can<sup>become</sup> sufficiently involved in the process.
16 PHN 1991 Sector Review 3.25 _Management and Dswibutdon of Resoures._ Proper management of physical, human, and financial resources will improie the effecwvenus and efflclency of P-N sector activities and ensure that resources are used in compliance with stated policy and strategy. _PJysical resource_ management can be improved by establishing or strengthening appropriately decentralized maintenance programs for buildings, equipment, and vehicles; by improving the planning of new infrastructure; and by setting up better systems for replenishing drugs and other essential supplies. The Tbnisia PCR highlights the importance of building and equipment maintenance to project sustainability.

3.26 Management of _human resourcte_ requires a clearly articulated strategy and capacity in manpower planning, recruitment, deployment. It also calls for weli defined pre-service and n-servie training programs focused on the provision of basic services, and skills for interacting with the community. The quality of staff performance and their motivation can be improved through a well-managed program of re ar supervision, the definition of professional at as and performance criteria, and the estabUshmeAt of incentives and career development paths. iTe India ¶lmil Naac PCR provides useful guidance on a system of management of local health workers that has met with great success. Key features suggested for replication include carefully defining recruitment criteria, limiting tasks to those that are manageable and high in priority, and specifying work routines. Furthermore, tus project has demonstrated that health worker skills can be effectively upgraded and sufficiently maintained by decentralizing training activities to an appropriate level, estabUlshing supervision ratios that facilitate on-the-job training, using MIS to track performance closely, and reporting of performance to clients and workers.

3.27 FInall, the management of _fnancial resoures_ has a substantial impact on the realization of poverty alleviation objectives in the PHN sectors. Resource mobilization, including aid coordination and cost rewvery schemes, is important for protecting the poor and promoting optimal use of essential preventive and curative services. Resource allocation within and across sectors should favor basic seAvices for the poor and vulnerable in order to be most cost effective and have the most impact on poverty. Also important is the development of strong financial management skills, including planning, budgeting, accounting, and cost containment. 'Me "Poverty Handbook<sup>1</sup> "m provides useful guidance on the use of Public Expenditure Reviews (PERs), Public Investment Reviews (PIRs), and other instruments to strengthen the fnacial sustainabllity of projects.

3.28 _Project Development and Management._ How policies and strategies are translated into implementable programs and projects also affects how well poverty alleviation objectives are achieved. As donor support to the PHN sector continues to move away from specific investiment projects toward broader support of sector policy, national governments, rather than the Bank or other donors, become increasingly responsible for the management and oversight of project development and implementation. Acvities financed through sector funds (para 24) and sector adjustment operations (see Sections C_2.a and c of this chapter), which transfer significantly increased responsibility for project analysis and management to national governments, in particular, require a strong national capacity in project identification, proposwd writing. outreach, appraisal, and supervision of subprojefts involving community and NOO initiatives. Other needed project management skills include procurement, disbursement, accounting, financial management, aid coordination, monitoring, evaluation, and reporting AFISP has recently issued guidelines for the design and implementation of socioeconomic development funds, which provides insight on these issues based on project experience.n

# _2 Lessons of Deg and Mcess an4 Some Useil Tooh_

3.29 Several of the lessons learned from Bank experience concern design features and processes, that seem to have a significant impact on the success and sustainability of Bank interventions. Many of them apply to the achievement of poverty alleviation objecives and are worth presenting here, however briefly. Some of these lessons apply to nonproject assistance (sector work and dialogue), some to project development and implementation, and some to both categories of assistance. TMe recommendations, while derived primarily from OED's two reviews of project sustainabilityu are corroborated by the findings of all seven PCRs produced this year.
17 PHN 1991 Sector Review Attention to the following process<sup>factors should</sup> _d. Project managment angemnu,_ that ensure increase the effectiveness and efficency<sup>of efforts in</sup> smooth implementation and encourage<sup>institution</sup> the PHN sector to improve the promotiont<sup>and</sup> building and sustainability-from the use<sup>of existing</sup> delivery of basic services to poor and vulnerable<sup>organizational structures to a gradual and better-</sup> groups and to develop institutional and management<sup>planned transfer of responsibility from temporary to</sup> capacity in support of that objective. permanent structures. Also helpful are clear<sup>commu-</sup> nication of all procedures and regulations governing a. _Sufficient analysis preceding project preparation_ implementation of<sup>World Bank projets (useful</sup> to permit a thorough understanding and appreciation<sup>guidelines on action planning workshops are</sup> of the soclocuitural environment and the<sup>institutional</sup> available14), organizational arrangements that faciliand organizational culture. Especally<sup>useful is</sup> tate effective coordination among multipls<sup>imple-</sup> analsis of policy, institutions, and the needs<sup>and</sup> menting agencies, and better planning<sup>for Bank</sup> perceptions of beneficiaries. The latter<sup>process</sup> dLsengagement from projects nearing<sup>completion</sup> should involve the ful participation<sup>of local govern-</sup> through the use of "graduation missions,. ments, NGOs, and community groups. Several<sup>tools</sup> and guidelines to facilitate such work are<sup>available in</sup> e. _Improvements in the quay of supeision_ work, the Bank, they include the beneficiary assessment<sup>including greater attention to institsitional capacities,</sup> tool (described in the "Poverty Handbook<sup>1</sup> "),<sup>the</sup> social and cultural issues, and sustainabilty, more participatory rural appraisal tool'<sup>3</sup> , and a series<sup>of</sup> time in the field, particularly to visit project sites;<sup>a</sup> fmeworks for institutional assessments.10 larger, more clearly defined role for field offices<sup>in</sup> e. _Improvements in the quay of supeision_ work,<sup>including greater attention to institsitional capacities,</sup> social and cultural issues, and sustainabilty, more time in the field, particularly to visit project sites;<sup>a</sup> larger, more clearly defined role for field offices<sup>in</sup> oversi3ht of implementation; and more intensive supervision at early and middle stages of<sup>implementation. A Policy, Research and External Affairs(PRE) working paper-" has pulled together field</sup> experience into a useful and insightful<sup>manual on</sup> PHN supervision of field sites.

b. _Fetibilky in project desig and implemeuioan,_ supervision at early and middle stages of<sup>imple-</sup> to permit the detecion of changes In the composi-<sup>mentation. A Policy, Research and External Affairs</sup> tion of target groups and of shifts In beneficiary<sup>(PRE) working paper-" has pulled together field</sup> needs to ensure the continued relevance<sup>of the</sup> experience into a useful and insightful<sup>manual on</sup> project Tlhs would require the development<sup>of</sup> PHN supervision of field sites. national institutional capacity and a properly<sup>de-</sup> signed MIS. Also required are mechanisms<sup>and</sup> f Increased _use Qf quaiidlocal erise_ in a capacities for adapting project objectives, justifying<sup>aspects of the Bank's work, e.g. NGOs, local and</sup> and communicating revised objectives to<sup>the parties</sup> community organizations, and universities<sup>and other</sup> concerned, and assessing future activities<sup>against</sup> local and regional institutions providing training, revised objectives. Useful in this regard are<sup>carefully consulting, and research services.</sup> designed and monitored pilot studies, supporting<sup>a</sup> research and extension approach. Such<sup>activities</sup> g. Greater _commnuniiypanipon,_ which results provide considerable scope for learning,<sup>and would</sup> in more apptopriate project desig<sup>and use of</sup> effectively respond to the need for flexbility<sup>in</sup> technology thereby increasing the chances<sup>of success</sup> projec design and implementation. and sustainability of Bank interventions. A learning research and extension approach. Such<sup>activities</sup> g. Greater _commnuniiypanipon,_ which results provide considerable scope for learning,<sup>and would</sup> in more apptopriate project desig<sup>and use of</sup> effectively respond to the need for flexbility<sup>in</sup> technology thereby increasing the chances<sup>of success</sup> projec design and implementation. and sustainability of Bank interventions. A learning group on popular participation, managed<sup>by the</sup> c. Deliberate _ateton to polihica4 nstutional_ International Economic Relations Division (EXTlE), _and financial sustajiwbility_ at al stages of a project. was recently formed and will seek to determine<sup>more</sup> One way to do this is through a long-run, programprecisely when participation is worth the effort<sup>and</sup> natic approach th,at encompasses aseries<sup>of projects,</sup> how the Bank and borrowing governments<sup>can</sup> each with its own modest, strategic objectives.<sup>Other</sup> effectively enoourage particpatory Bank<sup>projects.</sup> ways are to use PER/PIRs as a<sup>stratcgic planing</sup> Among the twexty projes this group<sup>will study is</sup> tool (see Poverty Handbook"11 for useful guidelines) the Guinea Population and Health project (FY88), and to give more attention to post-completion<sup>a project in which community involvement bas had</sup> sustainability in project design and supervision<sup>high returns to date.</sup> missions.
PHN 1991 Sector Review 18 _L Improved pknWng and management of technical asslstance,_ with the full participation of the government right from the planning stage. A recently completed report by a Bankwlde task force on technical assistance presents recommendations that have great relevance to work in PHN.<sup>16</sup>

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

# 1. _Ovenriw_

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

3.32 Virtually all FY91 operations support _instiutional development_ and improvements in _management_ capacity. A predominant feature of such assistance is support of decentralization policy in the PHN sector by strengthening lower-level planning, decision-making, and financial management; encouraging community participatlon; and redefining and limiting the role of central govermmenL Significant efforts have been made to involve NOOs and communities in the design and implementation of operations, although less so at the design stage than during implementation. Some operations also made a modest effort to explore the role of the private sector in the PHN sectors. The Korea Health lbchnology project is unique in this regard as the first IBRD operation in which 100 percent of the loan proceeds will be on-lent to the private sector (hospitals). There were noteworthy efforts to develop national capacity in infolknation collection and analysis, including research and monitoring and evaluation activity, which have been somewhat neglected in the past (El Salvador, India, Indonesia, Mali, Pakistan, Zaire, and Zambia, to name a few). Also, improvements are evident in the Bank's PHN support to human resources management: many components aimed at improving staff performance are more comprehensive than they have been in the past, including not only training (pre-service and inservice) and supervision, but also assistance to establish or improve operational guidelines, job descriptions, 'operational norms, re-deployment schemes, manpower planning, recruitment practices, and greater and more thoughtful attention to incentives.
19 PHN 1991 Sector Review

# 2. _InovadveCa2dM et f gOadojt_

# _a. Sector Fuds_

3.33 One-quarter of PHN operations approved<sup>this</sup> year were designed as social funds (see lTxt<sup>Table 2),</sup> which finance subprojects prepared and implemented by decentralized institutions and agencies<sup>represent-</sup> ing local populations and sometimes by the<sup>local</sup> populations themselves. Of the seven projects, three are in Africa, two in LAC, and one each in Asia<sup>and</sup> EMENA. The design of these projects draws<sup>heavily</sup> on the successful experience of the Bolivia Emergency Social Fund, one of the first funds of this<sup>type</sup> to be designed and implemented as a Bank operation, and on guidelines prepared by AFMSP'<sup>2</sup> , derived from Bank xperience with this relatively<sup>new ap-</sup> proach to socal sector lending.

3.34 Sector hfnds were found to be quite responsive to the lessons presented in Section B of<sup>this</sup> chapter. These funds are intended to support<sup>grass-</sup> roots activities for social seor developmen4<sup>particu-</sup> larly those benefiting poor and vulnerable<sup>groups.</sup> These projects foster institutional pluralism,<sup>decen-</sup> taliztion, and community participation by giving local- level entities--local govermnents, private sector groups, NGOs, community organizations-responsibility for assessing and articulating the social<sup>sector</sup> needs of poor local populations and for designing and implementing projects and ensuring their sustainability.

_3.35_ Sector funds increase the probability<sup>that</sup> subprojects are socally and culturally appropriate, provide opportunities for experimentation<sup>and learn-</sup> ing (with a view to extending successful initiatives nationally), promote community participation, support intersectoral coordination, and favor simplicity in subproject design. All but one of these projects include significant support for improving national capacity in the collection, analysis, and use of information for sector policy analysis, including operational research, surveys, beneficiary assessment, targeting methodologies, and monitoring and evaluation. Furthermore, subproject proposals are likely<sup>to</sup> provide government with rich information and insight on the social sector needs of various groups, which may influence social sector strategy.

3.36 Not all seven projes are allke. Only<sup>two of</sup> them (Nigeria ! icalth Fund and Nigeria Population) focus solely on the PHN sectors, and<sup>are imple-</sup> mented by line ministries. The remaining Eve<sup>are</sup> multisectoral and coordinated through oental (primarily finance) ministries. Five projects finance subprojects on a grant basis; one (Nigeria<sup>Health</sup> fund) onlends funds to states with the involvement<sup>of</sup> financial intermediaries for the purpose<sup>of whole-</sup> saling Bank health asslstance; and the Sri Lanka<sup>fund</sup> provides for both onlending for small credit opcrations and grants for the financing of subprojects.<sup>By</sup> combining immediate and direct assistance<sup>to the</sup> poor with efforts to build information and capacity for policy analyis, these projects are able to focus<sup>on</sup> both discrete short-term needs and equally important longer-term needL 3.37 Most of these projects support an agency<sup>--</sup> usually also created under the project - to manage and administer activities. lhese agencies are<sup>usually</sup> semi-autonomous and report to central ministries; their coordination with line ministries<sup>varies 'y</sup> project. With the exption of the Honduras<sup>project,</sup> whose fund agency has an explicitly defined<sup>three-</sup> year life, it is not clear whether or when other<sup>fund</sup> agencies might be disbanded and, if so, how activities would be sustained institutionally. Tb attract<sup>high-</sup> quality staff, many of these agencies are<sup>exempted</sup> from civil service rules and regulations,<sup>and their</sup> salaries are competitive That means that an eventual transfer of their responsibilities to the government would pose a dilemma that would be difficult<sup>to re-</sup> solve.

# b. _Social Sector Operatons_

3.38 The ten social sector projects, which<sup>comprise</sup> one-third of this year's portfolio of operations (see text Mbble 2) and which, incidentally, include a few sector fund operations, descrbed above, are more comprehensive in their approach to poverty alieviation and institution building than projects focusing exclusively on **thi** PHN sector. These projects support the refinement and implementation<sup>of</sup> integrated social sector policy. Because the; are multisectoral, they are coordinated through<sup>a central</sup> ministry (usually finance, or planning) that is strengthened to enable it to collect, use and analyze integrated and appropriate social sector information;
PEN 1991 Sector Review 20 formulate policy, and coordinate activities among sectors.

3.39 As opposed to 'pure' PHN operations, the majority of which are managed by one line ministry, social sector operations take a more holistic approach to poverty alleviation, which facilitates coordination and collaboration among the line ministries responsible for various aspects of social sector activity. Such operations also encourage greater economy and coherence in social sector investment by consolidating and rationalizing activities in information collection and analysis, and in the development and implementation of policies, programs and institutional reforms, such as redefining the roles of government (central and local), NGOs, the private sector, and communities in social sector activity. Because these operations are coordinated by a central ministry, they generally have high visibility and strong political support -- conditions that can be difficult to achieve and that make a large contribution to project success and sustainability. Strong political support is also likely to facilitate a reallocation of public resources to the social sectors and, within social sectors, to basic services serving the poor and vulnerable groups. Management arrangements for these projects are designed to foster good intersectoral coordination and oversight, with an emphasis on using existing units to implement them: while the projects are coordinated by central ministries, activities are implemented by line ministries.

3.40 The Venezuela and Zaire projects provide good examples of well designed social sector operations. The Venezuela project will assist the government to implement its Social Sectors Action Program, which shows a strong commitment to poverty alleviation. The program seeks to expand the national capacity to design, plan, implement, and monitor social programs and to develop a social sector strategy that will redirect social expenditures into well targeted and efficient programs. A presidential committee for poverty alleviation, with representatives of the ministries and institutions involved in social sector plaaning and a Fund for Social Investment, modeled after the sector funds described above, provide for intersectoral coordination and institutional pluralism. The Zaire Social Sector project will support social sector reform by increasing and carefully monitoring budgetary allocations to primary health care and education, rationalizing the roles of government and nongovernmental institutions in social services financing and delivery, and providing an adequate framework and data base for larger investments in the social sectors. It will also fill some of the basic PHN needs of disadvantaged population groups.

# _c. Sector Adjustment Operation_

3.41 The lbgo Population and Health Sector Adjustment operation is ihe first and only one of its kind in the PHN sector. It will support a comprehensive package of sector policy reforms that emphasize basic health and family planning services, panicularly for poor and vulnerable groups (underserved rural areas and women and children). Through balance of payments support that will be released in three tranches upon satisfactory completion of a series of reform measures, this project will support improvements in sector planning and management of sector resources; institutional reform, including beneficiary participation in the management of services; and increased resource mobilization through cost recovery.

# _d Emergency Recovery Operation_

3.42 The Yemen Emergency Recovery project, the only one of its kind this year, was put together rapidly to address the social services needs of migrants returning to Yemen because of the recent Gulf crisis. While the Bank has an ongoing dialogue with Yemen on medium-term economic planning and policy formulation, this operation is an emergency one only and does not address long-term social sector issues.

# _3. Issues_

3.43 As the focus of PHN operations has rapidly evolved away from the well defined investment project towards the broader support of national policies and programs, the importance and complexity of institutional and organizational issues which need to be addressed have increased. Consequently, PHN operations require increasingly greater attention to sector- or subsector-level institutions and their structures and functions, as opposed to the project implementation unit (PIU) only. While
21 PHN 1991 Sector Review attention to these issues in most PHN operations has broadened in sope sufficiently, the quality and depth of institutional development work in the sector could benefit from further improvement. A review of the sector analyses contained in the SARs for each of the 28 operations approved during FY91 reveals that, in some cases, institutional assessments were not undertaken fully adequately as a part of upstream sector or project identification work. In some SARs, the treatment of institutions and organizations is more descriptive than analytical. Sustainability and long term strengthening of sector-wide institutions are not always sufficiently addressed. Sometimes overlooked are: institutional alternatives for service delivery and for IEC activities, the incentive framework for long-term organizational performance and interorganizational collaboration and issues of leadership and stakeholder support, aU of which are essential for sustainability. Yet _all_ 28 projects in their "benefits and risks" sections note that weak institutional and managerial capacity constitutes the greatest risk to project success and sustainabUity. The constraints to improving PHN treatment of management and institutional issues are as follows:

## c. _Lack of Thme_

3.46 Detailed attention to institutional and management issues takes time and competes with other rigorous input requirements for lending, supervision and sector work, all of which have very tight coefficients and which are closely monitored by management.

3.47 Chapter IV includes some suggestions on how these constraints might be alleviated.

# _a. Number and Skills Mix of PHII Staff_

3.44 The growth in PHN staff over the last five years has not kept pace with the dramatic growth in PHN operations, documented in Chapter II of this report. Furthermore, as the scope and complexity of institutional/managerial issues continue to grow, so will the need for management specialists working on the PHN sector. A review of the composition of preapprai-al and appraisal missions for the FY91approved operations reveals a deficiency in management and institutional development expertise.

## _b. Absence of Standards and Guidelrnes_

3.45 There are currently no official standards or guidelines in the Bank for analyzing and addressing institutional/organizational and management issues in the PHN sector, which could guide task managers in undertaking such work and Bank management in monitoring and evaluating it.
# CHAPTER **IV. PROSPECTUS**

### A. Future Work Portfolio

4.1 The future lending program looks sttong. The very dramatic increase in the program size achieved in FY91 will be followed by a decline in FY92 in the number of projects and the volume of lending; these levels, however, still exceed those achieved in FY90, both in terms of the number of operations and the volume of lending. Furthermore, continued growth is projected for FY93 and FY94. The largest number of projects in FY92 is planned for Africa, though well over half of the financial commitments will be made to Asia.

a more rigorous review of institutional development work; (3) expanding the role of Country Operations Divisions (CODs) in developing a macroeconomic and multi-sectoral policy framework and a strategy for poverty alleviation and institution-building, within which PLIN policies and strategies would be refined and implemented; and (4) making more creative use of Bank instruments and leverage.

1. _Exangin Bank Epetise in Institutional Development_

## _a. Improving Capacity of Existing Sector Staff_

4.2 The sector work program is expected to continue at the same level over the next two years, with work on just over thirty studies planned annually. The Africa region is the most heavily engaged in sector studies.

### B. Conclusions and Recommendations

4.3 While the FY91 portfolo of PHN projects pays great attention to poverty and institutional issues-many with ingenuity and creativity--it stil reveals some variance in the depth, breadth, and quality of PHN analysis and interventions aimed at strengthening institutions and management capacity. The notably increased policy orientation of PHN operations is not always accompanied by fully adequate capacity building efforts to permit national institutions to assume responsibilities and implement activities generated by such operations. Chapter III has distilled a wide array of documented experience and wisdoLl in the Bank into a matrix of lessons or principles, which give direction in this regard. The quality and effectiveness of Bank efforts to strengthen institutions, particularly with a view to facilitating the achievement of poverty-alleviation objectives, can and should be further improved. Ways to achieve this include (i) expanding the Bank's expertise in management and institutional development in divisions responsible for the PHN sector, (2) strengthening the commitment to institutional development work by Bank senior management, as manifested in a reallocation of resources and a reorientation of incentives, which would support high-quality institutional development work, and in 4.4 For several reasons, lessons learned during project implementation are not applied as effectively as they could be in new operations and sector work This occurs most notably because of Bank incentive systems, which favor lending work and so limit somewhat the time and attention given to supervision work and PCRs, and because of inadequate assessment and dissemination of best practices. PHN staff need more access to guidelines, tools, methodologies, and training, drawn from experience and from state-of-the-art technology inside and outside of the Bank, for further improving the quality of their work. While the Bank has produced materials and guidelines documenting useful lessons and offering tools - and guidelines many of which were referred to in this report - such efforts need to increase. The demand in Operations for such material needs to be better articulated, while the collection, adaptation, creation, and dissemination of such material is a responsibility of both the technical departments and PHRHN.

_4.5_ Documented experience clearly highlights the important contnbution to project success and sustainability of Bank staff posted in the field. Management should therefore seriously consider allocation of additional PHN staff to field posts. b. _Increasing Use of In-House Management and Institutional Development E&pertise_ 4.6 Task managers should be encouraged to draw on expert resources elsewhere within the Bank to advise on or undertake the required institutional
PHN 1991 Sector Review analysis and the design of institutional development strategies and components. The Africa and LAC regions have divisions in their technical departments fer Institutional development and management, and for public sector management, respectively, that provide such support, although resources devoted to sector operating division are limited.

# _c. Increasing Use of Consultants_

4.7 A review of the composition of preparation, preappraisal, and appraisal missions for FY91- approved operations revealed that, in some projects, expertise in management and institutional development was under-represented relative to their prominence in the projects. Sector operations divisions may wish to consider supplementing missions with experts in the management field, which would not only benefit the project, but would also provide onthe-job training for Bank staff working with that expert. PHRHN and technical departments could facilitate this process by compiling and disseminating rosters of qualified consultants.

- _d. Increasing Instditional Development Epertise in Divisions Responsible for PHN Sector_

4.8 There are relatively few management and institutional development specialists among aU PHN staff in the Bank PHN's increasing focus on policy anci institutional issues caUs for reexamination of the skills mix of PHN staff with a view to increasing the proportion of institutional development specialists working in the sector. The shortage of such expertise in all SOD divisions (and not just PHN, in particular) was identified as a constraint in the Bank's capacity to support its overall development objectives, at a recent Bank symposium on public sector management, held in early September of 1991 and attended by staff from a large cross-section of divisions (TDs, SODs, CODs, PRE). Diversifying the skills mix in those divisions by recruiting institutional development specialists was strongly recommended.

## 2. _Chanl= hfores and Pracdces in the Bank_

4.9 This report recommends several changes in priorities and practices in the Bank, which would support high-quality institutional development work:

- a. OED has clearly demonstrated the key role of supervision for successful institutional development and project sustainability. Discussions with Bank staff reveal agrowing concem that a casualty of the tightening of supervision coefficients may be poor performance of institutions. Sector operations divisions could make more economical use of scarce resources devoted to supervision, by focusing more on key issues affecting institutions and management and by using the most appropriate and qualified expertise. In addition, the low level of supervision coefficients in the PHN sector needs to be addressed by senior management: this Issue wil surely be raised again in the ARIS. With the changing nature of PHN projects, which are increasingly more policy and institution oriented and which pass on more responsibility to government, and the even stronger emphasis on reaching the poor, whose administrative and implementation capabilities are generally weak, the nature and extent of supervision requirements need to be redefined and given due priority and resources.

- b. The importance of upstream diagnostic work has been repeatedly emphasized in numerous review documents, including some PHN PCRs produced this year. Yet some of the Baks sector work and project preparation does not include sufficiently in-depth institutional analysis. Even with a no-growth budget, more resources must be allocated to such upstream work, which, if wel done, will lead to greater efficiency in lending and supervision work.

- c. The discipline of systematic institutional analysis wiUl become Bank practice only when senior managers seek evidence of such analysis whenever institutional development designs or reforms are proposed in projects. Bank management should evaluate more rigorously

' The essence of these recommendations is drawn from Working Paper Series No. 392, 'Institutional Development in World Bank Projects: A Cross Sectoral Review', by Samuel Paul and has been greatly substantiated by the findings of this review.
25 PHN 1991 Sector Review lending and sector work with respect to: the objectives and scope of the analysis, elements of the institutional development issues investigated, the extent of borrower involvement in the diagnosis, the analysis of interest groups (including beneficiaries) and 'weir likely impact, and the quality and commitment of the local leadership.

# _3. Expanding the Role of Country Operations Divisions_

4.10 The full potential of PHN policies and interventions to contribute to institution building and poverty alleviation can be realized only when policies are grounded in a macroeconomic and multisectoral policy framework oriented towards growth with poverty reduction, accompanied by a sound strategy for building institutions and the capacity to manage and implement policy. That means that country operations divisions have a critical role in assisting key national decision-makers to understand and internalize poverty alleviation and institution-building objectives and to plan and prioritize sector interventions and allocate resources accordingly. Currently, however, macroeconomic and multisectoral policy dialogue is not always fully coordinated to facilitate the development of an efficient and comprehensive strategy for poverty alleviation or for institution building.

4.11 Thanks to the impact of the 1990 WDR on poverty followed by the "Poverty Handbook," attention to the poverty issue continues to grow. The "Poverty Handbook" is rich in information and guidance on how to analyze and measure poverty, and how to design country assistance strategies. It is likely to have strong, positive impact on those aspects of a poverty strategy. Over and above all of this, however, remains the need for greater country operations divisions'attention to institutional issues. Cnuntry operations divisions, in partnership with public sector management divisions where they exist, could play a major role in analyzing institutional issues in depth. They could also provide valuable assistance in developing strategies for strengthening institutions and management capacity as an integral part of macroeconomic and multisectoral policy analysis and dialogue, in order to identify and address constraints to sustainable implementation of national policy. Resident mission staff, as an extension of country operations divisions, could also make a valuable contribution in this area and their roles and responsibilities should be reviewed with a view toward increasing time spent on institutional issues.

# 4. _Making Creative Use of Bank Instruments and Resources_

4.12 With the rapidly changing nature of PHN - operations over the recent past more policy based, more integration of social sectors, more flexible financing mechanisms, delegation of more design and implementation responsibilities to countries, greater community involvement -- the way lending instruments are used might usefully change as well. Thus it may be useful to review the nature and features of the various lending instruments available, focusing on their strengths and weaknesses in addressing various PHN sector interventions in different political and economic settings.

4.13 Significant effort has been made to increase the use of qualified local consultants in all aspects of the Bank's work on the PHN sector. Their knowledge of the socioeconomic and cultural dimensions of the sector is particularly valuable when applied to managementand institutional issues and to community involvement in PHN activity. But more information is needed about the availability of local expertise at the regional and national levels. Tbchnical departments should develop reliable rosters of regional and national experts, perhaps through occasional missions to identify and assess such individuals and institutions. They should also set up closer ties with the various capacity-building efforts being undertaken within and outside the Bank, and the PHN sectors. Thist funds should be further exploited to finance such assistance, when appropriate. Even though some of these local resources may be fully quaUfied, Bank staff may hesitate to spend scarce budget resources on people with no Bank experience, given the enormous pressures they are under. A special fund using administrative budget or other resources, could be created to cover the costs of well-designed and clearly defined short- or medium-term "internships" for lhird World experts, who have never worked with the Bank and who need a chance to become familiar with Bank procedures and to demonstrate their expertise.
PHN 1991 Sector Review 26 4.14 Finally, with the exception of<sup>the notable</sup> efforts of EDI, the country-based orientation of<sup>Bantk</sup> assistance tends to constrain opportunities<sup>for the</sup> exchange of experience and idea _among_<sup>developing</sup> countries, a significant potential stimulus<sup>to learning</sup> and development. The Populadon<sup>and Human</sup> Resorrces Operations Division of the<sup>East Africa</sup> Department (AF2PH) has initiated<sup>such activities</sup> during FY91 through specilly designed<sup>sector work,</sup> which permits a number of countries in<sup>the region to</sup> analyze, compare, and improve their<sup>capacities In</sup> policy analysis, management and implementation. 'he Safe Motherhood initiative<sup>in francophone</sup> Africa has recently establisied a network<sup>of experts</sup> from the region to promote needed improvements<sup>in</sup> the region at the policy and program leve.<sup>These</sup> initiatives should be monitored, and the<sup>successful</sup> ones should eventually be replicated in<sup>other depart-</sup> ments and regions. Other ways of supporting<sup>com-</sup> munication, learning, and collaboration<sup>among</sup> developing countries should also be explored.

# _5. t0e Recmme_daqMns_

4.15 The subsector classification of PHR<sup>projects</sup> needs to be revisited to accommodate the<sup>changing</sup> composition of the PHN project portfolio<sup>-especial-</sup> ly its marked increase in social sector<sup>projects that</sup> encompass PHN, educadon and employment<sup>and</sup> often other sectors as well.

4.16 Last years Annual Sector Review<sup>recommend-</sup> ed that PHRHN intensify its effort<sup>to improve</sup> processes and systems for the collection<sup>and analysis</sup> of information on the Bank's PHN work<sup>portfolio.</sup> During FY91, a PHR sectoral information<sup>feature</sup> was set up on All-in-One that provides basic<sup>infor-</sup> mation on PHN and education lending<sup>and super-</sup> vision portfolios, drawn from the MIS.<sup>PHRHN is</sup> now embarldng on an information needs<sup>assessment,</sup> including a review of existing Information<sup>systems</sup> with a view to improving the availability<sup>and quality</sup> of essential information.
PHN 1991 Sector Review 27

# FOOTNOTES

1. World Bank. "Sustainabfluty of Projects: First Review of Experiene Report No. 571& (Operations Evaluation Department, Washington, D.C, June 14, 1985)

2. World Bank. Annual Review of Evaluation Results.- (Operarations Evaluation Department, Wbshington, D.C, October 30,1989) 3. World Bank 'IBRD and Bangladesh's Population Program." (Operations Evaluation Department, WVashington, D.C.

4. World Bank. 'IBRD and Indonesas Population Program.' (Operations Evaluation Department, VMshington, D.C.) _5._ World Bank. 'Population and the World Bank: A Review of Actives and Impacts from Eight Case Studles.' (Operations Evaluation Department, Vbshington, D.C, June 1991)

- 6 Berg, Alan. _ManuMlion J7a Can Be Done? Lessons fhm World Bank Eqiencwa_ (Baltimore, Maryland: Johns Hopkins University Press, 1987)

7. Economic Development Institute. _SwnheningLocalGovnment Sub.SaharanAfta_ Policy Seminr Report No. 21. (Wshington, D.C.: World Bank, December 1989) 8. Schacter, Mark 'Improving the Poverty Orientation of Public Expenditure: An Operational Approach.' (World Bank, Washington, D.C, June 1991) 9. Lmboray, J.L, and R. Nimi. 'he Health Center in Africa.' (AFIPN, World Bank, June 1991) 10. Paul, SamueL 'Institutional Development in World Bank Projects: A Cross-Sectoral Review.' World Bank Worldng Paper No. 392. (Washington, D.C, April 1990) 11. World Bank. 'Poverty Handbook. Working DrafL (August 4, 1991) 12. World Bank 'Socloeconomic Development FNads: A Guideline for Design and Implementation.! Social Dimensions of Adjustment Status Report and FY91 Work Plan. (Wshington, D.CC) 13. Heaver, Richard. 'Participatory Rural Appraisal: Potential Applicatons in Famlly Planning, Health and Nutrition Programs! (World Bank, Washington, D.C) 14. Slverman, Jerry M., and others. 'Action-Planning Workshops for Development Management Guidelines.' World Bank 'ibchnical Paper No. 56. (Washington, D.C, World Bank, December 1986) 15. Heaver, Richard. Using Field Visits to Improve Pamly Panning, Health and Nutrition Program Quality: A Supervisor's ManuaL' (World Bank, Washington, D.C, 1991) 16. World Bank 'Managing lbchnical Assistance in the 1990s.^ (rechnll Assistance Reviews lbsk Force, Wbshington, D.C, November 11, 1991)
# ANNEX 1. Statistical Annex
PHN 1991 Sector Review 31 Table 1: FY91 Population, Health and Nutrition Portfolio by Sectoral CoMposition (US$ mitlions)

|.....<br>......|.........<br>..............<br>....|.....<br>..|..............................|.....................................<br>PHN<br>,**.....**..........|Education<br>..........|Water<br>..........|Income Gen.<br>.... ..........|....................................<br>Infrastruct<br>................|.............................................................................<br>ure<br>Agriculture<br>..............<br>...............<br>.........|
|---|---|---|---|---|---|---|---|---|---|
|Country|Project|IBRD|IDA|S<br>X|S<br>X|S<br>X|S<br>X|S<br>X|S<br>X|
|**....** **.**..................................|................................................................||||...............................|......................................||||
|AFRICA||||||||||
|Ghana|Health&Population II||27.0|27.0 100.0||||||
|Madagasca|r Nat. Health Sector||31.0|31.0 100.0||||||
|Nalawi|PHN Sector Credit||55.5|55.5 100.0||||||
|Met|Health/Poputation/Rura|l|26.6|20.3 76.4||6.3 23.7||||
|Nigeria|Health Fund|70.0||70.0 100.0||||||
|Nigeria|Population||78.5|78.5100.0||||||
|Rwanda|Poputation||19.6|19.6 100.0||||||
|Senegat|Human Res I (Pop./Hea.)||35.0|35.0 100.0||||||
|Togo|Population/Health Ad.||14.2|14.2 100.0||||||
|*Zaire|Social Sector Proj.||30.4|30.4 100.0||||||
|Za bia|Social Recovery Proj.||20.0|11.7 58.5|4.6 23.0|||3.7 18.5||
|Zimbabwe|Family Health II|25.0||25.0 100.0||||||
|ASIA||||||||||
|Bangladesh|Pop.&HealthIV||180.0|180.0 100.0||||||
|India|ICDS I (ORIS&ANOHR)|10.0|96.0|106.0 100.0||||||
|Indonesia|Population<br>V|104.0||104.0 100.0||||||
|Korea|Health<br>Tech 1|60.0||60.0 100.0||||||
|Sri Lanka|<br>Poverty Alleviation||57.5|10.5 18.3|||32.3 56.2|14.7 25.6||
|EMNENA||||||||||
|Aigeria|Pilot PIllic HeaLth|16.0||16.0 100.0||||||
|EgM t|Emergency Social Fund||140.0|9.7<br>6.9|3.3 2.4||57.0 40.7|70.0 50.0||
|Pakistan|Family Health||45.0|45.0 100.0||||||
|Tunisia|Hospital Ngt.&Fin.|30.0||30.0 100.0||||||
|Tunisia|Population<br>&Family|26.0||26.0 100.0||||||
|Yemen|Emergency Recovery Credit||33.0|0.0<br>0.0|9.4 28.5|||20.7 62.7|2.9<br>8.8|
|LAC||||||||||
|El Salvador|Social<br>Sec. RHB|26.0||10.8<br>41.5|15.2 58.5|||||
|Haiti|Economicand Social<br>Fund||11.3|7.7<br>67.9|2.5 22.1|||1.1 10.0||
|Honduras|Social Fund||20.0|13.5<br>67.5|6.5 i2.5|||||
|Mexico|Basic Health|180.0||180.0 100.0||||||
|Venezuela|Social<br>Devt.|100.0||82.8<br>82.8|17.2 17.2|||||
|Total||647.0|920.6|1300.2<br>82.9|58.7<br>3.7|6.3<br>0.4|89.3<br>**5.7**|110.2<br>7.0|2.9<br>0.2|
|Total<br>Lendin|g for PHN Sector|1|567.6|||||||

* This multisectoral project encompesses education, poticy, and plaming.
32 PHN 1991 Sector Review table 2t Prim"r Heath Care (PlC) Cffxnt of PUI Landino FY91 (USS ttIlIons)

|cCIWTRY|<br>PRWECT|Official<br>Total<br>PHII Lading|<br>Total_*Pure_<br>PHNI|1<br>Of Wlic<br>Mn-PN<br>|ht<br>C||_2_<br>Baelace<br>PNCCoorpnts|
|---|---|---|---|---|---|---|---|
|||*|S|**S**|X<br>D|e eription|s<br>S|
|AFRICA<br>||- --||||||
|aha<br>|He"ath&Populatlon If<br>|27.0<br>|2r.0<br>|0.0|0.01||27.0 100.0%|
|Nadagesar<br>|Nat. Health Sector<br>|31.0|31.0|0.0|0.0X||31.0 100.0%|
|alatwi<br>|PHI S etor Credit<br>|55.5<br>|55.5<br>|3.6<br>|6.9S<br>|3|51.7 93.1%|
|mali|Health/PopuolaetiVurat|26.6|20.3|0.9|4.2X|*|19.5 °5.8X|
|Nligaria<br>|Nealth<br>Pisi<br>|70.0|r0.0|0.0|0.0%||r0.0<br>100.0%|
|Migeria|Poputetion|r8.:|78.5|15.6|19.9%|4|62.9<br>80.1%|
|Rande|Population|19.6|19.6|1.0|5.13|4|18.6<br>94.9%|
|Sanet<br>|Hmum Rae I (Pop./mees.<br> <br>|35.0|35.0|4.5|12.9%|3. 4|30.5<br>87.13|
|Togo<br>|PopulatoinjNoa1th<br>Ad.<br> <br>|14.2<br>|14.2<br>|0.0<br>|0.ax<br>||16.2 100.0%|
|Zaire<br>|Soolet Sector<br>Project<br> <br>|30.4<br>|30.4<br>|4.6<br>|15.0x<br>|3.6|25.8<br>85.0%|
|Zmbia|Soclt<br>Recovery ProJect<br>|20.0|11.7|0.0|0.0%||11.)<br>100.0%|
|Zimb_bw|I<br>mlty<br>Heatth It|2z.0|25.0|0.0|0.0%||25.0 100.0o|
|Totat for|APRICA|432.8|418.2|30.4|7.3%||387.9<br>92.7%|
|ASIA||||||||
|engtednh<br>|Pop.&Heaoth IV<br>|180.0<br>|180.0<br>|1.6|_0.9%_|3|178.4<br>99.1%|
|Irdia<br>|IC0S I (OIlS&AHDHlt)<br>|106.0|106.0|2.5|2.4X|3|103.5<br>97.6s|
|IndloeSi<br>|POpulationV<br>|104.0<br>|104.0|0.0|0.0%||104.0 100.0%|
|Korea|Heatth Tech 1|60.0|60.0|30.0|50.0%|5|30.0<br>4 0%|
|Sri<br>Lanka|Poverty<br>Alleviation|5s.5|10.5|0.0|0.0%||10.5 100.0O|
|||**.........**......<br>.|.........<br>.|................|||.............|
|Totat for|ASIA|so5.5|460.5|34.1|7.4,||426.4<br>92.6X|
|Algeria<br>|Pltot<br>Pubtie H"alth<br> <br>|16.0|16.0|0.0|O.O%||16.0 1f4.0S|
|EgYt<br>|Ewrgecy<br>Social<br>Ftmd<br> <br>|140.0<br>|_9.7_|0.0|0.0%||9.7 100.0%|
|Pakistan<br>|Ftlly<br>Health<br>|45.0|45.0|0.0|0.0%||45.0 100.0%|
|Tulnsfe|Nospitat<br>1st._1_fin.|30.0|30.0|15.0|50.0X|5|15.0<br>50.0%|
|Tunaisi<br>|Population<br>&FPmty<br>|26.0|26.0|0.0|0.0%||26.0 100.0%|
|YeOM|_rgwncy_<br>RecovRryCredit|31.0|0.0|0.0|n.o||0.0<br>n.e.|
|<br>||**.........**......<br>.|.........<br>.|................|||.............|
|Total<br>for E|NEMA|250.0|126.7|15.0|11.8S||111.7<br>88.2%|
|LAC<br>|<br>|||||||
|El Salvador<br>|Socit<br>Se.<br>ORB<br> <br>|26.0|10.8|0.0|0.0%||10.8 100.0%|
|Haiti<br>|Economic<br>d_Social_<br>_Fwud_<br>|11.3|r.7|0.0|0.0%||7.7100.0%|
|_Hondures_<br>|SocaltFtad<br>|20.0|13.5|0.0|0.0%||13.5 100.0%|
|NeIxco|aiec Health|180.0|180.0|0.0|0.0%||160.0 100.0%|
|Vanuteual|Soclet<br>et.|100.0|82.8|0.0|0.0%||82.8 100.02|
||**..**|**.......**......<br>.|.......|...........|......||.............|
|||33S.3|294.8|0.0|0.0%||294.8 100.fO|
||Totat|1567.6|1300.2|79.5|6.1%||1220.Z<br>93.9%|
|Ttl<br>||||||||
|oa<br>PlC<br>**Total**Bank|Landin<br>for<br>FT9|1220.7<br>226855||||||
|<br>PHC&aS of|<br> <br> <br>Total<br>ank LewdIng|.<br>5.4%||||||

1 _Net_ of non-PHI caoneto (e.g. In eCation, infrartructure, agriculturetrural devviopfnt...) 2 **entc** support to the PNC cenaIt is broadly defined a ny eupport to faclitate the ipltemntation of nationt PNC polfcleo. Thia would Inctud institution an coaity bultding; support of nutrition activities; support of fily plamfnn earvice delivery end IEC; oed stranthening of referral hospitals in suport of PNC. 3 Iorn-health related MID 4 Non-4P related Population 5 Aseistance to Hospital Sector not difretty auortiv of PlC strategy.

6 Other
33 PHN 1991 Sector Review I ~~~.

.............................

TabLe 3: Poputation, Health and Nutrition Lendfig Volumn, FY80-91 Amount and Percent of Total PHN Sector Lending by Region (Commitment in USS millions)

|..........<br>|..........<br>|...........<br>||.........<br>Three<br>|....<br>year av<br>|..........<br>erage|..................<br>s|||.....................<br>............|....<br>...........|Percent<br>...............|....................................<br>age<br>change|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
||..........|..............|..........|..............|............|....-|||||FY80-|82<br>to|FY83-85<br>t|<br>o FY86-88<br>to|
||FY80|-82|FY83-8|5|FY86-|88|FY89-91|||FY83-|85|FY86-88|FY89-91|
|AFRIC|A<br>7.7||39.3||78.|0|248.|8||413.|0|98.3|219.0|
|ASIA|47.7||89.0||105.3||330.C|||86.7||18.4|713.3|
|EMENA|<br>4.3||26.7||4.|3|163.|0||515.|4|(83.8)|3,661.5|
|LAC|4.3||30.7||71.|7|275.2|||607.|7|133.7|284.0|
||.........||-----..--|...|.......||.........|||.......|.|.....<br>-------|...................|
|TOTAL|$64.0||$185.7||$259.|3|$1,017.|0||190.|1X|39.7%|<br>292.2X|
|||FY80|<br>||FY81|<br>||FY82|<br>||FY83|||
||||No. of|||No. of|||No. of|||No. of||
||S|X|ProJ.|$|%|Proj.|<br>$|X|Proj.|S|X|Proj.||
|AFRICA|<br>0.0|0.0|(0)|0.0|<br>0.0|(0)|23.0|63.9|<br>(1)|<br>22.0|18.|3 (2)||
|ASIA|143.0|100.|0(.J|0.0|<br>0.0|(0)|0.0|0.0|<br>(0)|<br>27.0|22.5|**_(",_**||
|EMENA|<br>0.0|0.0|(0)|13.0|100.|0 (1)|0.0|0.3|<br>(0)|<br>37.0|30.8|(3)||
|LAC|0.0|0.0|(0)|0.0|<br>0.0|(0)|13.0|36.1|<br>(1)|<br>34.0|28.3|(1)||
|TOTAL|143.0|100.|0 (4)|13.0|100.|0 (1)|36.0|100.0|(2)|<br>120.0|100.|0 (7)||
|||FY84|||FY85|||FY86|||FY87|||
||||No. of|||No. of|||No. of|||No. of||
||S|X|Proj.|S|X|Proj.|<br>S|X|ProJ.|$|X|Proj.||
|AFRICA|31.0|12.7|(3)|65.0|33.7|(3)|82.0|19.5|<br>(5)|<br>31.0|57.4|(4)||
|ASIA|155.0|63.5|(2)|85.0|44.0|(2)|242.0|57.6|<br>(4)|<br>0.0|0.0|(0)||
|EMENA|<br>0.0|0.0|(0)|43.0|22.3|(2)|0.0|0.0|<br>(0)|<br>13.0|24.1|(1)||
|LAC|58.0|23.8|(1)|0.0|<br>0.0|(0)|96.0|22.9|<br>(2)|<br>10.0|18.5|(1)||
|TOTAL|244.0|100.0|~6)|193.0|100.|0 (7)|420.0|100.0|(11)|<br>54.0|100.|0 (6)||
|||FY88|||FY89|||FY90|||FY91|||
||||No.of|||No. of|||No. of|||No. of||
||S|**_K_**<br>|Proj.|S|K|Proj.|<br>S|K|Proj.|S|K|Proj.||
|AFRICA|121.0|39.8|(5)|81.0|14.7|(4)|232.7|24.9|<br>(8)|<br>432.8|27.6|(12)||
|ASIA|74.0|24.3|(2)|290.0|52.7|(4)|192.5|20.6|<br>(2)|<br>507.5|32.4|(5)||
|ENENA|0.0|0.0|(0)|80.0|14.5|(2)|119.0|12.7|<br>(2)|<br>290.0|18.5|C6)||
|LAC|109.0|35.9|(1)|99.0|18.0|(1)|389.2|41.7|<br>(6)|337.3|21.5|(5)||
|TOTAL<br>...............|304.0<br>...............|100.0<br>...........|(8)<br>...............|550.0<br>..............|100.0<br>.............|(11)<br>...........|933.4|100.0|(18)|1567.6|100.0|(28)||
PHN 1991 Sector **Review** 34 Table 4: FY91-Approved PHN Projects: Funds Components (USS millions)

|Region/|||||Total|Percent<br>of|Regional<br>as<br>XTotal|
|---|---|---|---|---|---|---|---|
|Country|Project|Fund||Amount|proj. costs|proj. cost|s fund amount|
|AFRICA||||||||
|Ghana|Health&Pop. II|Prizes||1.0|<br>34.4|3.0||
|Malawi|PHN Sector Credit|Social<br>Programs<br>Support||4.9|74.3|6.6||
|Mali|Health/Pop/Rural|Population||4.9|61.4|8.0||
|Nigeria|Health Fund|Health<br>System||94.5|<br>94.5|100.0||
|Nigeria|Population|Pop. Activities/Research||85.6|<br>93.6|91.5||
|Zaire|Soc. Sec. Project|Pilot||1.0|<br>37.0|2.6||
|Zambia|Social<br>Recovery<br>Project|Cofmmunity<br>Initiatives||41.7|<br>45.8|91.1||
|||Total||233.7|||25.5|
|ASIA||||||||
|Banglade|sh<br>Pop.&Health IV|Developing<br>Innovative<br>Proj.||4.9|601.4|0.8||
|India|ICOS I (ORIS<br>&ANDHR)|Cofmunity<br>Mobilization||11.0|157.5|7.0||
|Sri Lanka|Poverty<br>Alleviation|Nutrition<br>Fund||14.2|85.0|16.7||
|||Rural Works Fund||16.3|85.0|19.2||
|||Human Resource<br>Dev. Fund||14.5|85.0|17.1||
|||Credit<br>Activities||35.0|85.0|41.2||
|||Subtotal|80.0||85.0|94.1||
|||Total||95.9|||10.5|
|EMENA||||||||
|Egypt|Emergency<br>Social<br>Fund|Municipal<br>Services||217.6|572.3|38.0||
|||Community<br>Development||36.9|572.3|6.4||
|||Enterprise<br>Development||109.5|572.3|19.1||
|||Labor Mobility||82.0|572.3|**14.3**||
|||Subtotal|446.0||572.3|77.9||
|Yemen|Emergency<br>Recovery<br>CredI|t<br>Expanding<br>Social Infrastruc|ture|32.2|<br>59.5|54.1||
|||Strengthening<br>Social<br>Servic|es|17.0|<br>59.5|28.6||
|||Supporting<br>Agricultural<br>Acti|vities|<br>9.7|59.5|I6.3||
|||Subtotal|58.9||59.5|99.0||
|||Total||504.9|||55.1|
|LAC||||||||
|Haiti|Economic and Social Fund|Health &Nutrition||10.4|23.6|**44.1**||
|/||Education||4.9|23.6|20.8||
|||Infrastructure||5.7|23.6|24.2||
|||Technical<br>Asst. to Particia|ting<br>Org.|<br>0.2|23.6|0.8||
|||Subtotal|21.2||23.6|89.8||
|Honduras|Social Fund|Social Investment||61.3|<br>68.0|90.1||
|||Total||82.5|||9.0|

45.7 917.0 2008.3
35 PHN 1991 Sector Reiew Table 5: Population, Health & Nutrition Sector Reports Completed by Region, FY82-91

||||N|umber|of Rep|orts|||||
|---|---|---|---|---|---|---|---|---|---|---|
||||||...|-----------|------------|------------|------------|------------------__-|
|Region|FY82|FY83|FY84|FY85|FY86|FY87|FY88|FY89|FY90|FY91|
||||||...|--**---------**|**------------**|**-----**-------|-----|__|
|AFRICA|5|6|8|8|6|4|7|9|15|12|
|ASIA|1|4|4|3|2|0|1|9|8|7|
|EMENA|0|0|5|1|1|1|2|5|5|6|
|LAC|0|3|3|2|4|2|6|6|4|8|
||||||...|________<br>.__|_______<br>________|____<br>________|________|____________|
|Total|6|13|20|14|13|7|16|29|32|33|

|...--------------------------------------------------------------------|
|---|
PHN 1991 Sector Revew 36

# **Table 6:** Population **Health &** Nutrition **Sector** Reports Completed in FY91

|Region/<br>Country|<br>Project<br>|Report<br>Date|Report<br>Color|Final|
|---|---|---|---|---|
|**MFRICA**|||||
|Cameroon|*Women in Development.|11/90<br>|Green|Yes|
|Kenya|*Human Resources: Improving<br>|6/91|Grey|Yes|
||the Quality and Access.||||
|Kenya<br>|*Food and Nutrition.<br>|3/91<br>|Grey|Yes|
|Malawi<br>Nigeria|Population Sector Study.<br>Implementing the National<br>Policy on Population.|6/91<br>12/90|Green<br>Yellow|No|
|Nigeria|<br>Strategy for Food & Nutrition<br>Security.|6/91|Grey|Yes|
|Sao Tome & Pr.|Human Resource Dev. Strategy.|6/91|White|No|
|Senegal|Women in Development.|6/91|White|No|
|Sudan|*Toward an Action Plan for<br>|9/90|Grey|Yes|
||Food Security.||||
|Tanzania|Women and Development.|10/90|Yellow|No|
|Zimbabwe<br>Regional|Strategy for Women in Dev.<br>Gestion du Secteur de la Sante<br>outils de Gestion des Programmes<br>Sectoriels.|3/91<br>6/91|Green<br>Green||
|ASIA|||||
|Indonesia|*The World Bank and Indonesia's<br> <br>|2/91|Grey|Yes|
||Pop.<br>Program.||||
|Indonesia<br>Lao PDR|<br><br>*Health Planning and Budgeting.<br>Population, Health & Nutrition.|1/91<br>11/90<br>|Red<br>White|Yes|
|Papua N.Guinea|Health & Pop. Roview.|2/91<br>|Grey|Yes|
|Papua N.Guinea|Management, Manpower, Money.|2/91|Grey|Yes|
|Papua N.Guinea*|Structural<br>Adj., Growth & Human<br>Resource Development|5/91|Grey||
|Philippines|New Direction in Family Planning.|6/91|Green||
|B4ENA|||||
|Egypt|Poverty Alleviation and Adj.|6/90|Green||
|Maghreb|Demographic Challenge to<br>|8/90|Green||
||Sustainable Econ. Development.||||
|Poland|Health System Reform.|3/91|Green||
|Romania|<br>Accelerating the Transition:<br>Human Resource Strategies for<br>|7/91|Green|No|
||the 1990s.||||
|Saudi Arabia|<br>*Review of Roles, Functions and<br>Operations of the Ministry<br>of Health.|4/91|Yellow||
|Turkey|Issues and Options in Health<br>Financing.|9/90|Grey|Yes|
PHN 1991 Sector Review 37

# Table 6: (continued)

|Region/<br>Country|Projoet|Report<br>Date|Report<br>Color|Final|
|---|---|---|---|---|
|_TAC_<br>Brazil<br>Brazil<br>Costa Rica<br>Ecuador|Addressing Nutritional Problems.<br>New Challenge of Adult Health.<br>Public Sector Social Spending.<br>*Social Sector Strategy for<br>the Nineties.|11/90<br>8/90<br>10/90<br>11/90|Green<br>Red<br>Grey<br>Grey|Yes<br>Yes|
|Honduras<br>Mexico<br>Uruguay|Social Sector Programs.<br>Nutrition Sector Memorandum.<br>Population, Health & Nutrition.|2/90<br>8/90|Grey<br>White<br>White|No<br>No|
|Regional|Food&Nutrition Programs.|4/91|Yellow||

* PHN reports completed outside of PHR divisions.
38 PHN 1991 Setr Review

|**Table**<br>**71**<br>**Opera**|**tions**<br>**3valuation**<br>**Departaent**<br>**RePorts**<br>OR**PIE**|**Sector,**<br>fY91|
|---|---|---|
|**Region/**<br>**country**|**Project**|**Date**|
||proisat omnletion**LRenot.**||
|Malawi|Health Project.|12/28/90|
|Pakistan<br>India<br>Indonesia|Population Project.<br>Tamil Nadu Integrated Nutrition Project.<br>Provincial Health Project.|12/28/90<br>12/28/90<br>11/16/90|
|Tunisia<br>Yemen|Health & Population Project.<br>First Health Project.|10/11/90<br>12/28/90|
||Audit Renorts||
|Philippines|Second Population Project.|3/11/91|
||**country**<br>**2alaific Seotoral**Reviev||
|Bangladesh<br>Indonesia|IBRD & Bangladesh's Population Program<br>IBRD & Indonesia's Population Program|2/13/91<br>6/28/91|
||cast<br>4ta{1fit||
|Multi-Country|Population and the World Bank: A Review of<br>Activities and Impacts from Eight Case Stud|6/11/91<br>ies.|
39 PHN 1991 Sector Review Table 8: Lending for Population Projects and Components<sup>by Region, FY 86-91</sup>

|||No. of|No. with|Total PHN<br>|Population<br>|Population<br>|
|---|---|---|---|---|---|---|
|Fiscal||PHN<br>|population<br>|lending<br>|lending<br>|lending<br>|
|year|Region|Projects|component/a|($ million)|**($**million)|% of PHN|
|1986|AFRICA|5|5|81.1|9.7<br>|12<br>|
||ASIA|4|2|242.4|129.0|53|
||EMENA|0|-|-|||
||LAC|2|1|96.0|0.3|-|
||Subtotal|11|8|419.5|139.0|65|
|1987|AFRICA|4|4|30.8|7.9|26|
||ASIA|0|-|-|-|-|
||EMENA|1|0|-|-|-<br>|
||LAC|1|1|10.0|6.8|68|
||Subtotal|6|5|40.8|14.7|36|
|---------------|---------------------------------|---------------------||||__------__|
|1988|AFRICA|5|3|121.4|19.9|16<br>|
||ASIA|2|2|74.5|62.3|84|
||EMENA|0|-|-|-|-|
||LAC|1|0|109.0|-|-|
||Subtotal|8|5|304.9|82.8|27|
|---------------|---------------------------------|---------------------||||__------__|
|1989|AFRICA|4|2|81.3|0.4|.5|
||ASIA|4|1|290.0|24.6|9|
||EMENA|2|1|79.5|0.4|.5|
||LAC|1|-|99.0|-|-|
||Subtotal|11|4|549.8|25.4|23|
|1990|AFRICA|4|3|232.7|45.7|20|
||ASIA|2|1|192.5|96.7|50|
||EMENA|2|2|119.0|11.9|10<br>|
||LAC|4|2|389.2|15.0|4|
||Subtotal|12|8|933.4|169.3|18|
|1991|AFRICA|12|9|432.3|135.3|31|
||ASIA|5|2|507.5|163.5|33|
||EMENA|6|2|290.0|39.5|14|
||LAC|5|5|337.3|10.7|3|
||Subtotal|28|18|1567.6|351.0|22|

a. "Free-standing" population projects and PHN projects with population components.
40 PHN 1991 Sector Review Table 9: PHN Projects with Population Components, FY91 ($US millions)

|Region/<br>Country|Total Loan<br>Project Title<br>or Credit|Amount for<br>Population|
|---|---|---|
|AFRICA|||
|Ghana<br>|Health & Population II<br>$27.0<br>|$4.9|
|Mali|Health, Pop & Rural Water 11<br>26.6|3.0|
|Madagascar|National Health Sector<br>31.0|4.4|
|Malawi|Population, Health & Nutrition<br>55.5|5.8|
|Nigeria|National Population<br>78.5|78.5|
|Rwanda|First Population<br>19.6|19.6|
|Senegal|Human Resources Development 35.0|14.8|
|Togo|Pop & Health Sector Adjustment 14.2|4.3a|
|Zimbabwe|Family Health II<br>25.0|0 Ob|
|Total||135.3|
|ASIA|||
|Bangladesh|Fourth Population & Health<br>180.0|61.5|
|Indonesia|Population V<br>104.0|104.0|
|Total||165.5|
|EMENA|||
|Pakistan|Family Health<br>45.0|13.5a|
|Tunisia|Population & Family Health<br>26.0|26.0|
|Total||39.5|
|LAC|||
|El Salvador|Social Sector<br>26.0|1.5|
|Haiti|Economic & Social Fund<br>11.3|0.5|
|Honduras|Social Investment Fund<br>21.0|0.2|
|Mexico|Basic Health<br>181.0|3.5|
|Venezuela|Social Fund<br>100.0|50|
|Total||10.7|

Total Lending for Population 351.0

- a. These projects so thoroughly integrated population and health that it was impossible to derive a specific figure for population lending. Therefore, an arbitrary proportion of 30% for population was applied to each of these total loans or credits.

- b. No IBRD money went directly toward family planning in this project. However, co-financiers contributed $17.7 million toward family planning service delivery out of a total project cost of $116.9 million.
YHN 1991 Sector Review 41 lTble 10: Nutrition In Structural and Agricultural Adjustment Operations, FY91

|RegionlCountry|Operations||Nutrition Actions|
|---|---|---|---|
|AFRICA||||
|Burkina Faso|SAL I|-|Collect nutrition data to assist<br>in formulation of nutrition<br>policy.|
|Kenya|Agriculture SECAL|-<br>-|Prepare food security and<br>nutrition strategy.<br>*Adopta nutrition action<br>plan and implement nutrition<br>actions.|
|Rwanda|SAL I|-|Establish a Social Action<br>Fund and prepare FY92<br>Social Action Project,<br>including nutrition<br>components.|
|Tbnzania|Agriculture SECAL|-|Reduce price of food grains as<br>a poverty alleviation measure.|
|Togo|SAL IV|-|*Develop a nutrition action<br>plan.|
|||r-|Change agriculture policy to<br>encourage food crop<br>production for local<br>consumption.|
|Zambia<br>ASIA|Recovery Credit|-|Companion Social Recovery<br>Fund to compensate for<br>adjustment's negative impact<br>on nutrition.|
|Sri Lanka|Economic Restruct|-<br>-<br>-|*Restructure major poverty<br>alleviation programs: The<br>Mid-day meal, Food Stamp<br>and Jana Saviya (poverty<br>reduction -- includes<br>nutrition components)<br>programs.<br>Implement a food stamp<br>program for school children<br>of poor families instead of<br>providing meals to all<br>children.<br>Introduce operational<br>selection criteria to more<br>effectively target the Food<br>Stamp program to the poor<br>and increase the benefits to<br>those households.|
PHN 1991 Sector Review 42

# lTble 10: (continued)

|Region/Country|Operations|Nutrition Act|
|---|---|---|
|EMENA|||
|Egypt|SAL|Companion Social Fund to<br>compensate for adjustment's<br>negative impact on nutrition.|
|Poland<br>LAC|SAL I|-<br>Define health policy through<br>Implementation of studies of<br>food consumption and school<br>feedingprograms.|
|El Salvador|SAL I|-<br>Provide infant foods through<br>health posts; introduce a pilot<br>food coupon program and<br>implement a fortified biscuit<br>program for primary schools.<br>-<br>Establish a Social Investment<br>Fund.|
|Honduras|SAL II|-<br>Implement a food coupon<br>program.<br>-<br>*Agree on parameters for<br>measuring the effect of the<br>food program.|
|Mexico|Agriculture SECAL|-<br>Continue reform of food and<br>nutrition programs begun<br>under AGSAL L<br>Implement a pilot nutrition<br>and health project to evaluate<br>procedures, operational<br>viability and cost-effectiveness<br>of current nutrition and<br>health programs.<br>Use the results of the pilot<br>program to implement an<br>expanded national nutrition<br>and health program.<br>Continue to reduce<br>untargeted subsidies to urban<br>consumers and replace them<br>with targeted distnbution of<br>maize.<br>Present to the Bank an<br>evaluation of food and<br>nutrition programs and agree<br>with the Bank on general and<br>agency-specific action plans<br>for nutrition for 1993 to 1994.|

*Condition for tranche release.
43

**PHN** 1991 **Sector Review**

# **Figure 1:** PHN Projects **under** Supervision

<!-- Start of picture text --> ASIA 35%<br>1547.1 ~~~~~LAO 18%<br>AFRICA 46% 17<br>EMENA 15%<br>683.7<br>EMENA 14%<br>AFRICA 25% 14<br>L/ AC" 21092.7<br>LAO 25%<br>1120.2 ASIA 22%<br>21<br>Lending in Number of<br>US$ Millions Projects<br><!-- End of picture text --> .
44 PHN 1991 Sector Review Figure 2: Tot-l Project Resources for Nutrition in Bank-Asisted Operations, FYS1-91 <!-- Start of picture text --> US$ millions<br>500<br>450<br>400<br>350<br>300<br>250<br>200<br>150<br>100<br>50 _<br>81 82 83 84 85 86 87 88 89 90 91<br>Fiscal Year<br><!-- End of picture text --> Figure 3: The Bank's Nutrition Lending, FYS1-91 <!-- Start of picture text --> US$ millions<br>300<br>250<br>200<br>150,<br>100.<br>50<br>8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 0 9 1<br>Fiscal Year<br><!-- End of picture text --> _Tese_ figues ar lasedo an sm_ent of the total moure allocated to nutrition In nutdtin prject and nutrition ouponentm of proects desipated as PHN, _bealth,_ or populatin prc$eca, and education, food security and WID projectL They do not, bemuse of dffcties of quantlfication, Iclude structurl adjusment or agricultue sector autment pojL (For lstng the latter, see lbbl 12.) 7btal prect m o allocated to nuaition were estimated from cost tables in Staff Appmbial Reports or, In case whee thse wre not suficekntly detaied, they we upplied by the pec' task mamg. Bank nutrition klndig amounts are baed an a pmrated share of Bank fnancing of _eU_ prject se. If tbe nkloan comprbi SO pecent of the to poect and 15 percent o the prect b nutrtion, then l5 percent at the 50 peent b attributed to nutrition
PHN 1991 Sector Pv&w 45

# Figure 4: World Bank Lending for Population, FY80-91

## Millions of US$

<!-- Start of picture text --> 400<br>300-<br>200-<br>100<br>80 81 82 83 84 85 86 87 88 89 90 91<br>Fiscal Year<br><!-- End of picture text -->
_I_ I iI I i I I I ii i r iiiI

# ANNEX2

Uan and Credit Summaries of EY-91 - A-Dpmtd PHN **Opf** ns - ,ratio
**Loan and Credit Summaries of FY91-Approved PHN Operations'**

# **Africa Region**

# _Ghana - Second Health and Populaton Project_

The project will support the qualitative improvement, reform, and extension of coverage of the family planning and health services of the Mlnistry of Health and leading NGOs. Tle program in population will focus on institution building and on strengthening and expansion of family planning programs to Implement Ghana's long-standing populat.on policy-, In health it focuses on strengthening and expansion of primavy health care, procurement/supply, institutional development, manpower development and public expenditures. Project components are for: (a) drug and vaccine supply and drug infrastructure rehabilitation, (b) MOH institution-building, (c) supply, repair and maintenance of district hospital equipment, (d) population and family planning, (e) district-level primary health care, and (f) a prizes fund to provide incentives for better performar -e by health workers and health-promoting behavior by communities.

# _Madagascar - Health Sector Improvement Project_

The project would support the implementation of the government's Health Sector Program (HSP) over the period 1992-96, with objectives of: (a) reducing mortality and morbidity, (b) moderating fertility levels; and (c) improving the efficiency and sustainablity of public expenditures for health, the sector policy framework and institutional coordination mechanisms. By accelerating the integration of family planning services into the basic activities of the public health system, it would also contribute significantly to implementation of the National Population Law adopted in 1991.

The project would help finance: (a) delivery of comprehensive communicable disease programs to control malaria, tuberculosis, leprosy, sexually transmitted diseases (including AIDS), and the plague, and the establishment of a communicable disease monitoring system; (b) introduction/upgrading of family planning services as an integral component of maternal and child health care offered in at least 500 of MOH's clinics; (c) improved delivery of primaty health care services, iicluding reasonable access to essential drugs in all MIOH outpatient facilities; and (d) the first phase of a long term institutional development program to: (i) progressively restructure and strengthen the MOH's health delivery system to increase its efficiency and invite greater population/community participatihn; (ii) strengthen MOH's policy formulation and programming, monitoring and evaluation capacitr, and (iki) broaden the financing base and improve the sustainability of public health expenditures.

# _Malawi - Population, Health and Nutition Project_

The project's objectives are to improve quality, access, efficiency, and effectiveness in the sector through: (a) st.,ngthening of basic programs, focussing on primary health care, maternal and child health care, child spacing (family planning), malaria control, AIDS program, nutrition interventions, and women in development activities; (b) strengthening of support services, focussing on staffing issues, pharmaceuticals, and IEC5 (c) efficiency improvements, focussing on management strengthening, hospital decongestion, cost sharing, and budget reform; and (d) support to the Government's social dimensions of ,4justment initiative.

In line with these objectives, the project's component on strengthening of basic programs will include: (a) for primary health care and maternal and child health care, development and expansion of the

# These summaries are taken directly from the Staff Appraisal Reports.
_50_ PHN 1991 Sector Review Health Surveillance Assistants into outreach-oriented and village-based PHN promoters and service providers; rehabilitation and/or construction of rural health centers; provision of rural housing where needed to attract essential personnel; and provision of some vehicles to improve the effectiveness of district level services.; (b) for malaria, improvements in logistical support, in the supply of anti-malarial drugs, and in support for drug resistance monitoring, (c) for AIDS, acceleration of efforts in education and prevention campaigns and in acquisition of blood screening equipment; (d) for child spacing, launching of a Family Welfare Council to promote family planning and expansion of the MOH's program; (e) for women in development, institutional strengthening, upgrading of training activities, and testing of small scale demonstration projects on appropriate technology dissemination and credit provision; and (f) for nutrition, extension of a community-level food security approach developed and tested by UNICEF, and a micronutrient deficiency program. The component on strengthening of support services will include: (a) for staffing issues, upgrading of training programs and facilities for health cadres currently in critically short supply, and enhancement of personnel management information and planning capabilities; (b) for the IEC program, expanded activities for training health workers, and provision of resources for conveying population, health, and nutrition messages to communities; and (c) for pharmaceuticals, technical assistance and training on drug procurement, distribution and production, and improvement of facilities and equipment. The component on efficiency improvements will include: (a) rehabilitation of three urban health centers and construction of two others to shift more outpatient care away From the more costly and overcrowded hospitals, (b) rehabilitation of one district hospital, construction of another, and replacement of worn-out equipment in selected other hospitals; (c) introduction of reforms in patient fees; and (d) budget reforms involving increases in the MOH budget and the share of it devoted to outreach and peripheral health services. The component on the social dimensions of adjustment initiative will include support for a "social support program fund" to assist small z"ale pilot interventions derived from felt needs of communities and expressed through Government or NGO channels.

## **_Mali_** _- Second Health, Population and Rural Water Supply Project_

Through an integrated program of policy/institutional reforms and investments, the project will support the Government's efforts to improve the health status and well-being of the Malian population, notably women and children, implement its emerging population policy, and broaden access of deprived rural communities to health services and safe water.

lb attain these objectives, the project comprises three components. The health component will increav: the coverage and quality of health care: (a) directly in four Regions and the capital area of Mali throue,h the development of a decentralized, District-based health development program involving the construction/rehabilitation of primary and referral care centers, as well as active community, NGO and private sector participation; and (b) indirectly by improving the planning and management of the sector's personnel, physical asud financial resources as well as the provision of essential drugs. The population component will: (a) strengthen the institutions in charge of disseminatingrlimplementing the national population policy and of planning, managing and evaluating family planning (FP) programs; and (b) Increase the demand for, availability and quality of FP services nationwide. The rural water supply component will: (a) increase the supply of safe drinking water for the rural populztion in the project area; (b) support the Government's policy of community participatio& in the financial and technical management of rural water supply; and (c) implement an iodination program in areas where iodine deficiency is prevalent.

# _Ngia_ - _Health System FRnd Project_

The primary project objectives are to finance Improvements in State health systems by the establishment of a wholesaling mecWanism utilizing PFIs to appraise, supervise and co-finance State health
51 PHN 1991 Sector Review subprojects; and to assist the States in improving health system investment planning. The project comprises: (a) a line of credit, called the Health System Fund (HSF), for health subprojects in the various States to include one or more of the following components: (i) institutional development; (ii) strengthening of health services, including facility upgrading and new facilities; (iii) essential drug programs; (iv) strengthening of MCH/FP service delivery, (v) disease sufvelllance; (vi) information, education and communication programs; (vil) nutrition; (viii) promotion of non-governmental organizations (NGOs); and (ix) preparation work for future projects; (b) assistance to FMOH, for the strengthening of its Department of Planning, Research and Statistics, and the establishment of a management information system in FMOH; and (c) support to the State Ministries of Health by providing technical assistance and training.

# _Niria - National Population Project_

The overall objectives of the project are to strengthen the institutional framework and expand the experiential basis for undertaking a large-scale, intersectoral National Population Programme (NPP) over the coming uecades. Based on Nigeria's recently approved comprehensive National Population Policy, NPP is being developed under the leadership of the Department of Population Activities (DPA), which was established in FMOH in 1988. The project will assist Government in gradually evolving an effective strategy for the program by developing a mechanism for funding and evaluating subprojects that are designed and implemeated by a number of CAs in the public and private sectors. The project will consist of three basic elements. 7he first is the Population Activities Fund (PAF), which will provide grants to qualified CAs for subprojects they have prepared. Subprojects will fit within a rolling three-year work plan for NPP; detailed guidelines for subproject content are under preparation. Many of the subprojects will focus on increasing family plmnning (FP) practice through provision of services and intensive information/education/communication (IEC). Other subprojects will develop leadership commitment to NPP to help prepare CAs to provide support functions for NPP in planning, coordination, training, monitoring, evaluation, or research. It is anticipated that PAF will attract funds from other donors. Seven subprojects (Phase I Suibprojects), utilizing about 51% of the initial allocation for PAF, have already been jointly appraised by IDA and DPA. Second, the project will help develop a small PAF Agency (PAFA) that will manage PAF in cooperation with DPA. Jointly, PAPA and DPA will develop the capacity to assist CAs with preparation of additional subprojects (Phase II Subprojects) and to appraise and supervise thern. The third element of the project is designed to stimulate intensive analysis of socio-cultural constraints to fertility reduction, review relevant experiences from other countries, and design innovative interventions kir adoption by implementing CAs. It wIll take the form of support for the establishment and Implementation of the first stage of the Population Research Fund (PRF). PRF would be managed by NISER with guidance from several relevant groups including DPA and the National Population Commissifn (NPC), which is responsible for the census and demographic surveys.

# _Rwanda - FYrt Population Project_

The project will support the implementation of the National Population PolHcy and will contribute to: (a) reducing the total fertility rate (TFR); (b) improving maternal and child health (MCH); (c) integrating the demographic dimension in cross-sectoral development activities. These objectives will be reached by: (a) improving the quality and efficiency of Family Planning (FP) service delivery, (b) increasing demand for and access to FP services; (L) carrying out a set of population demand for and access to EP services; (c) carrying out a set of population studies and strengthening the FP information system; and (d) supporting multsectoral activities within the framework of the national population policy. Selected demographic targets for 1997 (last year of project implementation) include (figures for 1990 are in
PHN 1991 Sector Review 52 parenthesis): TFR at 7.2 (85); modern contraceptive prevalence rate (CPR) at 20.0 (9.0); and 276,000 FP users (100,000).

# _Senel - Population and Health_

The objectives of the proposed project are to support Government's efforts to: (i) control fertility and reduce the rate of population growth, through the implementation of a National Population Program; and (ii) restructure the health sector to enable It to provide basic health services of improved quality and wider accessibility, through the Implementation of its National Health Policy. lb achieve these objectives, the project would finance investments for (a) population to: (i) strengthen the National Rimily Planning Program; (ii) promote the status of women; (iii) sensitize youth on family welfare issues; and (iv) strengthen institutional capacity to promote the national population program; and (b) health to: (i) develop the district health system, including the promotion of community healt rganizations; (ii) promote the use and availability of essential drugs; and (iii) strengthen institutio.1<sup>il capacity in the health</sup> sector, with emphasis on manpower development, and budgeting and financial planning.

While the project is a specific investment operation, it will involve the adoption and implumentation of key policy measures in both the population and health sectors including: (i) liberalization of regulations on contraceptive distribution and use; (ii) adoption of organizational norms for the district health system, ensuring sufficient budgetary allocations, personnel re-deployment, and adoption of organizational and procedural guidelines for community health associations; and (iii) promotion of essential drugs.

## - _Tbgo  Population and Health Sector Adjusm Operation_

The credit would support the implementation of a comprehensive package of sector policy reforms ia the area of population and health aimed at assuring a satisfactory level of primary health care and family planning services to the population, especially in rural areas. It would address in the short to medium term, pervasive morbidity and mortality resulting from inadequate treatment and prevention of tropical communicable and parasitic diseases and would increase current use of family planning services among couples. The Credit weald help the Government achieve these results by providing balance of payment support; the resulting counterpart funds will be used over four years for: (a) instituting better sector planning; (b) reforming institutional deficiencies within MSP and at regional levels; (c) improving personnel and financial management in the sector, and (d) instituting cost recovery and improving beneficiary participation in management of services.

Specifically, reforms incorporated in the operation would effect a transformation of the Health Sector and the Government's population activities through policy measures geared to address prevailing key sector systemic constraints. It would: (i) launch the Government's new population policy by expanding family planning services, supporting NGO activities in family planning and creating greater awareness of availability and use of services; and (ii) reverse the deterioration in the quality of basic health care services and gradually increase their accessibility to the general population particularly in rural areas and for the most deprived groups. Specifically, the Program would: (a) integrate family planning into expanded primary health care activities; (b) strengthen institutional capabilities in: (,) planning and programming. (ii) budgeting, financial management and cost recovery, and (iii) sector coordination; (c) rehabilitate, reequip and provide adequate operating expenses for operating existing facilities, and (d) redeploy, train, and improve the productivity and efficiency of technical and management staff.
53 PHN 1991 Secor Review

# _Z&_ - _Social Sector Project_

(a) to protect vulnerable populaton groups from the adverse social effects of a deteriorating economic situation; (b) to maintain, in coUaboration with other donors, essential public health, nutrition and fmily planning programs; and (c) to prepare future projects and programs in the sodal sectors by developing new policies on women-in-development, population and environment, and by establishing a national capability for collecting and anabling soial indicators

# _Zambia - Social Recovey PNect_

lb fund community initiatives to help mitigate the negative effecs on the poor of the eownomic crisis. lb this end, the project will support the rehabilitation and improvement of eisting infrastructure and service delivery through the Micro-projects Unit in the Ministry of Finance. The project will strengthen communities' ability to improve their situation through self-help. Fnrther, the project wiU improve the information base and provide analyses to enhance the Government's planning and policy makdng in the social sectors.

## _Zimbabwe - Second Family Health Project_

The project will provide the required financial and human resources for most of the Covernment's five-year investment program (1992.96) for health/population/nutrition (H/P/N), and wil promote policy and institutional reforms, in order to: (a) improve maternal and chfld health and nutrition status; (b) reduce the rate of population growth; and (c) ensure that households in the 16 worst-served districts (40% of the population) have access to basic H/P/N services. lb achieve these objectives, the project will increase the output and effective utilization of trained Zimbabwean health, family planning, and nutrition workers; enhance MOH capacity to plan and manage H/P/N activities; and increase efficiency and mobilize additional resources.

'he project will support the following six components: (a) Famlly Planning; training, community outreach and static facility services, special youth services, EEC campaigns, evaluation and research, and better management; (b) Maternal and Child Health; midwifery training, maternity equipment, school health program, and operations research; (c) Nutrition; supplement^ary food production, growth monitoring, micro-nutrient supplementation, IEC, and training; (d) Rural Health Delivery: upgrading of 16 district hospitals and about 80 RHO, prvision of staff housing, ambulances and supervisory transport, medical equipment, and radio communication; (e) Health Manpower Development: institutional strengthening, curriculum reform, systems development and studies, and selective upgrading of training facilities; and (f) Health Management Strengthening: training and systems development in financial management, materials/equipment management, district-level informaton systems, and sector planning.

# Asia RegIon

# _Bw,#ad - Fouth Populadon and Health Project_

The project, which covers a flve-year time slice of GOB's development program in populadon and health (1991-96), has four main components: (a) strengthening FP service deliveiy, (b) strengthening health services deliery, and (c) improving supportive acivities to the deliery of FP and health services; and (d) women's and nutrition progmams. It will strengthen FP service delivery by improving access to FP services, strengthening MCH services, enhancing clinical servic- delivery and FP/MCH quality assurance, imparting in-service training of upazila and district staff in FP/MCH, construction and renovation of
PHN 1991 Sector Review 54 FP/MCH facilities, and marketing of contraceptives through the private sector. The project will strengthen health service delivery through increasing the range of maternal and neonatal health care, strengthening nursing and medical education, introducing medical quality assurance, supporting medical research, strengthening disease prevention and control, developing urban primary health care, continuing and expanding school health programs, improving district and upazila health facilities, and improving the utilization of Upazila Health Centers. In support of the first two components, the project will assist In strengthening information systems, improving FP and health management, expanding communications programs, supporting NGO activities, and developing innovative projects. Finally, the project will assist continuation of the three women's programs financed under the previous three projects and will strengthen and develop the national Nutrition Council, in anticipation of a substantial program of nutrition interventions.

# _India - Integrated Child Development Services Project_

The project would support the objective of the Central and Andhra Pradesh and Orissa state govermnents of improving the nutrition and health statuLs of children under 6 years of age, with special emphasis on those -3 years old, and pregnant and nursing women. Its specific objectives in project areas would be: (a) to reduce severe malnutrition in those children by 50% in both states; (b) in Andhra Pradesh to reduce moderate malnutrition and increase the proportion of those children in normal or only mild (Grade I) malnutrition status by 35% and help reduce the infant mortality rate (IMR) to 60 per 1,000 ihve births and the incidence of low birth weight (LBW) by 30%, and (c) in Orissa to reduce moderate malnutrition and increase the proportion of those children in normal or Grade I status by 25% and help reduce the IMR to 100 per 1,000 live births and LBW by 20%. The project would comprise the following components: (a) service delivery, to increase the range, coverage and quality of nutrition and health services to target groups through improvements in the design and implementation of software systems, training for health and nutrition workers, provision of nutrition and health education and health referral services, increasing the availability of drugs and equipment for maternal and child health and the supply o therapeutic supplementary food to malnourished beneficiaries, and construction of village nutrition centers, offices and residences for key field staff-, (b) communications to stimulate demand for project services and improve child feeding practices and care through production and dissemination of media messages, provision of equipment and materials and training, (c) community mobilization to increase local participation in and support for project services and activities through testing of innovative women's development activities including activation of village women's groups, development of income-generating activities, non-formal study courses for women and development of training programs for adolescent girls; and (d) project management and evaluation to manage, monitor and evaluate the project and conduct operations research to anabze and improve aspects of project design.

# _Indansia - Ffh Populaton Project (Family Planning and Safe Motherhood)_

The main objective of the project is to help the government intensify its efforts to lower fertility and maternal mortality during the 1990's. This would be achieved through two major parts: Part A to further strengthen the family planning program under the National Family Planning Coordinating Board (BKKBN) and Part B to assist the Ministry of Health (DEPKES) strengthening its policy and capacity to train and improve the availability and skills of midwives, designed to become a primary source of family planning and maternal and child health services at the village level. Through Part A, BKKBN would continue. to provide leadership to coordinating high quality family planning services using the public sector, non-governmental organizations (NGOs) and private providers, and it would extend the family planning program among hard-to-reach populations. lb accomplish these goals, Part A would have the following specific components: (a) lhrgeted Family Planning and Safe Motherhood promotion, intended to improve
PHN 1991 Sector Review _55_ the accessibility and utilization of services among the urban poor and populations in coastal and transmigration areas, promote family planning services in the organized sector and promote nationwide availabilitv of long lasting contraceptive methods including intra-uterine devices (IUDs), implant and sterilization services; (b) an IEC and Community Outreach would support improvements in BKKBN's IEC strategy and system capacity, promote participation of youth in family planning and activate new community groups in selected vilages; (c) Institutional Development would provide for staff development training activities and personnel policy changes to support BKKBN's family planning strategy, support reform and streisgthening of BKKBN's program monitoring, evaluation and research capacity and strengthen field operations through the provision of vehicles, equipment, contraceptives and other materials and remodeling of selected buildings. Part B would consist of three major components: (a) strengthening of a policy framework on the objectives and related training and planning principles that would govern the deployment of community midwives; (b) strengthening training capacity through training of trainers and improving teaching materials and equipment; and (c) supporting training and improvement of the effectiveness of about 16,000 community midwives, requiring improved certification and examination procedures for these workers and accreditation standards for nurse midwifery training schools. The project would also provide support to both BKKBN and DEPKES for costs related to Project Management including support for additional professional and administrative contract staff for the project duration in both agencies.

# _Korea - Health Technology Project_

Tne project would: (i) expand the diagnostic and treatment capabilities of NCD specialty units in large referral hospitals; (ii) replace and add biomedical equipment in hospitals located in large and medium-size cities and distribute it more equitably; and (iii) provide equipment to medium-size city hospitals designated as emergency centers in the national Emergency Medical Services network Agreed criteria would be strictly applied to the selection of participating hospitals and of equipment. The selection criteria for hospitals would consider the hospital's financial status, its location, its size, and the need for and potential efficient utilization of the requested equipment. The selection of the biomedical equipment would take into consideration the regional distribution among the eight medical regions, the relevance of equipment to medical needs, training of equipment users, availability of a recurrent cost budget for operating the equipment, and sharing of equipment by several facilities. The financing of high cost equipment would be excluded from the project, partly because there is an active leasing market for this type of equipment, and partly because some procedures are not reimbursable by the national insuranos and would therefore not be accessible to the poor.

Project implementation would be the responsibility of the Bureau of Medical Affairs in MOHSA. Independent review panels would be set ! ~ to select hospitals and equipment. MOHSA staff would receive training to manage the on-lending process and the sub-loans with the selected hospitals.

## _Sn Lanka - Poverty Alleviation Project_

The project will assist the newly created Janasaviya ihist Fund (the Thust), with a governing board having representatives from the Government, Non-Government Organizations (NGOs), private sector and the academia, in financing credit operations, human resource and infrastructure development, and nutrition intervention activities of NGOs and government agencies. The 'Blust will manage four funds: (a) a Credit Fund to lend to partner organizations (POs) which will on-lend to the poor in a manner prescribed by the Blust at interest rates which will make the credit fund operations self-supporting; (b) a Human Resources Development Fund for promoting the productive use of credit and for developing the lending capacity of POs; (c) a Rural Works Fund for building economically viable infrastructure and
PHN 1991 Sector Review 56 creasing wage employment; and (d) a Nutrition Fund for reducing the proportion of<sup>wasting and stunting</sup> in children and reducing the incidence of low birth weight and the prevalence of maternal malnutrition. In addition, the project will support an Employment and Poverty Policy Unit in the Ministry of Policy Planning and Implementation.

# EMENA Region

# _Algeria - Pilot Public Health Management Project_

The proposed project would help improve productivity and efficiency in the Algerian health care delivery system. It would introduce, on a pilot basis and in a limited area, management tools that will allow the Govemment to implement changes in the management and operations of the health system at central and local levels. These management tools would subsequently be extended nationwide. The pilot area would include the teaching hospital (CHU) and adjacent urban health district of Bab el Oued in Algiers, and the rural wilaya of Medea.

The project would: (a) improve resource management through the introduction of health managemeri and information systems for: (i) financial reporting and cost accounting, (ii) patient administraton, (iii) service and personnel performance evaluation, and (iv) building, medical and nonmedical maintenance; complemented by pre- and in-service training programs for managers and support staff; (b) improve quality of services by: (i) raising professional skills of public health sector personnel through stronger pre- and in-service training, and (ii) strengthening professional communication between health personnel at different levels; (c) improve the utilization of project area facilities through upgrading of their diagnostic and emergency handling capabilities and rehabilitation of basic systems such as electricity and water supply; and through the development of a masterplan for the teaching hospital of Bab el Oued; and (d) strengthen strategic planning and management in MOPH, including its capabilities to closely monitor and evaluate project results for eventual replication at national levels.

# _Egjpt - Social Fund Project_

As part of a continuing effort to ensure a social safety net associated with economic reform in Egypt, and in response to the adverse effects of the recent Gulf crisis, the proposed project will be the first phase of an overall program aimed at addressing the immediate and pressing needs of those most vulnerable to the reform process, in addition to facilitating the reintegration of Egyptian workers returning from Kuwait and Iraq. The proposed investments will focus on income and employment generation activities, and the provision of essential physical infrastructure and public services. The project will also include efforts to strengthen the Government's capacity to design and monitor future poverty alleviation policies and programs, and will establish mechanisms to protect selected target population groups (e.g., households that are dependent on unemployed workers, or that are headed by women) from the likely longer-term adverse social effects of adjustment.

# _Jordan - Emergency Recovery Project_

The project would support the Government's strategy for: (a) alleviation of some of the adverse effects of Jordan's economic adjustment program and the Gulf crisis on the poor in the short run, and (b) establishment of an institutional basis for targeted poverty reduction programs over the medium term. To this end, the project would help finance a new entity, the Development and Employment<sup>Fund (DEF),</sup> which is mandated to work with existing governmental and non-governmental organizations to create new productive employment opportunities targeted at households at or below the poverty line. DEF is
57 PHN 1991 Sector Review administratively constituted as a unit within the Industrial Development<sup>Bank, but operates in accordance</sup> with its own project eligibility and appraisal criteria,<sup>and is subject to the oversight of an 3utonomous</sup> DEF Management Committee comprised of representatives<sup>of relevant Government departments/agencies</sup> and non-governmental organizations. Bank and concessionary<sup>bilateral financing would be provided under</sup> the project to support DEFs first three years of operation.

# _Paksan - Family Health Project_

The project has three main objectives: (a) to improve the<sup>health status of the population of the</sup> two provinces; (b) to increase the effectiveness of the existing health<sup>care network; and (c) to build the</sup> institutional capacity to realize these objectives. The project<sup>has three main components: (a)</sup> strengthening health services from the village to the district<sup>level, focusing on improved maternal health</sup> services including family planning and integrating and<sup>expanding communicable disease control activities;</sup> (b) staff development focusing on improved staff capabilities and<sup>performance and increasing the number</sup> of female paramedical staff; and (c) management and organizational<sup>development focusing on improved</sup> management capabilities. The project will finance: construction<sup>or expansion of training facilities and</sup> limited health facility upgrading, furniture, equipment and<sup>transport; training costs; technical assistance;</sup> and incremental recurrent costs including medicines.<sup>It will be implemented by the provincial governments</sup> with technical support from local NGOs and universities.

## _Tunisia - Population and Family Health Project_

TMe Population and Family Health project aims to assist<sup>the Government of linisia (GOT) to</sup> lower both fertility and mortality, by targeting basic health care<sup>services to underprivileged groups with a</sup> strong focus on mothers and children. The quantitative target of<sup>the project are to recruit about 30,000</sup> new family planning acceptors per year in the public sector while<sup>continuing to serve over half a million</sup> women with such services through the project period. Further<sup>reductions in mortality and morbidity</sup> would be addressed through: (i) reducing regional disparities in<sup>access to basic health care (including the</sup> first referral level of care) and in the availability of resources;<sup>and (ii) improving the quality of Basic</sup> Health Care (BHC) of which Family PlanningrMaternal and Child<sup>Health services (FP/MCH) is a critical</sup> component. The project would provide: (a) works and equipment<sup>to BHC facilities to accommodate the</sup> strengthening of FP/MCH services and upgrade the technical<sup>quality of the services; (b) mobile clinics and</sup> vehicles to deliver family planning and other basic health services<sup>with a strong focus on underserved</sup> areas; (c) ambulances and equipment for the district hospitals; (d)<sup>works and equipment for five peri-urban</sup> diagnostic centers; (e) educational materials and expert services for a comprehensive<sup>pre- and in-service</sup> training program for staff who are to deliver the services; (f) expert<sup>services to improve strategic planning</sup> and monitoring capacities; and (g) spare parts and expert services for the<sup>development of a maintenance</sup> program for vehicles, equipment and buildings.

## _nia - Hospital Restructuring Support Project_

The objectives of the project are to support the Government policy<sup>in its effort to: (i) address</sup> major hospital internal efficiency issues to contain costs while improving<sup>quality of services; and, (ii)</sup> provide the information that would permit adjustments in financial burden-sharing<sup>by better linking actual</sup> utilization of hospital services to financial contributions. 'lb<sup>this end, the project would include the</sup> following components: (a) development of management capabilities and<sup>policy adjustments. The project</sup> would finance technical assistance, training and office technology<sup>(hardware and software) to develop and</sup> implement: (i) financial management and performance evaluation<sup>procedures; (ii) a Management</sup> Information System; (iii) the reorganization of the administration and<sup>patient registration units; and (iv)</sup>
PHN 1991 Sector Review _58_ sectoral strategies and reform program management: a framework and action plan for new burden-sharing arrangements, a medium-term strategic plan for hospital development, hospital architectural masterplans and reform program management. (b) Improvement of service quality. The project would support: (i) the replacement of priority medical equipment; (ii) the strengthening of hospital maintenance units; and (iii) improvements in patient accommodations, hospital hygiene, and handling of medical wastes.

# _Yemen - Emergency Recovery Project_

The objective of the project is to support a set of core components from the ERP that will help meet immediate retarnee-induced needs for essential social services, maintain basic nutritional levels, and expand housing facilities and social infrastructure. Actions will be focused on the geographic centers of concentration of returnees and will help to create employment opportunities associated with project expenditures. In addition, the project is expected to provide the framework for mobilizing bilateral and other multi-lateral support for the ERP Within the above objectives, components for the ERC have been selected on the basis of: (i) maximum potential assistance to returnees, (ii) capacity for emergency implementation, and (iii) Government's preferences and other sources of aid available for expanding social services. The project will provide financing for the following: (a) Expanding social infrastructure through: procurement of key equipment, materials, and training, for: (i) the labor intensive construction and maintenance of 410 km of priority and economically viable secondary and feeder roads related to centers of concentration of returnees (US$22.8 million); and (ii) the provision of 2,500 serviced sites for housing construction by returnees (US$9.4 million). (b) Strengthening essential social services through: expansion of existing education facilities (construction of 420 classrooms), equipment, materials and teacher training construction of, to incremental meet part of the increased demands from returnees and to partially compensate for shortages of expatriate teachers (US$17.0 million). (c) Supporting agricultural activities through: provision of gabion baskets (to help in land and water conservation), as well as supplies of seeds, chemicals, fertilizers and spare parts for farm machinery, and feedstuff and veterinary products, to help maintain crop and livestock production, thereby reducing the need for incremental food imports and helping to ensure basic nutritional standards for returnees, a majority of whom have returned to rural areas (US$9.7 million,. (d) Strengthening program management through: equipment, vehicles, training and operating expenses and technical assistance (12 staff months) for planning and procurement (US$0.6 million). The project would be fully implemented within three years, with components being specifically designed to create temporary employment for returnees. All construction would be restricted to small, simple structures, for which plans or models already exist, and with emphasis on quick implementation and wide distribution of benefits to centers of concentration. A map of ROY (IBRD 22921R) is attached to the report.

# LAC Region

# _Vl Salvador - Social Sector Rehabilitation Project_

The objectives of the proposed project would be to: (a) improve the delivery of basic social services targeted to some 80 of the most disadvantaged municipalities. Selected priority areas are based on the severity of malnutrition among children, according to the National Nutrition Survey conducted by the Institute for Nutrition for Central America and Panama (INCAP), and low supply of health and education services; and (b) strengthen the institutional capabilities of MIPLAN, MOH and MOE to efficiently plan and manage the delivery of social programs.
59 PHN 1991 Sector Review

## _Haiti - Economic and Social FAnd Project_

The objectives of the project would be to: (i) establish an effective<sup>mechanism, the Economic and</sup> Social Fund (ESF), as a means of responding flexibly and efficiently to the<sup>basic needs of the poor through</sup> NGOs, cooperatives, community associations and other grass roots organizations;<sup>(ii) assist the GOH to</sup> improve health, nutrition and education services and provide physical<sup>infrastructure, and employment</sup> opportunities to the poor; (iii) provide an effective channel for critically required<sup>donor financing and</sup> coordinate domestic efforts that are currently fragmented; and, (iv) strengthen<sup>the capacity of community</sup> groups, cooperatives and other grass roots organizations in preparing and implementing<sup>projects. The</sup> proposed operation would consist of a project component and an institutional<sup>development component.</sup> The project component (US$10 million, IDA contribution) would address<sup>the needs of the poor in health</sup> and nutrition, education and physical infrastructure. Financing would<sup>be provided for. (i) health and</sup> nutrition projects primarily for children, pregnant and lactating mothers, rehabilitation<sup>and construction of</sup> primary health care facilities, essential drugs, immunization, construction of small water<sup>supply systems,</sup> small-scale sewerage systems and latrines (US$6.4 million); (ii) rehabilitation<sup>and construction of pre-</sup> school centers and primary schools, provision of school furniture and pedagogic<sup>material, literacy and</sup> vocational training programs (US$2.5 million); and (iii) rural market and<sup>social service access roads and</sup> related drainage works (US$1.0 million); and advisory services to participating<sup>organizations (US$0.1</sup> million). The institutional development component (US$1.3 million)<sup>would finance administrative and</sup> technical assistance to the ESF, including salaries for selected ESF staff,<sup>equipment (vehicles and</sup> computers), consultant services and operating costs.

## _Honduras - Social Investment Fund Project_

The objectives of the proposed project are to: (i) mitigate the social<sup>costs of adjustment and allow</sup> economic reform measures to be put into place rapidly with the necessary support<sup>of the population, (ii)</sup> lay the basis for a decentralized program of direct support for the poor and<sup>malnourished to buy food, and</sup> (iii) support the improvement of service delivery In the social ministries. The<sup>project would have four</sup> components: (i) the financing of the FHIS (more than 95% of total project cost),<sup>(i) sutpport to a pilot</sup> targeted nutrition assistance program (the executing agency would be the<sup>Family Assistance Program), (iii)</sup> technical assistance to help design a program to improve the efficiency<sup>and equity of the services of MOH</sup> nd MOE, and (iv) the setting up of a monitoring and evaluation system of the government's<sup>social policy</sup> interventions through the use of a Living Standards Measurement Study<sup>(the coordinator of this program</sup> would be the Ministry of Planning).

# _Mexico - Basic Health Care Project_

The project would: (a) strengthen and extend basic health care<sup>services and targeted nutrition</sup> assistance to about 13 million uninsured poor in 47 health jurisdictions<sup>in Oaxaca, Chiapas, Hidalgo, and</sup> Guerrero and in the Federal District (Project States); (b) support<sup>institutional improvements to strengthen</sup> management capability to enhance the efficiency and effectiveness<sup>of the health care system; and (c)</sup> strengthen the implementation of sectoral reforms to decentralize<sup>budgetary, management, and operational</sup> responsibilities from the federal level to the states. Attainment of<sup>these objectives would support a</sup> broader government policy for poverty alleviation and contribute to<sup>improved health and nutritional status</sup> of low-income residents in Mexico's poorest states.

The project consists of two major components: (a) Health Services Component<sup>(89 percent of total</sup> project cost including contingencies), which would focus on improving<sup>and extending delivery of basic</sup> health care and nutrition assistance (PASSPA program) for 13<sup>million uninsured people. Specific actions</sup>
PHN 1991 Sector Review 60 include: (i) rehabilitating, upgrading, and expanding the health network and developing a maintenance program for facilities and biomedical equipment; (ii) providing equipment, furniture, vehicles, and basic medical supplies; (iii) hiring, reassigning, and regarding personnel to flt the PASSPA program; (iv) improving the supervision system and technical training for professional and auxiliary health staff; and (v) producing and distributing operational manuals and materials; and (b) Institutional Development Component (11 percent of total project cost). At the federal level, it would: (i) provide assistance to facilitate the decentralization process; (ii) conduct operational research to improve services delivery, to set policies and priorities, to mobilize additional resources for basic health care, and to carry out operational research and impact evaluation; and (iii) strengthen management information systems to improve planning, analysis, and management capacities. At the state level, this component would assist in improving: (i) the management, administration, and planning capacities of the State Health Authorities; (ii) personnel policies and management; and (iii) training opportunities in management and administration for managers and administrative staff.

# _Venuel - Social Development Project_

The objective of the proposed project is to assist the Government of Venezuela (GOV) in developing a social sector strategy to redirect its social expenditures into well-targeted and efficient programs, by financing high priority activities, within the framework of its Social Sectors Action Program. It aims to: (a) improve living conditions of a large and poor segment of the population, especially pregnant and lactating women, and children under six years of age, while mitigating the potential adverse impact of the adjustment program; (b) replace indirect subsidies with targeted social programs, while improving their efficiency and rationalizing their distribution; and (c) promote institutional development by improving the planning and management capacity in the Ministries of Health and Education, as well as the capacity to target, develop and monitor social programs in the Ministry of the Family. The GOV has drawn up a set of policies and actions to be undertaken (Social Sectors Action Program), which, together with the project components to be financed, will effectively implement its basic objectives and strategy for the social sectors. The project would support: (a) rehabilitation and development of the primary health care network, including provision of basic health and nutrition services for pregnant and nursing women and children under six years of age; (b) development and expansion of pre-school education, focused on the lower-income urban and rural areas; (c) information, education and communications services for health, nutrition, and education promotion; and (d) improvement of the GOVs capacity to design, plan and implement social programs and to monitor the effect of such programs. A technical coordinating office attached to the MINFAM would liaise with implementing agencies on project planning, budgeting, and implementation. Autonomous agencies attached to the MOE and MOH would be in charge of day to day administration of the project; technical supervision would be carried out by regular ministry staff. Special attention wouid be given to strengthening implementation and coordination capacity in the various institutions involved.
# ANNEX 3. Bibliography
# BIBLIOGRAPHY OF ANNUAL SECTOR REPORT

# _GenenwlI Miwelan*_

Economic Development Institute. EDI Activities Report. FY1990. (Washington, D.C.: World Bank, December 1990).

Griffin, Charles C 'The Need to Change Health Care Priorities in LDCs.' _Finance & Development, vol._ 28, no. 1 (March 1991): 45-7.

Paul, Samuel. 'Community Participation in Development Projects: The World Bank's Experience." World Bank Discussion Paper No. 6. (Washington, D.C., Februaly 1987).

United Nations Development Programme, _Human Development Reporn 1991._ (Oxford: Oxford University Press, 1991).

World Bank "FY92 Priorities and Budget Policy Directions." Board Report SecM90-1391. (Washington, D.C, November 1990).

World Bank a16th Annual Report on Implementation and Supervision - FY90." (Washington, D.C, December 1990).

World Bank 'FY92 Priorities and Budget Policy Directions.' (Washington, D.C., November 20, 1990).

World Bank. Medium-Term Planning Framework (FY92-94).' (Washington, D.C., February 14, 1991).

# _Managent Institutional Development_

Adamolekun, Ladipo. _Issues in Development Management in Sub-Saharan Aftica._ Economic Development Institute, Policy Seminar Report No. 19. (Washington, D.C: World Bank, October 1989).

Agarwala, Ramgopal. 'Planning in Developing Countries: Lessons of Experience." Worli Bank Staff Working Paper No. 576. (Washington, D.C., December 1983).

Cochrane, Glynn. "Policies for Strengthening Local Govermment in Developing Countries.' World Bank Staff Working Paper No. 582. (Washington, D.C., July 1983).

DaVanzo, Julie, and John Haaga. "Women in Development: Issues for the Latin American and Caribbean Region." World Bank Technical Paper No. 2. (Washington, D.C., April 1991).

Economic Development Institute. _Strengthening Local Govemments in Sub-Saharan Africa._ Policy Seminar Report No. 21. (Washington, D.C.: World Bank, December 1989).

Hegstad, Sven 0. and Ian Newport. 'Management Contracts, Main Features and Design Issues.' World Bank Technical Paper No. 65. (Washington, D.C., July 1987).

Kubr, Milan and John Wallace. 'Successes and Failures in Meeting the Management Challenge: Strategies and Their Implementation.' World Bank Staff Working Paper No. 585. (Washington, D.C., July 1983).
64 PHN 1991 Sector Review Lacey, Robert M. "Managing Dublic Expenditure: An Evolving World Bank Perspective." World Bank Discusslion Paper No. 56. (Washington, D.C., June 1989).

Paul Samuel. 'Institutional Development in World Bank Projects: A Cross-Sectoral Review." World Bank Working Paper No. 392. (Washington, D.C., April 1990).

'- "nstitutional Reforms in Sector Adjustment Operation: The World Bank's Experience." World Bank Discussion Paper No. 92. (Washington, D.C., June 1990).

'1raining for Public Administration and Management in Developing Countries." World Bank Staff Working Paper No. 584. (Washington, D.C., July 1983).

, and others. "Educating Managers for Business and Government: A Review of International Experierce." World Bank Discussion Paper No. 54. (Washington, D.C., June 1989).

Silverman, Jerry M. and others. "Action-Planning Workshops for Development Management Guidelines." World Bank Technical Paper No. 56. (Washington, D.C., December 1986).

World Bank _7he Afnican Capacity Building Initiative: Toward Improved Policy Analysis and Development Management._ (Washington, D.C., January 1991).

World Bank 'Managing Technical Assistance in the 1990s.' Report of the Technical Assistance Task Force. (Washington, D.C., August 1991).

# PopulaHon

Swamy, Gurushri and Catherine Patillo. 'Population in World Bank Economic and Sector Work - A Review of Some Best Practices and Methodologies." World Bank Intemal Discussion Paper, Africa Regional Series. (Washington, D.C., March 1991).

World Bank. Population and The World Bank: A Review of Activities and Impacts from Eight Case Studies." Operations Evaluation Departrent (Washington, D.C., June 1991).

Demery, Lionel, and Tony Addison. _The Alleviation of Povety under Smutural Adjustment._ (Washington, D.C.: World Bank, November 1987).

Ferroni, Mike, and Ravi Kanbur. Poverty-Conscious Restructuring of Public Expenditure: Social Dimensions of Adjustment in Sub-Saharan Africa." World Bank Staff Working Paper No. 9. (Washington, D.C.: World Bank, December 1990).

Holt, Sharon, and Helena Ribe. "Developing Financial Institutions for the Poor and Reducing Barriers to Access for Women." World Bank Discussion Paper No. 117. (Washington, D.C., February 1991).

Jorgensen, Steen, Margaret Grosh, and Mark Schacter. 'Easing the Poor through Economic Crisis and Adjustment: The Story of Bolivia's Emergency Social Fund." World Bank Technical Paper No.3. (Washington, D.C., May 1991).
PIIN 1991 Sector Review 65 LAvy, Santiago. 'Poverty Alleviation in Mexico." World Bank Working Paper No. 679. (Washington, D.C, May 1991).

Ribe, Helena, and Soniya Carvalho. rargeted Poverty Projects Supported by the World Bank: An Overview of Operations Approved During FY85-89." Draft repor. (Washington, D.C.: World Bank, April 1991).

Ribe, Helena, and others. "Towards a Social Action Program for Pakistan: Impediments to Progress and Options for Reform." Draft interim report. (Washington, D.C: World Bank, April 1991).

Ribe, Helena, and others. *How Adjustment Programs Can Hep the Poor: The World Bank's Experience." World Bank Discussion Paper No. 71. (Washingt nn, D.C., January 1990).

World Bank. "Assistance Strategies to Reduce Poverty." Board Report R90-243. (Washington, D.C., December 1990).

World Bank. _Povert and HNuman Development._ (New York: Oxford University Press, 1980).

World Bank. _Poverty and Hunger, Issues and Options for Food Security u6 Developing Countries._ Policy Study. (Washington, D.C., February 1986).

World Bank. _Taigeted Programs for the Poor During Stmuctural Adjustnent: A Summaiy of a Symposiun on Poverty and Adjustment April 1988._ (Washington, D.C., September 1988).

World Bank _The Social Densions of Adjustment in Afica: A Policy Agenda._ (Washington, D.C, March 199).

World Bank. _he World Bank's Support for the Alleviation of Poverty._ (Washington, D.C, June 1988).

World Bank. Social Dimensions of Adjustment Status Report and FY91 Work Plan. 'Socio-economic Development Funds: A Guideline for Design and Implementation. (Washington, D.C, March, 1990)
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