metadata: authors: 0: author: Simmons, George
1: author: Maru, Rushikesh
count: World
docna: 0: docna: The World Bank's population lending and
            sector review
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Reproductive Health,Nutrition,Educational Sciences,Family Planning Research
teratopic: Information and Communication Technologies,Health, Nutrition and Population,Agriculture
abstracts: cdata!: The objective of this paper is to review
            the historical experience of the Bank's lending and
            sector activities in the population field, and to evaluate
            the Bank's strengths and weaknesses in this field.
            Based on analysis of Bank documents, interviews and field
            visits, the review concludes that the Bank's overall
            performance in the population field has been commendable and
            its efforts to differentiate its activities in the various
            part of the world laudable. PHN's work in establishing
            policy dialogue with governments on population is identified
            as the area in which the Bank's impact has been
            greatest. The Bank has been particularly effective with
            development of policy in countries with new programs rather
            than in those with established programs. The Bank's
            ability to deal with high level policy issues and to
            establish inter-sectoral linkages is seen as strong and
            effective. The greatest weaknesses in Bank projects are
            identified as the lack of diversity in project format, the
            organizational structure through which projects are
            implemented and the manner in which projects are supervised.
repnme: repnme: The World Bank's population lending
            and sector review
display_title: The World Bank's population
            lending and sector review
listing_relative_url: /research/1988/09/700658/world-banks-population-lending-sector-review
topicv3: Nutrition m1326779 644,Education m1327048 470,Family Planning m1327501 1452,Population, Aging and Health m1327736 640,Health m1504661 3480
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Information and Communication Technologies,Health, Nutrition and Population,Agriculture
origu: Policy Plan & Prog Review Dept (PPR)
no_of_pages: 109
model_extractions: . Po~lkyaPnning, and RsewhS Populaton, Hlith, and **Nurilton** The Bank's decision to target its efforts to "key" countries - such as Kenya, India, and Bangladesh - has proven basically correct In recent years, the Bank has considerably increased its lending, number of projects, and attention to new areas, especiaUy Africa. In many countries, however, fertility remains iiigh.

The Bank should be able to improve projects by:

* Developing stronger links with a range of government agencies and NGOs.

* Focusing more attention on institutional development and sustainability.

The Bank has been more successful in developing policy and creating programs than in running effective projects.

Projects have been commonly run through ministries of health with little regional variation or autonomy and minimal roles for nongovemmental organizations (NGOs) and the private sector. Built-in evaluation has not always been present, and postcompletion evaluation has been late. As a result, projects have not been able to recognize and respond to specific and changing needs, and follow-up projects have been unable to take into account findings of project completion evaluation.

* Emphasizing smaller, less complex projects with more flexible and innovative designs.

Shortening project cycles so that mistakes can be avoided as new projects are developed.

The Bank should reassess its reliance on supervisory missions for project monitoring and consider greater use of resident specialists for constant guidance. The Bank should also consider developing a systems approach to project evaluation and schedule more regular project reviews. The Bank needs, in addition, to increase its coordination with other intemational donor agencies and with private voluntary organizations.

This paper is a product of the Population, Health, and Nutrition Division, Population and Human Resources Department. Copies are available free from the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Sonia Ainsworth, room S6-065, extension 31091.

'Ce PPR Working Paper Se8es disseminates the uidings of work urner ws y hin t Bana's Poel cyn Planning, and Research Complex. An objective of the series is to get these findings out quickly. even if presentations are less tha fully polished.| The fmdings, interpretations, and conclusions in these papers do not necessarily represent official poticy of the Bank.

Copyright 0 1988 by the International Bank for Reconstruction and DevelopmenVThe World Bank
# TABLE OF CONTENTS

||FOR|EWORD||
|---|---|---|---|
|I.|TNTR|ODUCTION. . . . . . . . . . . . . . . . . . . . . . . . .||
||A.|Scope of the Review .<br>.<br>.<br>. . . . . . . . . . . .||
||B.|A Historical Perspective on the World Bank's Work||
|||in Population . . . . . . . . . . . . . . . . . . . . . .|2|
|||1.<br>The Early Years. . . . . . . . . . . . . . . . . . .|2|
|||2.<br>The Berelson Report. . . . . . . . . . . . . . . . .|3|
|||3.<br>The Post-Berelson Report . . . . . . . . . . . . . .|4|
|||4.<br>Formation of the Population, Health and||
|||Nutrition Department.|4|
|||5.<br>The Early Years of PHND. . . . . . . . . . . . . . .|5|
|||6.<br>Fiscal Year 1984 to Present. . . . . . . . . . . . .|6|
||C.|A Framework for Assessing Program Effectiveness . . . . .||
|II.|THE|WORLD-BANK INVOLVEMENT<br>WITH THE DEVELOPMENT OF||
||POP|ULATION POLICY. . . . . . . . . . . . . . . . . . . . . . .|l|
||A.|Policy Dialogue . . . . . . . . . . . . . . . . . . . . .||
||B.|Sector Work .... . . . . .<br>......<br>. . . . . . .<br>.|14|
|||1.<br>Volumeand Regional Distribution of Sector||
|||Work .... . . . . . . . . . . . . . . . . . . .<br>.|14|
|||2.<br>Scope of Sector<br>Reports.<br>. . . . . . . . . . . . . .|16|
|||3.<br>Quality of Sector Work . . . . . . . . . . . . . . .<br> <br>|17|
|||4.<br>Impact of Sector- Work.... . . . . . . . . . . . . .|18|
||C.|The Role of Research. . . . . . . . . . . . . . . . . . .|L9|
|||1.<br>Research Done at Bank Headquarters and Its<br>||
|||Contribution to Projects . . . . . . . . . . . . . .|19|
|||2.<br>The Research Component within Projects . . . . . . .|229|
|III.|PRO|JECTS: DESCRIPTION OF EFFORT . . . . . . . . . . . . . . .|23|
||A.|General Description of Projects . . . . . . . . . . . . .|23|
|||l.<br>Number of Projects .23||
|||2.<br>Lending for Projects and Trends. . . . . . . . . . .|23|
|||3.<br>Regional Breakdown and Trends. . . . . . . . . . . .|25|
|||4.<br>The Population Component of PHN Projects and||
|||the Role of IDA. . . . . . . . . . . . . . . . . . .|27|
||B.|Project Design. . . . . . . . . . . . . . . . . . . . . .|28|
|||l.<br>Nature of Planned Interventions. . . . . . . . . . .|28|
|||a.<br>Balance between Health and Family Planning. . .|28|
|||b.<br>Definition of Target Groups . . . . . . . . . .|29|
|||c.<br>Community Participation . . . . . . . . . . . .|29|
|||d.<br>Construction as a Component of Projects . . . .|30|
|||<br>Rl f Edti d Dd Gti||
|||e.<br>oe o ucaon an eman eneraon||
|||Activities. . . . . . . . . . . . . . . . . . .|31|
|||f.<br>Role of Service Delivery. . . . . . . . . . . .|32|
|||g.<br>Large vs. Small Projects. . . . . . . . . . . .|32|
|||h.<br>Designed Efforts to Improve Management||
|||Systems<br>...|32|
|||i.<br>Monitoring and Evaluation . . . . . . . . . ...|34|
|||2.<br>Nature of Planned Approach to Organizational||
|---|---|---|---|
|||Structure..<br>.. . . . . . . . . . . . . . . . . .|35|
|||a.<br>Location of Organizational Responsibility||
|||in the Bureaucracy. . . . . . . . . . . . . . .|35|
|||b.<br>Approach to Regional Reorganization . . . . . .<br>|36|
|||c.<br>Design of Institutional Development (ID)<br>||
|||Activities.<br>. . . . .<br>. . . . .<br>|36<br>|
|||d.<br>Connections with Other Organizations.|37|
|IV.|THE|EFFECTIVEiNESS<br>OF PROJECTS. . . . . . . . . . . . . . . . .|4C|
||A.|Criteria for Measuring Effectiveness. . . . . . . . . . .|40|
||B.|Experience with Bank Projects . . . . . . . . . . . . . .|41|
|||I.<br>Policy Commitment. . . . . . . . . . . . . . . . . .|41|
|||2.<br>Institutional Develovmen.<br>.<br>.<br>.<br>.<br>. . . . . . . . .|41|
|||3.<br>Expenditure on Programs and Additionality. . . . . .|.4|
|||4.<br>Management Efforts to Organize Programs . . . . . .|44|
|||5.<br>Intermediate<br>Outputs such as Construction. . . . . .|.46|
|||6.<br>The Quantizy and Quality of Provider-Client||
|||Transactions . . . . . . . . . . . . . . . . . . . .|48|
|||7.<br>The Observed Behavior of Beneficiaries . . . . . . .|48|
|||a.<br>The Demand for Contraception. . . . . . . . . .<br> <br>|48|
|||b.<br>Acceptance of Family Planning and<br>||
|||Contraceptive Prevalence. . . . . . . . . . . .<br>|I'9|
|||c.<br>Fertility .... . . . . . . . . . . . . . .<br>.|50|
|||d.<br>Economic and Social Ob.jectives<br>of Development .|_51_|
||_C._|Summary of P.-oject<br>Effects. . . . . . . . . . . . . . . .|.52|
|V.|THE|PROCESS OF PROJECT DEVELOPMENT AND IMPLEMENTATION. . . . .|53|
||A..|Project Development..|53|
|||1.<br>Mission Approach to Pro.ject<br>Development and the||
|||Resident Population Specialist Alternative . . . . .|53|
|||2.<br>Reducing Delays. . . . . . . . . . . . . . . . . . .|55|
|||3.<br>Lending Coefficients<br>.56<br> <br>||
|||4.<br>Learning from the Past and Other Project<br>||
|||Experiences. . . . . . . . . . . . . . . . . . . . .|57|
||B.|Project Supervision and Implementation. . . . . . . . . .|59|
|||1.<br>Bank Procedures for S. lervision. . . . . . . . . . .|59|
|||2.<br>The Nature of Supervisory Missions from the Courntry<br>||
|||Perspective. . . . . . . . . . . . . . . . . . . . .|59|
|||3.<br>The Evaluation Component . . . . . . . . . . . . . .|60|
|||4.<br>Supervisory Coefficients . . . . . . . . . . . . . .|61|
|||5<br>S|6|
|||.<br>ummary. . . . . . . . . . . . . . . . . . . . . . .|t|
||C.|Coordination with Other Agencies. . . . . . . . . . . . .|62|
||D.|The Impact of World Bank Procedures and Governing Rules||
|||on Project Development and Implementation . . . . . . . .|64|
|||1.<br>Loans vs. Grants . . . . . . . . ... . . . . . . . .<br> <br>|64|
|||2.<br>The Relationship between PRN and the Rest of||
|||<br>the Bank . . . .<br>. . . . . . . . . . . . . . . . . .|64|
|VI.|LES|SONS LEARNED AND FUITURE<br>STRATEGIES<br>.<br>.. . . . . .<br>. . . .<br>66|
|---|---|---|
||A.|Analysis of the Nature of the Task.<br>.67|
||B.|The Overall Influence of the Bank in Policy Matters.<br>. .<br>67|
||C.|Needed Changes in Projects. . . . . . . . . . . . . . . .<br>69|
||D.|The Bank's Role in the Development of NGOs. . . . . . . .<br>69|
||E.|Relations with Other Donors**. . . . . . . . . . . . . . .**<br>70|
||F.|The Mix of Skills among the Bank Staff. . . . . . . . . .<br>70|
||G.|The Efficiency of Bank Work in the Field of Population. .<br>70|
||H.|What are the Prospects for Increased Lending? . . . . . .<br>71|
|ViI.|REC|ONMMNDATIONS. . . . . . . . . . . . . . . . . . . . . . . .<br>72|

# Prepared by:

**George B. Simmons, The University of Michigan Rushikesh Maru, The University of Michigan ax The Indian Institute of Management With the Assistance of Suzanne Thomas, The University of Michigan**
# TABLE OF TABLES

|II-1.|Number of PHN related economic and sector<br>reporta completedGince1969, by year<br>. .<br>.<br>.<br>.<br>.|15|
|---|---|---|
|II-2.|The number of PHN related sector and economic<br>reports completed since 1969, by region and<br>time period .<br>. . . . . . . . . . . . . . . . . .|15|
|II--3.|Distribution of PHN related sector and<br>economic reports since 1969, by title and<br>time<br>period<br>.<br>.<br>..|16|
|III-1.|The<br>number<br>of<br>Bank supported PHN projects<br>FY1970-86, by nominal subject area . . . . . . . .|24|
|III-2.|PHN Loan Commitments in Population (US$ m4llion) 1970-1986 . . . . . . . . . . . . . . . .|25|
|III-3.|World Bank supported population, health, and<br>nutrition projects by type, region and year,<br>as of November 30, 1986<br>. . . . . . . . . . . . .|26|
|III-4.|Percentage of funding devoted to population<br>activities in non-population<br>projects<br>. . . . . .|27|
|III-5.|MER Activities in Completed Population<br>Projects<br>. . . . . . . . . . . . . . . . . ... . .|35|
|IV-1.|PHN Project Approval and Completion Date and<br>Amount of Delay in Completion (as of March<br>1987)<br>. . . . . . . . . . . . . . . . . . . . . .|45|
|V-1.|Lending Coefficients<br>(staff weeks) for<br>Agriculture, Education, PHN and Urban<br>Projects, FY1981-87<br>. . . . . . . . . . . . . . .|56|
|V-2.|Lending Coefficients<br>for Agriculture,<br>Education, PHN and Urban Projects, FY1981-85<br>.<br>.|62|
|A-1.|Comparison of Sector Work in the<br>Phillippines,<br>1973 and 1984<br>. . . . . . . . . . .|76|
|A-2.|Project appraisals in countries where no<br>sector work has been completed, by year .77||
|A-3.|Sector work completed that has not resulted<br>in a project as of November 1986 . . . . . . . . .|78|
|A-4.|Summary of all PHN projects, total<br>commitment, and source of Bank funding . . . . . .|79|
|A-5.|CumulativeIDAand IBRD lending, by year . . . . .|81|
|A-6.|Budgetary breakdown of projects by dispursal<br>and functional category<br>. . . . . . . . . . . . .|82|
|A-7.|PPARand subsequent project dates<br>. . . . . . . .|97|
i

# FOREWORD

This paper was commissioned in 1985, by the former Population, Health and Nutrition Department (PHND). The objective was to review the historical experience of the Bank's lending and sector activities in the population field, and to evaluate the Bank's strengths and weaknesses in this field. It was carried out primarily by two consultants, George Simmons and Rushikesh Maru of the University of Michigan, under the general direction of Dr. Fred Sai, Senior Population Adviser to the World Bank.

The review of population activities is the last in a series of reviews of the sectors in PHND. It is also the fourth in a series of reviews of population activities carried out since the Bank began lend'ng to population in 1970. The present review was begun and completed prior to the recent reorganization of the Bank and was written in the context of the "Old Bank". It was not intended to be a review of the organizational structure of the PHND. The review was also not mandated to analyze staff composition in terms of specialized skills and experience. Nor was it intended to be a descriptive review; detailed description of what comprises a Bank population project is therefore, limited.

Specifically, the review was expected to focus on PHND's experience in developing, designing, implementing and evaluating population projects. It tried to assess the impact of projects in terms of attainment of project objectives, establishment of institutional capacities necessary to further project work, development of coherent and effective national population policies and a capacity for furcher policy development. It examines the extent to which sector work has been effective in identifying and designing projects and fostering policy dialogue. The review attempts to determine the strengths and weaknesses of the Bank's general approach to development as they relate to the population sector: for example, does the fact that the Bank works through credits and loans limit its effectiveness in this sector?

Based on analysis of Bank documents, interviews and field visits, the review concludes that the Bank's overall performance in the population field has been commendable and its efforts to differentiate its activities in the various parts of the world laudable. PHN's work in establishing policy dialogue with governments on population is identified as the area in which the Bank's impact has been great.cst. The Bank has been particularly effective with development of policy in countries with new programs rather than in those with established programs. The Bank's ability to deal with high level policy issues and to establish inter-sectoral linkages is seen as strong and effective.

The greatest weaknesses in Bank project work are identified as the lack of diversity in project format (projects tend to have a standard format using standard components and show little innovation), the organizational structure through which projects are implemented and the manner in which the projects are supervised. A notable feature of Bank-funded projects is the
i.

provision of resources for construction. While there has been a gradual shift over the years from a hardware orientation to more software-oriented activities, it remains an important, although occasionally overly dc inant, element of Bank projects.

Bank projects are tvpically larger and more complex than those of other donors, often encompassing a full range of national program activities. While this keeps the Baaik invol^- . in the central issues of the national program, coordinating all of thk. aments involved can be d:fficult and :'esult in delays and implementati i problems. Project completion is often delayed up to three years, due in ?art to the scale and co..vlexity of the -- projects and to the fact that full utilization of funds simply takes time possibly disbursement schedules are not realistic. Second generation projects often begin before the first project is complete, thus removing the opportunity to apply any lessons learned to developmqnt and implementation of follow-up projects.

'he review comments extensively on the Bank's heavy reliance on supervision missions to monitor project progress. It questions whether the mission approach -- which is often seen as disruptive to the ongoing work of the project and not able to provide adequate attention to all aspects of the project -- is preferable to the use of, for example, the resident specialist approach, which would provide constant monitoring and guidance to the project. * The review also suggests that the resident specialist approach might improve institutidn development efforts, an area which has received much mention in projects but where there has been limited success. The Bank's approach to institution development consists of structural reorganization, system design and skill development through formal training to develop strong institutions capable of designing and executing effective programs. The review concludes that the supervision mission approach generally does not provide sufficient technical assistance and monitoring to lead to effective institution building.

Bank projects typically approach population activities through the provision of primary health care. This often confines the Bank to working through ministries of health, which are often administratively and politically weak and whose traditional priority is to provide curative, clinic-based care, not to effect attitudinal and behavioral changes. The review also finds that the Bank has not been effective at tapping resources such as NGOs. Such collaboration could prove difficult as the Bank only lends to governments.

The quality and scope of sector work is seen as having improved over the years. The purpose of sector work is to provide a base for project identification and development, and for initiating policy dialogue with policy makers and program managers. Damographic and population analysis has been particularly strong in the sector reports; the reports have been less thorough in their analysis of program effectiveness issues.

The review presents a set of recommendations based on these findings. These inciude strengthening linkages with agencies other than ministries of health; increasing priority given to policy dialogue; increasing attention
iii to institution developmexiL, sustainability and IEC; emphasizing where possible smaller, less complex projects with flexible and innovative project designs; improving evaluation and its integration with project operation^. Sector work should continue to be a priority, with more attention given to issues relating to program effectiveness and the role of NGOs. The review suggests that the Bank explore the possibility of supplementing the current pattern of missions possibly using the resident specialist approach: this can be either a specialist for an individual country or for a group of countries; improve coordination with donor agencies; attempt to shorten the project cycle (the elapsed time from project identification to project completion) so systematic learning can take place more rapidly; and increase resource commitment to research activities and make such activities more operationally oriented focussing on areas such as finance, provider-client transa-tions, peripheral level management and demand generation. The review also concluded that the Bank needs to retrain some current staff or selectively recruit new staff to help implement recommendations concerning sector work, research and project design.

The review does not represent the view of Bank management. Nor is there a consensus among the Bank audience as to its merits. Some PHND staff felt that it represented a good overview of the Bank's activities in the population field -- what it has been doing, problems encountered and future direction. Others felt the review was superficial based on insufficient data and analysis. However, given the terms of reference, it is not clear whether the consultants could have performed a deeper analysis. Despite the doubts expressed about the analysis on which the recommendations are based, the general consensus concerning the recommendations suggested in the review is that they are in the right direction and provide a useful basis for discussion of the future role of the Bank in population activities.

It is difficult to say what tne implications of this review are in the context of the "New Bank." Some of the problems identified maybe more difficult to address under the new regional structure, such as communicating information on lessons learned in projects across countries and across regions, and increasing the operational orientation of research. Addressing other problems may be facilitated by the Bank's new structure: for example, working with ministries other than ministries of health (e.g. Ministries of Social Welfare on Education) may be easier with population activities now within Country Directorates with other divisions. Hopefully, the review will stimulate discussion and action to improve the effectiveness of the Bank's work in the population field.

Dr. Fred Sai and Lauren Chester iii
# I. INTRODUCTION

# A. Scope of the review

This report reviews PHN experience with population sector and project work. The review complements similar reviews that have been undertaken of the health and nutrition sectors and extends and updates an earlier review of the population sector. Following its terms of reference, it focuses on the country experience of project design and implementation and the experience of PHN stff irn working with governments to design and carry out projects wflh a strong population component. The focus on project activities precludes discussion of administrative or procedural issues relating to the Bank as a whole or to PHN itself except as they relate directly to the experience of projects. It should also be noted that the report does not deal directly wlth issues relating to the current reorganization of Bank activities.

The project activities of PHN are-defined as 'population,' 'health' or 'nutrition.' -Some projects are labelled 'population and health.' These labels are misleading to the extent that they are taken as descriptive of project content. 'Health' projects are presumably those which are designed to reduce morbidity and mortality. 'Population' projects must be either directed towards the larger issues relating to the size, distribution and growth patterns of the populatidn, or to the somewhat narrower set of questions related to fertility and especially to fertility con'-rol. Family planning constitutes the most central but certainly not the only activity directed towards fertility control. Moreover, it should be noted that virtually all projects undertaken within the department have implications for both fertility behavior and health. Even 'population' projects have a strong orientation to health and to health institutions. As a result of all of these considerations, we have taken the scope of this review to include all projects and other PHN activities that have any content explicitly oriented towards fertility control.

This review has been undertaken by a team comprised of staff from PHN and outside consultants. The major sources of information have been: interviews with the staff of the department in Washington; documents made available to the review team concerning population sector work; and interviews and observations made during visits to a number of project sites, both in Asia, where some of the oldest and largest projects are located and in Africa, which represents the new frontier for future investments. Within the two continents we visited Bangladesh, India, Indonesia, Kenya, Malawi, Nepal and Senegal. Many of our illustrations of the 'softer' aspects of Bank population activities such as policy dialogue and inter-donor
coordination, and the process of project development and implementation, are derived from these field _visits._

**B.** An Hlstorical Perspective On The World Bank'& Work _In_ Population (drafted by Lauren Chester)

During the almost twenty years that the World Bank has been active in the population field, there have been major changes in the scale, content and organization of Bank population activities. There have also been far-reaching changes in the environment in which these activities are carried out. A review of the history of Bank involvements in this field provides a background against which the present situation can best be understood.

# 1. The Early Years

The B nk's decision to enter the population field was announced by President Robert McNamara in his first address to the Board _c1f_ Governors in September 1968. Population growth was a subject that could not be ignored, "because the World Bank is concerned aboe all with economic development, and the rapid growth of population is one of the greatest barriers to the economic growth and social well-being of our member states." He proposed three courses for action: infbrm deveL6ping countries that rapid population growth slows development; finance facilities for family planning; and initiate joint operational research programs to determine the most effebtive methods of family planning. The Population Projects Department (PPD) was established in September 1969. Dr. Kandiah Kanagaratnam was named department Director. PPD's lending began in FY1970 with a US$2 million loan to Jamaica.

The Sector Working Paper on Population Planning, written in 1972, states that the Bank entered the field of population mainly because it was convinced tbhat the attempt to improve living standards in many developing countries was being seriously undermined, if not thwarted, by rapid population growth. The potential for improving human welfare, particularly health, through population programs was another reason cited for entry into this field. The Bank would offer financial and technical assistance to those countries wishing to slow growth by providing knowledge of and access to family planning services.

In 1973, a population program review panel, comprised of Parker Mauldin, Paul Schultz and srv''ral others, was convened to study the Bank's role in the populacion field. The conclusions of this panel, whose summary report was issued in June, 1973 were important in shaping the Bank's early work in population.

The panel made several recommendations for the Bank's operational and research programs. These included: 2
- population projects should be broad in scope, developed as comprehenaive "family welfare" projects including health, nutrition, and family planning,

- the Bank's approach to population projects was sound and should continue in the direction of more comprehensive projects incorporating innovat:ve approaches with strong evaluation components;

- the Bank should play a leading role in Influencing high level policy makers in developing countries;

- research encouraged by the Bank should be action-oriented (through field experiments and pilot projects) and mainly done at the country level. Research on determinants of fertility, incentive schemes and impact of family planning programs should be encouraged.

Following this mandate, 12 population projects were approved between the Bank's first loan in 1970 and the end of FY1986, totaling nearly US$130 million.

# 2. The Berelson Report

In December 1975 the Board of Directors announced the appointment of a 5-member External Advisory Panel on Population, to be headed by Ber~hard Berelson. The objective of this panel was to examine Bank policies, strategies and problems experienced in addressing the population sector and to advise the Bank on how it could best assist member countries in analyzing and dealing with their population problems.

In its report to the Board in August 1976 the Panel recommended that the Bank continue direct lending to population because, even though the early demographic impact of lending was likely to be limited, the Bank's participation "is important in legitimatina work in this field at the highest political levels and in locating it squarely within a developmental context." The majority of the projects approved during the review period had as their stated objectives to support governmental family planning programs. The Panel found that three-fourths of Bank funding up to that time had gone to hardware.

The Panel proposed a set of 12 recommendations for ways in which the Bank could improve its population work. For example, in terms of lending, the Bank should try to support village-level projects; finance population-related health activities; be receptive to new ideas for project design and more flexible in its procedur'cs; and give special consideration to key countries. In general, the Panel also suggested the Bank explore the deve_opment of more satisfactory relationships with other donors.

3
# 3. The Post-Berelson Reoort

In the summer of 1978 the Bank invited Messrs. Berelson and Freedman of the Panel to reassess the Bank's population work in light of the Panel's recommendations. Their reexamination found that substantial efforts had been made to implement the recommendations. There was some redirection of the Bank's population work as a result of the Panel's review: populationrelated health activities and community-based strategies figured p.:ominently in projects approved or in the course of preparation from FY1977-FY1979; projects included a wide range of activities to strengthea the desire for smaller families (for example, formal and :1on-formal population education, home-visiting campaigns, mother's clubs; vocational training for women and mass media programs); and projects were also more focused on some of the key countries, or those having serious population problems, e.g., Bangladesh, India, Indonesia and Thailand.

# 4. Formation_of the Population, Health and Nutrition_Department

During the 1970s, work in both nutrition and health was being executed by, although not confined to, PPD. The Bank began work on nutrition in 1972. Nutrition was the responsibility of PPD from 1972 to 1975; it was then transferred to the Agriculture and Rural Development Department. Three nutrition ptojects were approved between FY1976 and FY1978. In 1974, the Bank adopted a formal health policy. .Under this policy, there was no lending for health projects; health operations were limited to co'mponents of projects in other sectors.

In July 1979, the Board of Directors adopted a recommendation that the Bank begin lending for health projects in additiun to financing health components. The reasons for this change in policy were set forth in the February 1980 Health Sector Policy Paper:

- The Bank's capacity in country programming, sector analysis and proje(.t formt-lation would help ensure success in broadening health care coverage;

- A broader policy of lending for health was an essential element in the Bank's commitment to alleviating poverty;

- Direct lending for health would complement and rationalize the Bank's support for health components; and

- Health lending to countries without formal policies on family plannin. would afford opportunities for dialogue on population issues and for supporting family planning services through the health care system.

4
To carry out this new work in health, and to continue work in population and nutrition, the new Population, Health and Nutrition Department was established in October 1979, combining staff from PPD, the Nutrition Division of the Agriculture and Rural Development Department and from health activities of the Office of Environmental and Health Affairs. Dr. John Evans was appointed Department Director; Dr. Kanaga,atnam, senior advisor.

# 5. The Early Years of PHND

The early years of this department saw significant growth, both in terms of staffing and output. In FY1980, the Department had 39 higher level staff; by FY1983 this had grown to 56. From FY1980 to FY1983, 13 projects totaling US$278 million were approved; during the life of the PPD, a total of 18 projects had been approved totaling US$287 million (FY1970-79).l Although health was now an operational objective of the Bank in its own right, stress was placed primarily on the relationship between health and population, both in the delivery of family planning services and on the opportunities to open a dialogue in countries which had not yet developed explicit family planning objectives. Fertility reduction remained PHND's dominant objective, although of the 10 projects approved from FY1981-83 only two were called population projects, one was Population/Health and seven were health projects. Of the seven health projects, four did have ekplicit family planning components.

The formation of PHND included, in addition to operational divisions, a Policy and Research Division (PRD). Previously, the bulk of population research had been done by the Population and Human Resources Division of the Development Economics Department (DEDPH). In the early years of PHND. the primary concern of PRD was to identify key issues in the health sector and help orient the Department's multi-disciplinary staff, whose work had previously focused on population, to the health field. The DEDPH was dissolved in 1982 and its staff transferred to PRD. PRD then became the major focus of research on population and health in the Bank.

Dr. Evans left PHND early in 1983; Mr. John North was appointed Director in June 1983. By this time, the Bank had become a world leader in lending for health projects.

> 1Excludes nutrition projects.

5
# 6. Fiscal Year 1984 to Present

PHND began a shift back toward greater emphasis on population in FY1983-84. This reflected the Department's and the Bank's priority on strengthening efforts toward decelerating population growth. The 1984 World Development Report focused on population, and work began on a population policy paper for subSaharan Africa in FY1984. The Bank's commitment to increasing attention on population was articulated by then President Clausen in his address to the International Population Conference in Mexico City, August 1984: ... the World Bank is both willing and able to do more in the population field. Requests for population assistance are rising and where there are programs that we can effectively support we shall certainly respond. We plan to at least double our population and related health lending over the next few years and our major focus will be on Africa and Asia where population and related health problems are still most dramatic.

Commensurate with this, the PHND has put special emphasis on assisting client countries, especially in Africa, to plan and implement effective fertility reduction efforts. In this context, an active program of population sector work has providedo a basis for dialogue with national officials on priority issues, and a framework for developing Bank projects to support population efforts where they are nreeded and wanted. Health projects, particularly in Africa, have provided a framework for population and family planning activities. There has been a shift in the work program of the Policy and Research Division toward initiatives more closely supporting and drawing upon project and sector work. PRD's work program has also reflected the renewed emphasis on population and on strengthening efforts toward decelerating population growth.

With population receiving top priority in PHND's operational objectives, resources are being concentrated on the following:

- strengthening the population policy dialogue with governments, placing special emphasis on the importance of fertility reduction as a national development objective as well as a health promotion tool for women and children;

- continuing the orderly expansion of lending for family planning;

- fully integrating family planning in Bank-assisted health projects;

6
- working with other Bank units, particularly the regions, to promote a multisectoral approach to population issues. This will entail systematic attention to population and fertility issues in country economic work and Country Policy Papers, as well as in education, agriculture and rural development;

- expanding the Bank's operational linkages with external organizations active in the sector, such as WHO, UNFPA and IPPF, as well as bilateral agencies and NGOs.

The Bank's commitment to population, heal hi and nutrition was reaffirmed by President Conable in his spe..ch to the Safe Motherhood Conference in Nairobi, February 1987. President Conable stated that lending to these sectors would double by 1990, totaling as much as $500 million, with projects in about 50 countries.

# **C. A Framework For** Assessing Program Effectiveness

Population sector activities are unusually complex in comparison with other development projects. They involve organized efforts to change behavior in areas that are particularly private. Population projects do not generate physical and marketable output as is usually the case with agricultural or industrial projects, and they are often undertaken in complex bureaucratic environments involving more than one agency. The role of donor agencies in this sector, being removed from direct action, is doubly complex. For these reasons it is particularly important to have a framework within which an assessment of Bank activities can be undertaken.

In this review the general approach of the Working Group on Family Planning Effectiveness of the National Academy of Sciences is adopted. Several helpful observations are made in the NAS report. First, while it is recognized that family planning programs have many possible impacts, the key measure of success which is adopted is the level of contraceptive prevalence which is achieved given the underlying level of demand. Second, family planning programs are recognized to be complex systems and it is argued that their effectiveness is determined by a number of elements that derive from the system. Third, the report suggests some ways that the system can be decomposed to assess the working of the system.

Figure 1, taken from the NAS report, is a flowgraph of the factors influencing program effectiveness.

The ultimate goal of most population programs is to influeuice fertility. (In most countries there are also goals for mortality reduction, but these will be given little emphasis in this review since they have already been covered by the Health

**7**
Fnure 1. A Framework Ior the Analysis of amily Planfib Etlectiveness <!-- Start of picture text --> DEMAND FOR FERTYITY CONTROL<br>Oend for Children:<br>GENERAL 4sI IROX<br>IMATE<br>ENVLOlMENT (values end4 dosviDluab lty uae deutres | 7 D De4 1wOf OI11IERANTSPROXUAATS<br>isno.c Socal ti iuzr n _ _ teiA V at<br>luocil. culhura n4 Supply .1 Cluldron: MogSulMacn<br>_ econooc ttclors. - itural Itiebly_<br>"KW oegJnizata. - Chid swrsvdl<br>-- nmmbI<br>I £ Current Conea cUflive Side o f<br>Cu cepUen<br>OD fectnwgv<br>POLICIES & PROGRAMS TRANSACTIONS C<br>Populaiin Progrm Pliliscal Support Sorucouaw Pol4cy Prov,der-CI.nl JTrnbactions. ypt uKludw . I Ube of Abw flRT|on L I_t<br>Poldzatc1 -Adostualive Leddeeship qudnoly<br>S losze "tofessq*l<br>I M~~~rganBimenlsoa *nl hIi hJesCal adr ul leel |rgd 1111111 u4. ovleall l<br>i Ia lbweauct cl kwell | | Program f_ ngeal nIsRaa All dbLy: °I<br>__________________ S. Seevice Reclmed Activauios and SteruIadelin nlae 4w lele s<br>and 1vlwaiso t A w1_ ,<br>I<br>-J<br>t_______________ ___________________________________________________<br>Source: R. Lapham and G. Simmons, eds. (1987) Organizing for<br>Effective Family j1ararainQ Programs (Washington, DC: National<br>Academy of Scieraces).<br><!-- End of picture text -->
Sector Review. Migration and population distribution have been handled by other parts of the Bank.) The most immedlate cause of or explanation for observed variations in fertility is the set of proximate determinants. From a programmatic perspective the most important of these is contraceptive use, although age at marriage or entry into sexual union, abortion and breast feeding all can be influenced by public policy. In the figure, contraceptive prevalence is influenced by the demand for contraception and by its supply as indicated by the various contacts between providers and potential clients.

Thus, there are two channels through which public policies and programs can influence the proximate determinants of fertility and thus fertility itself. First, it can try to influence demand, and second, it can influence supply.

In.fluencing demand can be attempted through education, mass media, household visitiny and other channels. It can also take the form of structural change designed to improve the circumstances in which people live and thus their felt need for children. Activities that have been identified in the literature as potentially having this latter effect include female education, income security programs such as food for work, and primary health care. Demand generation activities require the change agency to have direct or indirect transactions with the population that it is trying to influence; these can take various forms, as noted, and are often carried out by agencies with another primary mission and with little involvement in the provision of services. Population education in schools is but one of many possible examples.

The second route through which public policies and programs can seek to influence fertility behavior is through the provision of services. These services can take the form of clinical procedures such as IUD insertions or vasectomies, the supply of non-clinical methods to the household, follow-up, etc. All efforts in this area also involve contacts or "transactions" between representatives of provider agencies and their potential clients. The transactions can take place at clinics, through household visits or through the mass media. In some instances such as social marketing programs, these transactions may involve intermediary individuals or institutions, such as shopkeepers.

The NAS report puts special emphasis on the importance of provider-client transactions or exchanges as the basis of any family planning program. The resources devoted to a program ultimately have to reach the potential user if they are to have any effect. Reaching the user will involve a direct contact, as when a physician provides a service, or an indirect contact, as when a commercial agency (say a pharmacy) provides advice as a result of a program-sponsored educational effort. These "transactions" can be c.lassified by type, and by the qualitative 9
and quantitative dimensions. A considerable, although quite incomplete body of evidence suggests that the type, quantity and quality of transactions influences the success of programs as measured in terms of contraceptive prevalence. The NAS reviewers felt that the transaction dimension of programs was relatively neglected both in the day to day contact of programs and in research.

Both demand generation and service provision need to be organized and supported as any other programs. Thus an important component of any project is the set of organizing activities that facilitate the necessary transactions between the provider and the potential client. These organizing activities are themselves complex. In the NAS framework, a useful distinction is made between the family planning organization narrowly defined and the complex of other organizations that make up its environment. Internal management concerns include the organizational structure used for delivering services (e.g., the role of the private sector' patterns of staff recruitment, training and compene.tion; supervision; monitoring and evaluation; etc.. Management concerns relating to the environment i-nclude the generation of political and financial support for program activities, relationships with other agencies undertaking activities that impact on the population sector, etc.. There is considerable evidence that effective family planning programs are characterized both by good internal management and by effective relationships with and support from the environment.

In our analysis of Bank population activities we will use this framework to examine different aspects of sector work and projects and how they have contributed to making national population programs more effective. Bank projects are not designed to support all of the activities in the population sector, and it is to be expected that they will differ in the amount of attention they have given to different aspects of population program implementation. The HAS evidence suggests that national programs which take a systematic view of the factors influencing program effectiveness are better able to increase and sustain higher levels of contraceptive prevalence over time. While it is not always possible or desirable for a project to be comprehensive, selective interventions must be chosen after careful diagnosis of the nature of the client population, transaction activities, organizing or management activities, and the political and administrative environment of the program. The sector review, project identification and formulation activities provide opportunities for such analysis, while project design and monitoring help adaptations over time to the changing needs of the clients and the changing nature of the environment.

10
# II. THE WORLD BANK INVOLVEMENT WITH THE DEVELOPMENT OF POPULATION POLICY

One of the important functions of the Bank is8to help the receiving countries in the development of national population policies. This is achieved through policy dialogue, sector reports, and policy-oriented research. In this section, we shall review the Bank experience with these policy-related activities.

# A. Policy Dialogue

The maln channels of policy dialogue are informal contacts with the top leaders, project negotiations and monitoring, discussion of the sector reports with the host country program managers, participation of managers and top political leaders in the EDI-sponsored policy seminars, structural adjustment and economic sector reports, and institutional development for policy analysis.

The effectiveness of policy dialogue has varied from one country to another, depending on the stage of program development within the same country. In general, the Bank has been relatively more successful in influencing policies at the beginning of a country program than at later, more mature program stages. Similarly, its success in policy dialogue has been greater in smaller'countries than in large countries such as India and Indonesia. This broad generalization should be qualified by recognizing other factors such as the personal style and competence of the mission leaders and members, the level of investment, the existence of allies within the program organization, the overall context of the policy dialogue (e.g., simultaneous major structural adjustment negotiations), the extent of support from the regional department within the Bank, the sophistication of policy analysis prepared by the Bank staff, and the ability to be flexible enough to take advantage of a new opportunity presented by a changing environment. The Malawi case presented below illustrates some of the key elements in a successful policy dialogue.

In Malawi, government policy has shifted from a pre-1981 pro-natalist stance to the acceptance of child spacing as a formal policy, and a low key discussion of population issues among the top civil servants and policy makers has even begun. This is partly a function of support from a few committed civil servants and technocrats within the government, but the Bank also played a significant role in this process.

A variety of methods were employed to initiate and sustain the dialogue. A 1981 conference of experts and officials paved the way for a formal recognition of the child spacing goal. The Bank capitalised on this opportuni.ty and included a child spacing 11
component in its first project even at the late stage of the signing of the agreement. The structural adjustment mission report (1982) included population growth among the top four priority issues for the eighties. A population sector review was conducted in October 1984, which was then used as a basic document in a conference of senior officials from various ministries. Another document, a national health plan prepared under the Bank project, provided an analytic basis for discussion of child spacing within the context of primary health care at a conference of Principal Secretaries held in April, 1986. Some of the officials also mentioned during our interviews that visits to other countries and participation in the EDI-sponsored seminars helped in clarifying policy and program issues. The Bank has broadened the policy dialogue are.ia by includlng planning and economic ministries and the office of the President along with the Ministry of Health.

The Malawi case illustrates how an orchestration of a number of factors mentioned earlier helps in successful policy development. Other countries in Africa present a mixed outcome and a very slow movement towards articulated population policy. Even where the skills and style of the mission leaders have a positive impact, other supportive elements, such as strong advocacy from the region and new opportunities from the environment, did not exist. Moreover, even where the country adopts a favorable policy position, rapid and significant success in delivering services to a large proportion of the eligible population is far from assured. Ghana and Kenya illustrate this possibility.

In well established programs such as India and Indonesia, the Bank played a crucial role during the first population projects in the early seventies, designing the service delivery strategies. Recently, however, the Bank has basically played a supportive role in institutionalizing policies and programs proposed by program managers. This limited policy influence is a function of the government's unwillingness to allow foreign agencies to engage in national policy discussion, as well as of the reduced scale of the Bank's share in foreign funding for the population sector, especially in India. Despite their modest role with regard to the overall national program, Bank funded projects in India have come under public scrutiny and criticism due to their limited impact on program outputs. Also, contrary to its experience in the agricultural sector, the Bank has not enjoyed high credibility as a policy analysis group in India or Indonesia. During the past year, this situation has been changing. The government considers a sector review for the state of Uttar Pradesh supported by the Bank an important input in devising new strategies. Similarly, the Indonesian program managers have revised their estimate of the CPR as a result of a Bank commissioned study. In Indonesia IV, the project has provided $2.0 million for policy development and a long term plan 12
of action. Low key but significant policy analysis may be the best method of policy development or refinement in such mature programs.

There are many other examples of moderately successful policy development in AfricF During our field visit to Kenya, we were convinced that the Bank has helped to build policy commitment and new policy structures during the past few years. The_Health Sector Review (pg. 24) mentions the positive impact of sector work on policy development in Malawi, Zimbabwe, Botswana, Lesotho, Zambia and Cameroon. In Latin America, the political environment is different from that in Asia and Africa. The Latin American governments tend to bring about population policy changes without publicity or formal announcements. Thus, the Bank's efforts in this region have at times helped policy development through informal discuLssions. For example, the Mexican government's population policy statement was a result of technical assistance from the Bank; but it has not led to the formulation of a population project funded by the Bank. Similarly, there have been small but definite gains in population policy development in Brazil, Colombia, Morocco, and Jordan. There are many more countries in Africa, Latin America and the Middle East where policy development has not made much progress. In a few places, such as Egypt, the Bank's influence on population policy may have diminished. In Nepal, despite visits from several missions, Bank supported project activity is not imminent, and the policy situatiorf may be deteriorating. We have not been able to analyze all such cases. However, our field investigations in seven countries of Asia and Africa illustrate how complex and sensitive is the policy development function, and that the strategies for policy development have to be fine tuned to the size, stage and political environment of each country.

During recent years, the Bank has played a particularly active role in the development of population policy dialogue at the regional level in Africa. It has organized conferences and training programs for African policy makers. While reports suggest that these meetings have not been uniformly successful, they represent an important effort to reach a particularly important audience, and where followed up by project officers and regional loan officers, the results have been positive. The Policy and Research Division's analytic work on the African population situation was effectively used in these seminars. Similarly, special meetings to bring together government and NGO representatives on a regional basis have been effective. We feel that such regional efforts at policy dialogue are likely to be effective and should be employed on a regular basis. The Bank may also want to explore country specific policy development activities of the kind carried out by RAPID II under USAID sponsorship or by the ILO under UNFPA sponsorship.

13
Policy development and commitment can b- considerably facilitated by strong support from top manaement In the Bank, and from the loan officers and country economists in the regional departments. During our interviews, it became clear that the PHN staff perceive enhanced top management commitment to populat4on issues during the past few years. However, practical translation of such commitment into policy dialogue has varied from one region to another and from one country economist to another. At the initial stages of commitment building and later stages of major strategic shifts in older programs, support from top management and the region are essential to the success of policy dialogue.

# B. Sector Work

Sector work has served two basic purposes. First, it has provided a knovwledge base for project identification and development. Second, sector reports have served as basic documents for initiating policy dialogue with program managers. During recent years, a significant proportion of staff time has been devoted to sector work. In 1985, 9.6 PHN higher level staff years were utilized for sector work as cc:r._red to 1.3 staff years in 1979. The PHN staff years devoted to sector work as a proportion of total staff years devoted to combined activities of lending, supervision and sector work increased from 5'percent to 20 percent during the same period.<sup>2</sup> We now briefly review the volume, scope, quality and impact of population sector work on the Bank's lending activities.

# 1. Volume and Regional Distribution of Sector-Work

Table II-1 shows the number of PHN-related sector and economic reports prepared since 1969. A total of 71 such reports were prepared between 1969 and 1986.3 Of these, more than twothirds were completed since 1979, which points to a considerable increase in sector work since the reorganization of the department in 1980.

In terms of regional distribution, East Africa, EMENA and LAC regions show an increase in sector work after 1979 (Table II2). For example, as compared to only seven reports on African countries during 1969-79, there were seventeen reports from 1980

> 2 Review of PHN Lending_in the Health Sector, October 11, 1985, pg. 7.

> 3 This excludes informal white cover reports. We could not get a complete count of such reports, as they are not included in any formal reporting system.

14
# Table II-1

|Number of PHN related econom<br>reports completed sinc|ic and sector<br>e 1969,|
|---|---|
|by year||
|FY<br>Number|Cumulative|
|by year|by year|
|____________________________<br> <br>||
|1969<br>3|3|
|1970<br>5|8|
|1971<br>1|9|
|1972<br>0|9|
|1973<br>3|12|
|1974<br>2|14|
|1975<br>3|17|
|1976<br>1|18|
|1977<br>2|20|
|1978<br>2|22|
|1979<br>6|28|
|1980<br>2|30|
|1981<br>5|35|
|1982<br>4|39|
|1983<br>5|44|
|1984<br>10|54|
|1985<br>10|64|
|1986<br>7-|71|
|Total<br>71|71|

Source: Internal Documents Unit

# Table II-2

The number of PHN related sector and economic reports completed since 1969, by region and time period

|Region<br>------------------------------------------|<72<br>---------------------|72-75|76-79|80-83|>83|Total|
|---|---|---|---|---|---|---|
|S.Asia|3|0|3|3|3|12|
|E.Africa|1|2|0|6|7|16|
|W.Africa|2|0|2|2|2|8|
|E.Asia/P|2|4|2|3|4|15|
|LAC|1|0|2|2|5|10|
|EMENA|0|2|1|1|6|10|
|--------------------------------------------------<br>Total|--------------<br>9|8|10|17|27|71|

Source: Internal Documents Unit 15
to 1986. Thus, both the volume and regional distribution of sector work has undergone significant change. There is a relative shift from Asia, the traditional stronghold of population activities, to other regions, and specifically to Africa.

# _._ ScoDe of Sector Reports

Table II-3 shcws the distribution of sector reports by title. Only 16 reports deal exclusively with population and/or family planning 4issues. The majority (ten) of these specialized population sector reports were completed by 1979. From Table II3, we see that the increase in the volume of PHN related sector work since 1979 has been mainly due to health, nutrition, and combined PHN reports. Only six sector reports completed after 1979 focus exclusively on the population sector.

# TABLE II-3

Distribution of PHN related sector and economic reports since 1969, by title and time period

|Title|<72|72-75|76-79|80-83|>83|Tbtal|
|---|---|---|---|---|---|---|
|AgReform<br>I|<br>0<br>|0|0|1|0|1|
|Eco<br>I|7|0|5|4|2|1<br>18|
|Fert/Region<br>l|0|0|0|1|0|I<br>1|
|Fert/Trends<br>I|<br>0|0|0|0|1|1<br>1|
|Food<br>I|<br>0|0|2|0|0|1<br>2|
|Food/Nut|.0|0|0|0|1|1<br>1|
|FPP<br>I|2|5|0|0|0|I<br>7|
|H<br>I|<br>0|0|2|2|5|1<br>9|
|HumCapital<br>l|0|0|0|1|0|1<br>1|
|H/N<br>l|0|0|0|1|0|1<br>1|
|P<br>I|<br>0|3|0|2|2|1<br>7|
|PHN<br>I<br>|<br>0|0|0|1|12|1<br>13|
|P/H<br>I<br>|<br>0|0|0|1|3|1<br>4|
|P/HumResourcesl|0|0|0|1|0|1<br>1|
|P/SocialServ l|0|0|1|0|0|1<br>1|
|Spatial<br>I|<br>0|0|1|1|1|1<br>3|
|----------------------------------------------------------|------------||||||
||9|a|11|16|27|71|

# Source: Internal Documents Unit

Among the population variables, population distribution has received less attention in sector analysis than the questions of population size and growth. Only three sector reports (Colombia, 1976; El Salvador, 1979; and Indonesia, :.984) provide detailed 16
analyses of population distribution. Similarly, mortality received limited attention in pre-1980 sector reports. Ho,.ever, since the reorganization of the department, trends and causes of mortality have beei adequately analyzed.

The role of NGOs in the population sector has still not received adequate attention in sector work. Even in countries where NGOs account for a large share of family planning activities, the sector reports generally do not go beyond description of NGO activities. Some relevant examples are the Philippines (1973 and 1984), Egypt (1985), Guatemala (1981), Haiti (1981), and Malawi (1984). A few exceptions are the Population Sector Report for Mauritius in 1983, and the Food and Nutrition Sector Report for Bangladesh in 1984, whl:h make specific recommendations for involving NGOs in the national program.

# 3. Quality_of_Sector Work

The Review of PHN Sector Work and Lending in Health ,19801985 (1986) incluk'es a detailed analysis of the scope and quality of all PHN sector -eports completed since 1980. Its overall assessment is summi:ized as follows: PHN sector work increased in comprehensiveness, depth of analysis and overall quality over the five year period. Several areas received increasing attention over time: health costs and financing, the hospital sub-sector, pharmaceuticals and nutrition ... Better preparation and larger missions contributed to the gradual improvement in scope and quality.

In order to supplement this review, we analyzed four pre1980 sector reports and thirteen cost-1980 reports<sup>4</sup> which the earlier review did not cover. In general, our findings are consistent with the conclusions of the Health Sector Review: there has been a definite improvement in the sc:ope and quality of PHN sector reports. A comparison of the 1973 Population Sector Review and the 1984 PHN Review for the Philippines illustrates this trend (Appendix, Table A-1). The 1984 review is much more detailed and rigorous in its analysis of the determinants of birth rate; the consequences of population growth for land use, health and education, the labor force, and production; regional differences in services and client needs; and cost and expenditure data. Some of the special sector reports, such as

> 4Egypt (1981 and 1985), Philippines (1973 and 1984), Haiti (1986), Guatemala (1986), Bangladesh (1985), Guinea (1986), Honduras (1983), Indonesia (1980 and 1986), Malawi (1986), Mauritius (1983), Nepal (1982), Pakistan (1978), Thailand (1975).

17
Indonesia (March 1980) and Egypt (1981), are highly comprehensive and show great depth of analysis. Both these reports also provide a good secondary analysis of survey data.

Most sector reports are strong in demographic and population analysis but weak in analyzing program effectiveness issues, especially those which are salient at the program-client interface level. Typically, sector reviews do not go beyond description of the service delivery and IEC system and preliminary assessment of the management structure at the central government level. Since management issues are likely to be sensitive and sector reports need government clearance, the reluctarce to deal with certain issues is understandable, but since chese issues lie at the heart of effective program and project development, it is important that a mechanism be found to address them. The Mauritius (1983) and Egypt (1985) reports are exceptions, as they focus on management aspects in some detail.

The coverage and depth of sector reports vary considerably. Basic demographic analysis is handled with reasonable consistency, but the discussion of program management, other government departments and NGOs does not conform to any se,pattern. It seems that the composition of the review team may account for.some of the variance in scope and auality.

# 4. Impact of Sector Work

It is very difficult to assess the impact of sector work on Bank activities and the development of population policies. The Health Sector Review concluded that sector work had had a considerable impact in terms of both these criteria. Our interviews also brought out that the operations staff find the sector work useful in project development and policy dialogue.

We have already discussed sector work in relation to policy dialogue in the previous section. We found that sector reports have been an important input in policy dialogue in Africa and Latin America. It is not clear that the same holds for some of the mature programs in India, Indonesia, Egypt, Pakistan and Bangladesh. In fact, it should be mentioned that sector work regarding mature programs hai been extremely limited.

At the aggregate level, there seems to be a clear correspondence between the volume of sector work and the number of projects: compared to 71 PHN related sector and economic reports, there are 60 projects. However, we find that sector work has not always been a precursor of project development. Our tentative analysis indicates that there are 22 projects in 17 countries where no sector work was done before the project was appraised (Table A-2). There are 23 sector reports for 22 countries where the sector work has been completed, but where no 18
projects had been signed by November 1986 (Table A-3).<sup>5</sup> However, of these 22 countries, eleven countries had a project in the pipeline as of April 30, 1987. This indicates a strong association between sector work and project formulation in recent years. Of course, there is no reason to expect a one-to-one correspondence between sector reports and project development, as sector reports are used as a basis for deciding on the feasibility of undertaking a project. Similarly, in some countries, sector analysis is undertaken as a part of the project appraisal exercise. However, it would be useful for the PHN to analyze those cases where sector work did not lead to project or policy development.

# C. The Role of Research

Research is done both at Bank headquarters and as a part of project activities. In a field such as population where there is still great uncertainty as to the most effective approach, the potential contribution of research is enormous. However, developing effective research programs is always difficult, and the task of developing research which will be of use to project staff seems particularly challenging.

1. Research Done at Bank Headauarters and Its Contribution to Projects

Population related research has been done at the Bank under a number of different organizational structures. In 1971, a Population and Human Resources Division was established in the Development Economics Department. This division performed basically as the Policy and Research Division of PHN does today, carrying out work on various policy issues, research and operational support. Its work was generally expected to complement the operational work of the Population Project Department. As mentioned earlier, in 1974 a Population and Human Resources Division was established under the Research Department. That division undertook a number of studies related to fertility and was generally expected to complement the operational work of the Population Projects Department. As mentioned earlier, this Division joined the Policy and Research Division of PHN in 1982, thus centralizing research responsibilities into one department. During the past several years, the division has developed a formal research agenda relating to health and population, expanded its staff and produced a number of important research studies. Much of the research undertaken by the division deals with health. In this review we are concerned primarily with population, but it should be noted that some of the research that

> 5 These figures do hot include informal white cover reports. We were informed by many Bank staff that these reports do form a basis for informal discussion with country counterparts.

19
is classified as health-related has important implications for population as well. For example, the study of aspects of health finance or of pharmaceuticals has implications for family planning programs, which are usually closely associated with health programs.

In addition to the population research conducted by the Policy and Research Division of PHN, the Bank also contributes to the work of WHO in the development of new contraceptive technologies. This contribution is administratively outside of PHN. Modest amounts of population related -search are also undertaken in the Education Department and in other parts of the Bank.

The general theme of current research in the Policy and Research Division is the internal efficiency of alternative policy and program strategies. The current focus of research in population falls into five areas:

- -* effectiveness of alternative family planning delivery systems,

- the role of the private sector in contraceptive distribution,

- incentives for small family size,

- populations projections for use in the sector work of other divisions in PHN and by the rest of the Bank, and research with a special focus on Africa.

In addition, "health" related research on cost-recovery and on drug procurement and utilization have relevance for the population sector. This agenda for research was established in 1984 and represents an attempt to change the orientation of the Policy and Research Division to be more supportive of the operational work of other divisions.<sup>6</sup> The outout of the Policy and Research Division is impressive. By the standards of outside research organizations, there is little doubt that the productivity of the Bank staff is distinguished. Two questions that have been raised in our review deal with the extent to which the division contributes to the work of the operating divisions, and the extent to which the topics chosen for emphasis are those most calculated to contribute to long run objectives of Bank work in population.

It is notable that in our discussions with PHN staff outside of the research areas, there was little mention of the contributions of the division to the ongoing work of developing and implementing projects. The policy study Population Growth 6Internal Memorandum, "Population: ideas regarding future research and policy work," June 15, 1984.

20
and Policies :.n Sub-Saharan_Africa is an exception, and the participation of policy and research staff on missions was also appreciated, but it is our impression that the limited staff of the division has not yet developed research strategies that strongly imoact on the lending work of the department. In significant measure, that is probably the result of limited staff resources (there were only six full-time higher level staff members in the division at last count), and the possible addition of new staff should improve the situation.

The contribution of the division to lending activities would be greater if there were a greater emphasis on operational issues relating to the projects for which PHN has responsibility. Specific topics would include provider-client relationships in country programs, the operation of demand generation efforts in country projects, managerial patterns in country programs and the organizational characteristics of country programs, especially with regard to the problems of interagency coordination, the relationship with NGOs, and institution building activities. There are also many research issues relating to specific aspects of Bank projects to which the high level skills of the Bank research staff could contribute significantly. An example is the analysis of the area projects in India and their impact. Having listed this set of topics which need attention, it is important to note that the division is currently initiating research on many of these topics, within its resource limits.

In other sections of this report, we have identified a number of areas of concern in the design of Bank population projects, e.g., management, institutional development, and provider-client interaction. These are also areas of concern for research, and each suggests a long list of potential research topics. Such a list might include the following:

- What are the current practices with regard to management, i.e., supervision, finance, appointment and reward systems, etc., in various Third World countries? How are these practices related to program or project performance? How can these practices be changed in the context of the larger organizational environment in which projects are carried out?

- What has been the nature of institutional develppMent efforts carried out by various donors? What are the factors that influence success or failure of these efforts? What are examples of successful institutions in the field of population? How did they develop? What was the role of donor institutions?

- Who are the providers (actual and potential) and who are the clients of family planning and related services in various Third World settings? What is the,nature of provider-client

21
interactions? Where di they take place? What is their frequency and duration' What is their quality in the eyes of clients and as measured objectively?

The special characteristics of this research effort are that it is empirical, uses appropriate modern research techniques (such as surveys, statistical inference and participant observation), and focuses on programmatic issues including the previous experience of the Bank in its own projects and activities. More detailed suggestions for a research agenda with a programmatic orientation can be found in the NAS report or in a number of recent reviews sponsored by USAID or UN agencies.

In our visits to countries, research undertaken by the Bank was not cited as an important factor in determining the effectiveness of programs. Given the many uncertainties concerning both which approaches are likely to be most effective in reducing population growth and the many questions concerning the current operations of programs, this lack of a strong identified role for research is striking. A shift towards the kind of emphasis outlined above might give research a more prominent role. Another and related improvement would be to incorporate more research in project activities.

# 2. The Research Component siithin Projects '

Many projects contain provision for a research activity. Projects in Sierra Leone, Bangladesh and Kenya have all had at least some research component. Most observers with whom we spoke felt that these elements had been weak. A major problem has been the inability of program organizations to utilize fully the results of project research for improving program effectiveness. Even those projects that do not have an explicit research component do provide for project evaluation using research techniques. The full range of evaluation and monitoring within projects has been recently reviewed by PHN,<sup>7</sup> and a number of suggestions have been made for strengthening the activity: doing more to assure national commitment to evaluation and research, reviewing the role of external technical assistance and strengthening the role of MIS in projects.

In sum, research and policy analysis have a central contribution to make to population work of the Bank. The accomplishments of the Policy and Research Division are impressive, but the possible list of topics still demanding attention is long.

7L. Chester, "Monitoring and Evaluation Components in Completed Population Projects," PHN Technical Note 85-2.

22
## III. PROJECTS: DESCRIPTION **OF** EFFORT

In this section, we present a general description of population projects undertaken by the Bank and the strategies around which they are designed. The emphasis here is on the original design of the project. Later sections will deal with project effectiveness and with the process by which projects are appraised and implemented.

# A. General Description of Projects

# 1. Number of Projects

Table III-1 shows the number of projects undertaken between 1970 when the first population/health project was initiated, and 1986 by nominal subject area and by time period. Several points stand out in this table. First, the overall number of projects undertaken in the population, health and nutrition area has increased substantially beginning with one or two projects per year during the early 1970s and reaching levels of seven or more projects per year during the past four years.. There seems to have been either a mild peak in lending activity in 1979-80 or a drop during 1981-82. Second, the division of projects between population and health has fluctuated with more emphasis on population in the early and late periods and more stress on health during the early 1980s. The number of projects classified as "nutrition" has been small. Third'. the Bank has clearly succeeded in its goal of expanding lending in the population sector, but the number of "population/health" projects per year is not absolutely large (three in 1986) and is relatively small in comparison with the number of "health" projects. Note as stressed in the earlier discussion that these categories are not mutually exclusive since many "population" projects have extensive "health" content and vice versa.

# 2. Lending for Prolects and Trends

Table III-2 shows the increase in lending for PHN type projects. During the 1970s the total level of commitments was generally less than $50 million per year. In 1986 it was over $400 million. Of the total, since 1983 less than one third of lending has gone for "population" and "population/health" projects ($256.65 million of $830.15 million; Table III-3); but in 1986, the total committed to population projects ($134.3 million; Table III-2) is a significant amount, the same order of magnitude as the UNFPA budget and about 50% of the USAID budget during the same period.

23
TABLE III-1 The number of Bank supported PHN projects FY1970-86, by nominal subject area

|Year|No. of<br>projects|Popu-<br>lation|Pop/<br>Health|Health|Nutrition|
|---|---|---|---|---|---|
|---------------------------|----------------------------|||||
|1970|1|1|0|0|0|
|1971|2|2|0|0|0|
|1972|2|2|0|0|0|
|1973|1|1|0|0|0|
|1974|2|2|0|0|0|
|1975|2|2|0|0|0|
|1976|3|2|0|0|1|
|1977|2|1|0|0|1|
|1978|2|1|0|0|1|
|1979|4|4|0|0|0|
|1980|4|3|0|0|1|
|1981|1|0|1|0|0|
|1982|2|1|0|1|.0|
|1983|7|1|0|6|0|
|1984|7|1|1|5|0|
|1985|7|1|1|5|0|
|1986|11|2|1|7|1|
|Total|60|27|4|24|5-|

Source: Internal Documents Unit 24
# Table III-2 PHN Loan Commitments in Population (US$ million) 1970-1986

|Fiscal<br>Year<br>---------------------------|<br>No. of<br>projects<br>-------------------------------|Popu-<br>lation|Health|Pop./<br>Health|Nutri-<br> <br>tion<br>Total|
|---|---|---|---|---|---|
|1970|1|1|0|0|0<br>12.00|
|1971|2|2|0|0|0<br>7.80|
|1972|2|2|0|0|0<br>34.40|
|1973|1|1|0|0|0<br>5.00|
|1974|2|2|0|0|0<br>17.00|
|1975|2|2|0|0|1<br>40.00|
|1976|3|2|0|0|1<br>50.30|
|1977|2|1|0|0|1<br>18.00|
|1978|2|1|0|0|0<br>55.00|
|1979|4|4|0|0|1<br>114.00|
|1980|4|3|0|0|0<br>168.00|
|1981|1|0|0|0|0<br>12.50|
|1982|2|1|1|1|0<br>36.00|
|1983|7|1|0|6|0<br>118.40|
|1984|7|1|1|5|0<br>243.05|
|1985|7|1|1|5|0<br>191.00|
|1986|11|2|1|8|0<br>419.00|
|- - - - -|- - - -<br>- - - - -|<br> - - - - - -<br>-|...--<br> - - - - - - - -|- -<br>- - - -|- - - - - & - - - - ----<br>- - -|
|Total|<br>60|27|4|25|4<br>1,541.95|

## __. Regional Breakdown and Trends

Table III-3 shows the same set of projects arranged by type, region and time period. Asia has received the largest number of projects, but in recent years lending activities in Africa have increased significantly. It is notable that most of the lending for population is concentrated in Asia while projects in other parts of the world are for health. The number of projects in the Africa region has expanded significantly, but most of them are "health" projects. Among these projects, many have a small family planning component, generally less than 10% of the committed loan or credit.

25
# Table III-3

# World Bank supported population, health, and nutrition projects by type, region and year, as of November 30, 1986

The number of projects appears first, followed by the loan commitment (in U.S.$ Thousands).

# Population and Population/Health

|<72|72-75|76-79|80-83|>83|
|---|---|---|---|---|
|S. Asia|2(36.2)|1(32.0)|2(64.0)|3(199.0)|
|E. Africa|1(12.0)||1(23.0)|2(6.35)|
|E. Asia/P|3(43.2)|4(111.5)|2(65.0)|1(46.0)|
|W. Africa||||1(5.3)|
|LAC<br>2(5.0)||2(11.8)|||
|EMENA<br>1(4.8)<br>.__________--------------------------------------------------__---------|1(12.0)|1(25.0)|1(12.5)||
|Total<br>3(9.8)|7(103.4)|8(180.3)|6(164.5)|7(256.65)|
|Health and Nutrition<br><72<br>-------------------------------------------------------------------|72-75|76-79|80-83|>83<br>--|
|e<br>Asia||1(32.0)|1(32.0)|__|
|E. Africa|||1(6.8)|3(31.8)|
|E. Asia/P|||1(27.0)|3(204.0)|
|W. Africa<br>.|||1(15.0)|6(142.3)|
|LAC||2(44.0)|2(36.5)|4(153.5)|
|EMENA<br>-------------------------------------------------------------|||2(17.6)|2(41.9)<br>--------|
|Total<br>Total||3(76.0)|8(134.9)|__<br>18(573.5)|
|<72|72-75|76-79|80-83|>83|
|S.Asia|2(36.2)|<br>2(64.0)|3(96.0)|<br>3(199.0)|
|E.Africa|1(12.0)||2(29.8)|<br>5(38.15)|
|E.Asia|3(33.2)|<br>4(111.5)|<br>3(92.0)|<br>4(250.0)|
|W.Africa|||1(15.0)|<br>7(147.6)|
|LAC<br>2(5.0)||4(55.8)|2(36.5)|<br>4(153.5)|
|EMENA<br>1(4.8)|<br>1(12.0)|<br>1(25.0)|3(30.1)|<br>2(41.9)|
|-------------------------------------------------------------|||||
|Total<br>3(9.8)|<br>7(103.4)|11(256.3)|14(299.4)|__---------<br>25(830.15)|

26
# 4. The Population Component of PHN Proj cts_and the Role of IDA

Of the 60 PHN projects listed in Table A-4, Table III-4 lists those non-population projects for which been have been given an estimation of the percentage of population activity. Among these 18 health and population/health projects, the population component is less than 10% in eight projects, and 1025% in six projects.

There is a feeling that willingness to accept loans for population is influenced by the lending terms, although we lack sufficient evidence to support t;lis. The issue may require further investigation by the Bank. The data available are presented in Table A-5.

# Table III-4

# Percentage of funding devoted to population activities in non-population projects

|:=__________________________________________________|Fiscal<br>Year<br>Approved<br>___|Project<br>Total<br>US$m|Proportion<br>devoted to<br>population|
|---|---|---|---|
|Botswana I (H)|1984|26.60|7.5%|
|Burkina Faso I (H)|1985|28.00|2.0%|
|Comoros I (H)|1984|3.12|14.0%|
|Ghana I (H)|1986|15.60|5.0%|
|Ivory Coast I (H)|1986|29.70|22.0%|
|Jordan I (H)<br>|1985|30.50|25.0%|
|Lesotho I (P/H)|1985|7.42|19.0%|
|Malawi I (H)|1983|8.70|9.0%|
|Mali I (H)|1984|29.30|<10%|
|Morocco I (H)|1985|47.60|10.0%|
|Niger I (H)|1986|29.30|6.0%|
|Nigeria I (H)|1985|53.00|<5%|
|Rwanda I (H)|1986|14.45|(1.18)8|
|Senegal I (H)|1983|16.70|<10%|
|Sierre Leone I (P/H)<br>|<br>1986|5.70|20.0%|
|Tunisia II (P/H)|1981|41.00<br>|(1.13)|
|Yemen AR I (H)<br>|1983<br>|n/a<br>|0.0%<br>|
|Yemen, PDR I (H)|1983|n/a|0.0%|

Source: Responses to a survey circulated by Lauren Chester

> 8 Dollar estimates are given where percentages are not available.

27
# B. **Project Design**

As indicated in the introduction, population activities can have as their objective changing tCis demand for birth prevention services or providing the services or both. Projects can also be directed at influencing the organizing activities designed to facilitate either of these two objectives. Within each of the broad categories there are also many possible ways of approaching a problem. Some projects may be designed to work on a very broadly defined approach to fertility reduction, but most projects are somewhat selective in their approach. Given limited resources and administrative energy and the need for internal consistency in project activities, even projects with broad objectives must define a strategy for achieving their goals. In this section, we discuss the strategies that characterize the population projects of PHN under two headings: the nature of the planned intervention and the nature of the planned organizational structure. We use the term 'planned' to give emphasis to the focus on strategy and design.

As an appendix to this report, we have prepared a table with budgetary breakdowns for PHN projects (Table A-4). Many of the generalizations made in the next paragraphs are based on our reading of the plans for projects embodied in these appraisal budgets.

# 1. Nature of Planned Interventions

# a. Balance between health and family planning

The projects supported by PHN have a relatively strong health orientation. Among the countries we visited, only in Indonesia is the current project with population content run outside the Ministry of Health. Compared to other major donors such as UNFPA or USAID, there is a very strong emphasis on health content and on the use of health infrastructure in Bank projects. As mentioned in the introduction, this orientation is the result of a conscious decision to approach population through the provision of primary health care: "health lending to those countries without formal policies on family planning would afford opportunities for dialogue on population issues and for supporting family planning services through the health care systems." Most of the Bank staff with whom we have discussed the issue believe strongly that health activities are a vehicle for introducing a concern for population growth. It is felt that the Bank's need to use loans rather than grants strengthens the case for this approach. Outside critics feel that the heavy emphasis on the "health approach" commits the Bank to working

> 9 Anthony R. Measham, Review of PHN Sector Work and _Lending in Health, 1980-85, March 1986, pg. 1.

28
with weak institutions and blinds it to opportunities outside health, e.g., in ministries such as labor or education or in other agencies. Also, the past experience with health ministries has not been very encouraging. The PPARs for the completed projects list a weak commitment to population programs among health administrators in Egypt, the Philippines, Trinidad and Tobago, Iran, Kenya, and Tunisia.

# b. Definition of target groups

It is our impression that more attention has been given to questions of staff size, training and supervision than to the central question of what the staff are expected to do. What is the exact nature of the services that are to be delivered and of the related IEC effort? In general, there seems little discussion of issues such as the method mix and how a project may influence its evolution or how client groups might be segmented for most effective intervention. The Tamil Nadu nutrition project may provide an example of how such an approach could be used in the "soft" sectors of PHN.

# c. Community participation

Community participation has not been a common element in population project designs. A recent review of community participation in Bank projects identified eleven PHN projects with explicit community participation strategies, including nutrition (3), health (3), and population projects (5).lO Indonesia and Bangladesh provide leading examples of community participation strategies in population projects. The primary organizational devices used to elicit community participation were user groups, community workers and field extension workers. Most of the projects do not go beyond involvement of community members in information sharing and consultation. Unlike some of the irrigation and urban projects, "HN projects did not provide for financial contribution from beneficiaries at the design stage.

It should also be mentioned that there have been few projects that have involved beneficiaries in the design process in any systematic way. This involvement is very difficult for national level projects that are designed for five years by the central government, but research on the experience of other organizations and explicit attention to the need for this involvement would be a beginning point.

The Bank review mentioned above concludes that in terms of taking the initiative for incorporating CP project strategies, 10 "Community Participation in Development Projects: the World Bank Experience," March 11, 1986. Draft.

29
the role of the Bank staff by and large has been reactive rather than proactive. Our field visits also endorsed this observation. This lack of initiative on the part of the Bank staff may be due to the Bank's close association with national governmental structures, lack of orientation towards community participation, lack of relevant skills, and a practically non-existent in-house knowledge base about community participation strategies and methodologies. It should be mentioned that the nutrition projects have utilized community involvement much more successfully than the population projects.

The impact of community participation strategies has varied. Indonesia provides the most successful example. Although Bangladesh continues to be very active in this field, there have been problems in implementation:<sup>11</sup> The first project did attempt to involve the communities in the construction of UHFWDs ...

However, this practice was discontinued after reported unsuccessful experience during the first two years of the second project ...

Even project components such as Mothers Clubs -.. are to a large extent managed by the Government, and there is limited training for women leaders to become effective motivators, community mobilizers, and organizers.

The PPAR for the Dominican Republic Population and Family Welfare Project observes that the results of the CBD component of the project were "mixed" (1985, p. 22). The implementing NGO could not meet service targets, there were delays in funding, and the relations became strained between the government agency and the NGO before the program was discontinued.at the end of 1979. Efforts to increase community participation are an important element in orienting project activities towards the periphery and deserve continued attention in Bank projects. It must also be recognized, however, that there are no simple formulas for making these programs work. Thus, continued effort will be required to find the best formula for each country.

# d. Construction as a component of projects

One of the notable characteristics of the Bank compared with other donors in the population field has been its willingness to provide resources to support the construction of clinics, training centers, housing for rural field staff and other infrastructure. During recent years, the Bank has put more emphasis on management and demand generation activities and less 1lProject Performance Audit Report: Bangladesh First Population Project (1986, p. 24).

30
on corstruction than it did during the early phase of its activities in the population sector. Nonetheless, construction is still a very important element in Bank projects (see Table A-6 for support of this proposition). Civil works constitute nearly half of the project budgets in most countries. We believe this is appropriate since other donors are reluctant to provide loans or grants for construction and there is a clear need in many countries for the improvement of facilities. The potentially problematic element in lending for construction is that for various reasons, construction tends to become the lead element in the projects. It demands a disproportionate amount of time from Bank and national staff, and it is not always closely coordinated with the software aspects of the projects. It also tends to confine the choice of the service delivery strategy around the health infrastructure and thus limits the scope for alternative delivery channels.

In a number of countries there is concern that the recurrent costs associated with using the capacity generated through the construction program may be higher than can be sustained. Since the Bank and other donors are reluctant to lend or provide grants for salaries and other recurrent costs, the burden of financing the ongoing operation of many programs falls on the government. In countries where a significant amount of infrastructure development has already taken place, sector support loans 77sy be a viable strategy to maintain and use capacity developed in the population sector. A sector loan is currently under discussion in Indonesia, and the idea might be useful in other countries as well.

# e. Role of education and demand generation activities

Demand generation efforts in population programs have usually begun with (and often ended with) IEC activities. The design of IEC comzonents for Bank supported population projects has been a weakness. The exact nature of IEC objectives and the steps necessary to achieve them has not been 3pelled out in most projects. In talking to project managers in the field we detected a great deal of confusion as to the IEC component of projects. IEC project elements have lagged in countries such as Kenya, India and Egypt, and supervision has been applied more effectively to keep construction on target than to keep IEC programs close to plan. This weakness derives from the lack of orientation to IEC in the countries themselves (especially in health ministries), but the Bank has not been successful in establishing enough offsetting pressure to make this aspect of projects successful. Project managers in many countries are aware of the problems and are exploring new approaches.

Alternative efforts to increase demand through such activities as women's education or employment, incentive programs, and social security linked alternatives to large 31
families have received even less attention than IEC. This may result from the general lack of consensus an the field as a whole as to how these activities can be integrated into population projects. It should also be noted that a few projects, such as in Indonesia and Bangladesh, include some elements of a broadly based demand generation strategy, and that the Policy and Research Division is exploring some aspects of demand generation. Thus, future projects may include more attention to these activities, but for the moment the Bank has limited staff capability and field presence in this area.

# f. Role of service delivery

Servf,:. delivery lies at the heart of the Bank population project strategy. In most countries, the i-..tial projects seem to have been designed primarily to increase the coverage of the population with basic services. In countries with more than one generation of population project, there seems to have been an evolution towards an emphasis on quality and utilization of services rather than just accessibility and coverage. However, the quality issue has been addressed mainly through training and skill building; other factors influencing quality of services such as performance standards and targets, supervision, motivation, etc., are not consistently addressed in department projects. Since improved skills are not likely to be effectively utilized in the absence of other supporting factors in the work environment, a fuill systems perspective is needed to bring about the desired changes. Recent projects such as Bangladesh III have tried to address the problems of service quality.

# g. Large vs. small projects

The scale and complexity of Bank projects is considerably greater than that of other donors. In many cases Banlc projects encompass the full range of national program activities. This scale has the advantage that the Bank is immediately involved in the central issues of national program formulation and implementation. It has the disadvantage that the simultaneous coordination of all #lements in massive projects can lead to delays or problems of implementation. It may also reduce the ability of the Bank or the national program to respond flexibly to new opportunities or problems. The delays in beginning implementation of Bangladesh III are probably in part a function of the scale of the project. While there is no rule to fit all situations, we feel that a pattern of smaller, possibly focused projects with some overlapping a- time may be more effective in many countries.

# h. Designed efforts to improve management systems

Population projects are carried out within the larger context of government development programs. These programs thus 32
share the government approach to management; i.e., finance, personnel, reporting structure, systems o, monitoring and evaluation, etc. Many Bank population projects are designed to address recognized management weaknesses, but in most cases attention is focufed on limited problems within the project jurisdiction because the larger management questions are offlimits. Personnel is a good example.

Because the Bank works primarily through government agencies, it usually accepts the personnel systems that exist in the government service. In many countries, project success is greatly hampered by personnel policies such as frequent transfers, lengthy and cumbersome recruitment procedures, and lack of opportunities for promotion. Since most of these practices are common throughout the government, it is difficult for projects to have their own personnel policies. Most projects recognize this difficulty and revert to generalizations about needed management without very much specification of issues and how they are to be addressed within a particular project. This results in part because often neither Bank representatives nor their counterparts in the national capital have a good understanding of management at the periphery, that is, of how projects are actually managed at-the service delivery level. In earlier projects, there seemed to be little concern with such issues, but recent projects have shown a greater commitment to management and implementation issues. On Bangladesh III, for example, these issues are central to the project. Some efforts have been made to have countries agree during negotiations to certain conditions regarding key personnel, but there is no clear assessment of how well these undertakings have worked to improve either the project or the national performance. This is one area where links with other parts of the Bank that have more experience with the determinants of bureaucratic effectiveness may improve project design.

Supervision is another related example of an area in which there are recognized weaknesses in the management of population (and health) programs. Project documents from the period after 1980 indicate that some projects have included substantial efforts to improve supervision of clinical practice and field work. In the Nigeria I project, for example, it is recognized that, the quality of care ... delivered at the primary level of the health system could be significantly improved ... if greater efforts and resources were allocated to raising the technical knowledge and skills of health workers. Among the key constraints identified by the 33
Sokoto State Government (is) the absence of a systematic approach to technical supervision The project allocates a significant portion of the total budget to developing solutions to these perceived problems. Niger I also includes an effort to upgrade the quality of field work, and again emphasis is given to improving the supervision component of field service delivery that had previously been neglected.

In sum, although Bank population projects are placing increasing emphasis on management issues, they are regularly constrained by the necessity of working within the government structure; by the lack of broadly based empirical knowledge concerning management practice, especially away from the national capital; and by a lack of experience with alternative approaches. Stronger linkages between the research and implementation divisions of PHN may help in both of these areas. It is also important that projects be designed with enough flexibility that adjustments can be made during the life of a project on the basis of cumulated experience.

The Bank is taking steps to strengthen its capacity in the management area. For example, it has commissioned a review of successes in delivering services to particularly disadvantaged groups*13

# i. Monitoring and evaluation'

All projects have plans for monitoring and evaluation. However, a recent PHN internal review<sup>14</sup> concluded that evaluation and research received more attention than monitoring. Table III5 lists the major monitoring, evaluation and research (MER) activities included in completed projects. Most of the activities are in the form of special studies, rather than in the form of designing a strong on-going program evaluation system. The MER activities are generally carried out through technical assistance (mainly from external consultants, except in India and Indonesia), MIS design, evaluation and research, and external program reviews. further research is needed on the way these systems are used to improve decision making in the field.

> 12 SAR, 1985, paragraph 3.22.

13See David F. Pyle, "Provider-Client Interaction at the Periphery: What's Worked in Large-scale Population, Health and Nutrition Projects in the Third World." John Snow, Inc. June 1987 (draft).

> 1 4 "Monitoring and Evaluation Components in Completed Population Projects," Lauren A. Chester, PHN, Technical Note 852, April 1985.

34
# Table III-5

# MER Activities in Completed Population Projects

Manpower Studies Jamaica, Trinidad and Tobago Indonesia, Kenya Facilities Scheduling or Jamaica, Indonesia, Egypt Maintenance Studies Management, Service Delivery India, Malaysia, Egypt & or Program Effectiveness Studies Dominican Republic Family Size Motivation and Kenya, Egypt Acceptor Studies Review Existing or Design New Trinidad and Tobago, Evaluation Systems Malaysia, Dominican Republic Develop or Improve Management Trinidad and Tobago, Information System Tunisia, India, Indonesia, Dominican Republic External Reviews Jamaica, Trinidad and Tobago, Tunisia, Malaysia Establish Demonstration Project Areas

-------------------------------------------------------

Malaysia, Indonesia __--.____Source: Staff Appraisal Reports, PHN, as summarized in Lauren A. Chester (April, 1985), p. 37.

# 2. Nature of Planned Aproach to Organizational Structure

Projects are defined not only by expectations concerning the nature of activities to be carried out under the mandate of the project but also by the organizational approach to their implementation. In this section we discuss aspects of organizational structure.

a. Location of organizational responsibility in the bureaucracy Most Bank projects with population content are located in ministries of health. This location tends to be confining in a number of respects. Ministries of health tend to be relatively weak in political and administrative terms, and they often have a 35
defensive attitude towards working with other agencies. There is also a tendency for the staff of health ministries to define population (or health) interventions in terms of services that can be delivered from health service infrastructure. There are, however, a few countries where the Bank has been working closely with other government agencies, especially in Indonesia, Malaysia, and, more recently, Kenya.

# b. Approach to regional organization

Bank population projects tend to be heavily centralized. Project management is typically located in the capital city headquarters of the Ministry of Health. India is an exception, but even there where projects are designed to be implemented at the state level, there has been heavy involvement of the Ministry of Health in Delhi. Even in countries where it is widely recognized that there are many unanswered questions concerning the most effective program design, there has been relatively little encouragement of regional experimentation.

# C. Design of institutional development (ID) activities

In the Bank's current terminology, 'institution building' has become perhaps the mosz important purpose of Bank lending. This means that transfer of financial resources and construction of physical facilities, however valuable in their own right, asre less important in the long run than the creation of a sound and viable local "institution", interpreted in its broadest sense to cover not only the borrowing entity itself, its organization, management, staffing, policies, and procedures, but also the whole array of government policies that conditions the environment in which the institution ooerates.<sup>15</sup> The quotation above underlines the central role and provides a comprehensive definition of institutional development. ID is one of the most difficult tasks in technology transfer as it not only involves new skills but also new kinds of behavior. The Bank's population projects have a very large institutional development component.

ID has involved a wide range of activities, such as policy development through regional seminars, policy dialogue, and development of policy analysis capability; the creation of new organizations (the Population Council in Kenya or Population Centers in India); the creation of new units within existing organizations (the IEC and Training Divisions within the MOH in the Philippines); the strengthening of existing top management 1<sup>5</sup> The Project Cycle, Washington, D.C., 1982, pp. 12-13.

36
structures through office space, equipment and human resource development (the most common intervention); the expansion of rural health/family planning services (Indonesia, India, Iran); skill-building through management (India) and technical skills (Iran, the Philippines, Kenya); the development of new management information, monitoring and evaluation systems (India, Egypt); and research and pilot projects to develop community-based service delivery systems (Egypt, Indonesia, Bangladesh).

The most frequently-used modes of ID have been experimental research and pilot programs, management system design, training and organizational restructuring with the help of outside consultants or Bank missions. Each of these activities has been helped through technical assistance (TA), both external and internal, in the form of short-term and long-term consultants, external review teams, and on-going Bank supervision missions.

# d. Connections with other organizations

Perhaps because Bank projects are so closely identified with ministries of health, systematic connections with other units of government, voluntary agencies, and the private commercial sector are often inadequate. The Bank has taken some initiatives in this area. .In IPP I, there was an effort to give some part of the responsibilities for service delivery in Karnataka to an NGO. The effort was not followed up in the second project. Recently, the Government of India has expressed a strong interest in expanding the role of NGOs, but the Bank projects have not been at the cutting edge of this effort. The Third Kenya project provides for NGOs to be involved through the newly established Council.

Perhaps most important the Bank has recently undertaken an innovative agreement with the IPPF to stimulate the role of NGOs in health and family planning projects in Africa. This effort could bring governments to recognize the potential importance of NGOs and to incorporate them in future agreements with the Bank.<sup>1 6</sup> Despite these efforts to involve NGOs in some projects, it is our impression that the Bank has for the most part been ineffective in bringing a wide range of organizations iiito its projects to supplement the activities of the ministries of health. There would seem to be untapped opportunities for involving NGOs.

Our field visits and meetings with the representatives of various NGOs clearly established the need to strengthen the private sector involvement in population projects. In South Asia, both India and Bangladesh have large organized NGO sectors,

> 16 See memo from M. Sanyal to Dr. Sai and Mr. Hodgkinson, June 25, 1987.

37
and both governments are open to NGO participation in health and family welfare. In the African countries, a variety of self-help groups, such as the hurambee movement in Kenya, have the potential to become involved in family planning. In countries such as Zimbabwe, women's organizations are effective in reaching target groups. There are, of course, some countries where the government is reluctant to involve the NGO sector in development. This is probably true of Nigeria and Indonesia. Thu latter presents an interesting case, as Indonesia has a strong tradition of involving traditional community groups, but is reluctant to involve urban-based organized NGOs in a big way. However, the Ministry of Population is perceived to be much more open in this regard than the BKKBN, and the Bank project includes a modest NGO component to be implemented through the MOP.

It is important to be clear about the role of NGOs within the overall national program. NGOs can provide services in areas not reached by the government or provide those services which the government may find politically or culturally sensitive such as teenage counselling or abortion. NGOs can also experiment with new service delivery strategies and provide model intervention packages. Finally, the NGOs can act as an interest group in the field of population. In any project that seeke to involve NGOs, a clarification of respective roles based on their comparative advantage should be worked out.

INGOs can be more flexible and responsive to new needs than the large government systems. This advantage should not be lost in the enthusiasm to load them with more activities and funds. Also, NGOs have their own organizational weaknesses. They are small in size, divided and fragmented, and heavily dependent on a few committed individuals. Thus, institution building for NGOs must form a part of any viable project.

USAID has mounted a large NGO project in India. Its experience so far suggests the following lessons. (1) NGOs need technical help in project formulation and evaluation. (2) They cannot absorb large amount of grants. Thus, the donor agency will have to reorient its procedures towards administering small projects. (3) When funds are channeled through the government, there is a tendency on the part of some of the governments to ensure uniformity in project designs. This may defeat the very purpose of NGO involvement. (4) It would be helpful if funds can be administered through an autonomous intermediary organization rather than through the government. (5) The government's funding procedures should be carefully re-examined and revised to suite the context and capabilities of the NGOs.

One of the major advantages of the USAID effort has been that it can work through some US based or international NGOs. The Bank should also examine the possibility of working through intermediaries, including other donor agencies which are better 38
suited to work with small NGOs. This may include UNICEF, DANIDA, SIDA, foundations, IPPF, internationally based NGOs, etc. Many of these NGOs are involved in activities which indirectly support fertility reduction such as adult education and income generating economic projects. The PHN can actively collaborate with other sectors on identification and formulation of such projects.

It is clear that the Bank is already taking initiatives in the area of NGOs. The agreement with the IPPF is a good example. PHN has also commissioned a separate review of the possibilities for government, NGO and Bank collaboration.<sup>1 7</sup> In most projects, ministries other than health are given only secondary roles. Given the potential importance of factors such as women's education for fertility (see the 1984 World Development Report for details), and of other ministries in implementing communication and planning functions, this emphasis leaves the impression that opportunities are being lost. We recognize, however, that the administrative problems with coordinating among agencies can be enormous.

1<sup>7</sup> See J. Sheffield, "Government, NGO, Bank Collaboration: New Opportunities for the Bank." The World Bank, May 1987.

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# IV. THE EFFECTIVZNESS OF PROJECTS

The previous section dealt with project design. This section deals more with the actual experience of projects.

# A. Criteria for Measuring Effectiveness

The ultimate purpose of Bank lending in the population sector is to assist national development by reducing population growth. A complex causal chain links Bank activities with these outcomes:

- (1) policy commitment

- (2) institution building

- (3) expenditure on programs, additionality

- (4) management efforts to organize programs

- (5) intermediate outputs such as construction

- (6) the quantity and quality of provider-client transactions

- (7) observed behavior of beneficiaries as measured by:

- a. the demand for contraception

- b. acceptance of family planning or health services

- c. contraceptive prevalence or health status

- d. fertility and mortality

- e. economic and social objectives of development.

in principle, the effectiveness of the Bank's projects could be assessed against any of these criteria, but in practice, the complexity of projects and programs, the influence of non-project factors and lengthy time-lags between project initiatives and final effects makes the use of the more advanced criteria difficult. The original goal of the first Kenya project was a modest reduction in fertility. During the ten years after the agreement was signed fertility rose, and while it is fair to conclude from this that the effect of the project on fertility was not as planned, it is hardly fair to hold the project accountable for the increase. In practice, supervisory missions tend to emphasize measures of project accomplishment such as levels of expenditure, training sessions run, buildings constructed, etc. We believe it would be helpful to give more attention to measures of program activity such as the quantity and quality of transactions or of intermediate output measures such as prevalence.

We have used a variety of sources for this section: personal interviews, project completion and audit reports, and published reviews of country experience.

40
## B. Experience with Bank Projects

This section summarizes our observations concerning the effectiveness of Bank projects as measured by the indicators listed above.

# 1. Policy Commitment

Section II of this report discussed the Bank experience with policy dialogue and sector activities designed to enhance policy commitment. In the discussion of projects it should be mentioned that project work also facilitates building a commitment to population policy. Some projects, such as Kenya, have an explicit component for policy development. The project completion and audit reports for the first Kenya projects cited lack of commitment to population policy within the agencies responsible for project implementation as a major problem. A similar lack of commitment is cited in the audit report for the first Egypt project, and may have been responsible for some of the problems with the second project. In Malaysia, government ambivalence may have been responsible for some delays in implementing portions of projects. These observations suggest that policy commitment is a regularly encountered problem in Bank population projects and needs consistept attention.

## 2. Institutional Development

Most of the PPARs/PCRs have classified ID performance as good, average, or poor. Whenever the PPAR/PCR did not give an explicit rating, we have used our judgement on the basis of their discussion of ID activities. Thus, of the 12 projects, three projects had a "good" ID performance (India-I, Indonesia-I, Indonesia-II), three had an "average" performance (Egypt-I, Bangladesh-I, the Dominican Republic), and the remaining six had a "poor" ID performance (Philippines-I, Trinidad and Tobago-I, Iran-I, Kenya-I, Jamaica-I, Tunisia-I).<sup>1 8</sup> Our review of ID experiences in completed projects brings out the following facilitating and inhibiting factors in ID:

# Facilitating_Factors

- 1) Top management commitment and political support (Dominican Republic, Indonesia)

- 2) Continuing focus on population issues through policy dialogue, evaluation studies, and donor-coordination (Indonesia, Bangladesh)

18There was some disagreement between PPAR and PCR on the rating of ID performance for Kenya-I and the Philippines-I. The PPARs' ratings were "poor", but the PCRs rate these projects as "average" performers.

41
- 3) Funding for pilot projects and operations research, in both government agencies and NGOs (Indonesia, Bangladesh)

- 4) Creation of in-country institutional capabiliti.; ror technical assistance (TA) and research (India)

- 5) Long-term institutional relationship between TA rLeources and program managers built into the project (India)

- 6) Management and technical training encompassing all levels of program personnel (Indonesia)

- 7) Long-term training for leadership development (Indonesia)

- 8) Long-term consultants and advisors with clear terms of reference working with local counterparts (Indonesia)

- 9) Synergistic development of system design, training and research (India, Indonesia)

- 10) ID as part of a long-term policy and organizational development strategy (Indonesia-I1)

- 11) Strong local presence of the Bank through long-term consultants or resident PHN representatives (Indonesia, Bangladesh)

- 12) Phased implementation of ID components through pilot programs (Indonesla)

- 13) Design of special project units with planned process of Integration with program organization (India, Indonesia)

- 14) High degree of involyement by program managers in project process

Inhibiting. Factors

- 1) Low priority attached to fertility control by political leaders and the MOH (Trinidad and Toba<y-

- 2) Change in commitment due to sudden change in economic or political environment (Iran, Trinidad and Tobago)

- 3) Policy differences between implementing agencies (Egypt)

- 4) Too small a software component (Egypt)

- 5) Conflicting procedures of the Bank and the country; lack of knowledge of Bank procedures among program managers (the Philippines, Egypt)

- 6) Differences in perception of project priorities between the Bank and the program managers (Egypt-I)

- 7) Frequent changes in program leadership (India)

- 8) Lack of integration of various ID components (e.g., experimental projects without adequate system changes to adapt to new ideas (EgVpt-I), the training of nurses in FP without policy changes that can allow nurses to perform technical functions)

- 9) Project management unit isolated from program management (India-I, the Philippines-I)

42
- 10) Bank mission's preoccupation with physical and financial targets leading to less time availability for ID (the Philippines-I)

- 11) Frequent changes in mission composition (the Philippines-I)

- 12) Poor organizational design of FP-MCH integration (Kenya. Jamaica)

- 13) Creation of new structures without adequate attention to behavioral or power dimensions (e.g., Interministerial Committee in Kenya-I)

- 14) Lack of rapport between external consultants and country managers (Iran, Dominican Republic)

- 15) Inability of external consultants to devote adequate time to ID activities (Jamaica, Dominican Republic)

- 16) More TA than the absorptive capacity of the country (Dominican Republic)

- 17) Poor design and location of facilities leading to under-utilization (Jamaica, India)

- 18) 5-year project period inadequate for ID (Indonesia-I)

We believe that the Bank has experienced relatively limited success in the area of institutional development. Our observations and interviews indicate that the Bank's current operating style of working from a distance is not conducive to effective institutional development. The representatives of other donors and many of the country officials with whom we met felt that a solid presence on the ground is absolutely necessary. Similarly, there is a feeling that in many situations a perspective longer than five years is required for institution building.

Institution building is a very technical assistance intensive activity. Long term consulting assistance and long term training for indigenous professionals may also be required. Either the local Bank representative or a long term consultant will have to play a catalytic role in this task. Such a role requires sensitivity to local administrative culture, process intervention skills and considerable past experience with ID processes. Also, it will be helpful to identify a local counterpart who is equally insightful and able. In fact leadership training and development may be the core activity for effective ID.

At present, the Bank's operational skills and analytical base are extremely weak in this area. This is an area where it would be useful for the Bank to undertake applied research evaluating its own experiences, documenting other successful cases and developing new methodologies for institutional interventions.

Within the context of the Bank projects, institutional development is seen to consist of structural reorganization, 43
system design and skill development through formal training. However, it may be helpful to redefine ID as a process by which organizations acquire and own certain key values, obtain power to translate these values into action, and are able to review and renew themselves.

# 3.__Expenditure on Prgarams and Additionality

Project completion and audit reports and supervision reports all deal extensively with the level of disbursements.

Usually, projects seem to have eventually utilized most of the funding that was provided in the original agreement, but full utilization was often delayed. Moreover, in virtually all projects, the actual disbursement schedule was skewed towards the end of the project, thus delaying the average expenditure even further. We have not compared the disbursement profile of PHN projects with those of other departments of the Bank, but the persistent pattern of significant delay suggests the need for project managers to rethink the schedules that they are using to see if the situation can be improved. A project completed in 1980 is not the same thing as a project completed in 1976. The delay, among other consequences, complicates further loans for population activities in the country concerned. Table IV-1 lists the completed projects of PHN with their appraisal and actual completion dates. Typically, project completion has been delayed by three years overall, although there has been a significant improvement in recent years.

The additionality represented by the resources provided within Bank projects is an important issue. There are countries where the availability of Bank funding has undoubtedly increased the magnitude of resources available for population activities. African projects would seem to fall in this category. The issue is less clear in the larger countries of Asia. In India, for example, some respondents suggested that since the GOI is strongly committed to a population program and since the general level of funding from the Bank for all development activities in India is fixed, there is little possibility for the availability of funding from the Bank for population to lead to either more development resources for the country or to an enlargement of the population sector.

# 4t Management Efforts to_Organize Progr_ams

In most of the project completion and audit reports there are comments concerning the extent to which national project managers have attempted to help achieve the goals of the project. In the discussion of tl-e projects in Indonesia there are favorable accounts of the degree of commitment and effort made by project officials, and with regard to Egypt and Tunisia it is made clear that senior managers did not always push hard for the 44
Table IV-1

# PHN ProJect Approval and Completion Date and Amount of Delay in Completion (as of March 1987)

|FY||Loan/cred|it Final|Final<br>Dispurs|Origina<br>al<br>Completi|**Delay**<br>in<br>l Projec<br>on<br>Comoleti|Averag<br>Delay<br>in<br>t Proje<br>on<br>Comoleti|e<br><br>ct<br>on<br>Time|
|---|---|---|---|---|---|---|---|---|
|Approv|ed<br>Project|Amount|Disburs|ed Date|<br>Date|(month|s) (month|s)<br>Period|
|70|Jamaica<br>I (P)|2,000|<br>2.00|0 5/77|<br>12/74|<br>29|||
|71|Trinidad<br>& Tob.I(P|)<br>3,000|<br>3,00|0 5/80|<br>12/75|<br>53|||
|71|Tunisia<br>I (P)|4,800|<br>4,74|5 3/82|<br>12/76|<br>63|||
|72|Indonesia<br>I (P)|13,20|0<br>12,8|91 7/82|<br>6/78|47|||
|72|India<br>I (P)|21,200|<br>21,20|0 5/80|<br>6/78|23|||
|73|Malaysia<br>I (P)|5,000|<br>4,87|0 6/82|<br>12/77|<br>**54**|||
|74|Egypt<br>I (P)|5,000|<br>5,00|0 7/80|<br>6/77|37|||
|74|Kenya<br>I (P)|12,00|0<br>12,00|0 4/80|<br>6/77|34|||
|75|Bangladesh<br>I (P)|15,000|<br>15,00|0 6/83|<br>12/80|<br>30|||
|75|Philippines<br>I (P)|25,000|<br>23,34|5 10/83|<br>12,'7|9<br>46|||
||||||||41.|6<br>(1970-75)|
|76|Jamaica<br>II (P)|6,800|<br>6,02|6 10/83|<br>9/80|37|||
|76|Brazil<br>I (N)|19,000|<br>19,00|0 7/83|<br>6/81|25|||
|76|Indonesia<br>11 (P)|24,500|<br>19,83|6 10/84|<br>6/83|16|||
|77|Dominican<br>Rep.<br>I (P)|<br>5,000|<br>4,86|9 8/82|<br>6/80|26|||
|77|Indonesia<br>I (N)|13,000|<br>12,66|2 9/83|<br>3/82|18|||
|78|Thailand<br>I (P)|30,000|<br>27,10|7 8/85|<br>5/81|51|||
|78|Colombia<br>I (N)|25,000|<br>25,00|0 2/86|<br>12/81|<br>50|||
|79|Malaysia<br>**11**(P)|17,000|<br>5,88|1 6/85|<br>6/83|24|||
|80|Indonesia<br>III (P)|35,000|<br>24,20|9 9/85|<br>8/84|13|||
|79|Bangladesh<br>11(P)|32,000|<br>30,83|8 12/85|<br>6/83|30|||
|79|Egypt<br>11 (P)|25,000|<br>16,98|9 10/86|<br>12/82|<br>46|||
||||||||30.<br>35.|5<br>(1976-80)<br>8<br>(1970-80)|

project. Intensive collaboration between Bank officials and country project managers gives the former a good opportunity to observe the latter in action. It undoubtedly provides encouragement to government officials to persist in their efforts. Of the eight completed population projects for which information on types of problems mentioned by supervision missions is available, management problems were most frequently mentioned in six projects and the remaining two mentioned management as the second most important problem.

More attention needs to be given to the management of projects at the lower levels in the system. Manaqement at the 45
periphery is a key link between the central direction of the project and any possible project effects.

# 5. Intermediate Oqtpluts such as Construction

Aside from disbursements the most consistent concern of project managers is with intermediate outputs relating to program objectives such as training, construction and the procurement of equipment and furniture.

The Bank, for various reasons discussed earlier, tends to provide more funding for construction than other donors. The construction component of projects is a matter of great concern to supervisory missions. The audit reports have also commented extensively concerning construction. Unfortunately, much of the commentary is negative. The Tunisia audit report, after indicating the parallels with problems in Jamaica details the delays and problems of poor design which plagued the project. In Bangladesh, according to the audit report, ... The construction component :.is farther delayed due to technical, organizational, procedural and contractual problems. Once completed, major difficulties were encountered in making facilities operational, largely due to design and quality control deficiencies. Nearly all the sites visited by the audit mission required major repairs and maintenance, while much of the equipment provided ounder the project was either not installed or not functional at the time.<sup>1 9</sup> The audit report for the first India project suggests that the design for sub-centers supported by the Bank was good and effective, but it is worth noting that during our visits to both Bangladesh and India, non-governmental observers made repeated comments concerning problems with the buildings constructed under Bank projects. In particular, the location of buildings with regard to the villages to be served and the degree of involvement of the community were seen as issues needing review. Delays in the construction component of projects seem to be a frequent source of delay in projects as a whol'-, and underuttilization of facilities constructed as a part of Bank projects is reported to be a problem in some countries.

The recruitment and training of different program staff is another major element in Bank projects. It receives !;omewhat less attention in the audit reports than does construction, but the poor performance of workers is often cited as a problem. For example in the Bangladesh PCR it is observed:

> 1 9 ProJect Performance Audit Report: Banaladesh, First Population Project, pages vi-vii.

46
The poor performance of field workers continues to actverfnely affect performance of the program and remains a c_use of concern. An action program to strengthen training, supervision and logistics was prepared to improve performance of the workers and formed a part of the credit agreement of the second project.<sup>2 0</sup> It is our impression that the training component is generally well designed and implemented in PHN projects. While there were serious problems of implementation in the first generation of projects in Kenya, Iran, and Trinidad and Tobago, many other first generation projects had good (India, Indonesia, the Dominican Republic) to average (Jamaica, Bangladesh, the Philippines) training performance. Also, over the years the design, preparation and implementation of training seems to have improved considerably. A recent review of training components in 183 Bank projects drawn from a variety of sectors for the year 1985 indicate that PHN had not only the highest proportion of project costs committed to training, but also "PHN was consistently the most thorough and systematic sector in preparing training components.121 Better designed PHN training components inciuded a long-term perspective on training capability and manpower development, detailed implementation and monitoring plans.

The Review mentioned above does not evaluate the impact of training on staff capabilities and project performance. This has been a weak link in otherwise well-designed training programs, i.e., little attention paid to impact evaluation. It is reasonable to assume that by itself, training will not lead to dramatic improvements in project performanice or even to service quality and ianagement unless it is supported by other changes in organizational environment and management systems. It is generally in this area of synergistic development of training as a part of overall management improvement that Bank projects need greater future attention. Also, the training institutions created by Bank projects have faced problems of continuing top level support for quality maintenance after the project period as in India. Thus, questions about sustainability of training capability both in terms of quantity and quality need to be addressed.

> 2 0 Project Completion Report: Bangladesh Poulation I Project,_ Credit 533-BD, page 16.

> 2 1 Review of Bank Lending Operations in Education and Training (Washington, D. C.: The World Bank, Education and Training Department), February 1986.

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# 6-. The_Quantity and Qualitv of Provider-Client Transactions

Even though there are serious difficulties in measuring project impact on fertility or even contraceptive acceptance, efforts can be made to examine the impact of programs in terms of intermediate effects such as the amount and quality of the contact between the project and its intended beneficiaries. The NAS report to which we referred in the introduction has stressed the importance of examining the extent to which programs are reaching clients as a means of both understanding program and client behavior better and of monitoring and evaluating program effects. While it can always be argued that fertility or mortality effects will take a substantial amount of time to take place and even longer to measure, the same cannot be so easily said of the number of visits that fieldworkers make to potential users of contraception or of the observed quality of services provided in clinic settings. Moreover, the quantity and quality of client transactions can be studied empirically in a number of ways (e.g., through surveys or participant observation). Unfortunately, until recently, there was little to indicate that a concern with these issues had been built into Bank (or, in fairness, other donor) projects. Recently some of the operations staff of PHN have been working with the Policy and Research Division to develop ways of building these concerns into projects. It may prove to be an important step towards defining measurable outcomes for PHN projects.

# 7. The Observed Behavior of Beneficiaries

# a. The Demand for Contraception

One of the objectives of population projects is to increase knowledge of contraception and hopefully, in the process, to increase the demand for contraception. The dynamics of demand for contraception are not well understood. The measurement of demand is itself controversial. Traditional measures such as "unmet need" or family size desires have often been used to measure demand, but they have recognized disadvantages in that they do not measure intensity nor deal with the family context or the cost constraints on behavior. These measures are normally developed from surveys that may be too broadly based to relate to the particulars of a specific market. New approaches to assessing demand, perhaps drawn from the experience of social marketing or private sector projects, may be helpful in this area.

Most observers believe that if population programs are to be effective in the long run, they will have to incorporate demand generation elements. This need has been recognized in many of the Bank population projects, but, unfortunately, demand side activities seem to have been among the weakest elements in these projects. In Kenya and India, for example, t-here have been 48
consistent reports of underspending on the demand side activities. There may be a number of origins of this problem. One is that software, in general, seems to receive less attention during supervisory missions than construction or other hardware. A second is that the ministries of health which are usually the lead agencies in Bank projects have little expertise in or commitment to demand generation activities and efforts to bring other agencies into the process have not always been successful.

Bank projects have made little use of the marketing skills of private sector agencies that have been central to the contraceptive social marketing activities supported by USAID.

# b. Acceptance of Family Planning and Contraceptive Prevalence

Measures of the utilization of services are often used as indicators of project effectiveness, but their limitations should be recognized. First, since Bank projects are directed at middle and long range objectives, their immediate impact may be more on system capacity than on the level of service utilization. Second, there are many factors other than project activities that influence the initial acceptance or continued use of services. Therefore, the simple statistics of acceptance are not sufficient evidence of project effectiveness. Third, the indicators themselves can be misleading. In Indonesia, for example, thanks in part to a special Bank mission report, it is now clear that contraceptive prevalence estimates based on service statistics may have been significantly overstated by BKKBN statistics. In Bangladesh there has been substantial controversy concerning service statistics related to condoms. Thus, service statistics, while part of a system of information on effectiveness are incomplete in themselves and should be supplemented both by detailed analysis and by the use of other measures of performance.

Measures of contraceptive prevalence have proven particularly useful for assessing program effectiveness. Measures of prevalence do not resolve the problems of lags between project inputs and effects or of complex causality, but they do provide an alternative measure of effect that does not depend on service delivery statistics. Moreover, contraceptive prevalence surveys have often been able to supplement information on current use with information about knowledge, accessibility and sources of supply, all of which permit a more complete assessment of program impact. Information from regular and effective prevalence surveys may help amid the kind of problems that arise with service statistics. Bank support for prevalence surveys has varied from country to country. Support for these surveys seems to have come from USAID in most cases. This is an appropriate division of labor, but it is important that Bank supervisory missions make use of this data and emphasize its importance to leaders.

49
In a number of countries with large Bank projects, contraceptive prevalence has been observed to increase substantially. Indonesia is a prime example, but increases have been observed in India, Bangladesh, Kenya, the Dominican Republic, and Malaysia, as well.

# c. Fertility

Measuring the fertility or mortality impact of projects or programs is difficult and controversial. It is especially difficult to measure these effects in the short run, and with regard to fertility change at the national level, the five year duration of most Bank projects is a relatively short period. Two general comments can be made about the fertility outcomes of Bank projects, however. First, there seems to be little evidence to suggest that Bank projects have hitherto had very much measurable impact on fertility. Second, there does not seem to have been any systematic effort to measure what impact there may have been. These points are elaborated in the following paragraphs.

Many of the project comoletion and audit reports have a tone of resignation when they discuss fertility impacts of the projects.

Egypt: ... As expected, the contribution of the project to short-term population objectives was negligible.22 Jamaica: ... The project's impact on fertility trends and nutrition status, however, could not be determined due to difficulty in isolating these effects from those of other program interventions.<sup>23</sup> Indonesia, as in many other respects, seems to be an exception. The Project Completion Report draws the following conclusion.

... As this report has documented, the project has undoubtedly succeeded in meeting its ambitious objectives: contraceptive targets have been exceeded in most years, family planning is no longer considered an especially sensitive issue on religious or political

> 22 Egypt: First Pqpulation Project1 ProAect_Performance Audit Report. October 19, 1982, page iv.

> 2 3 Jamaica Second_Population Project: Project Performance Audit oReort. April 9, 1985, page iv.

50
grounds ... and the total fertility rate has been considerably reduced.<sup>2 4</sup> The audit, however, questions whether this conclusion can be drawn from the evidence presented.

Neither in the PCR nor in the appraisal report is there a specific framework or set of indicators on the basis of which causal relationships can be established between the project's stated objectives on the one hand and project activities on the other. As a result there is no hard 'causal' evidence as to the extent that 'micro' project activities contributed to 'macro' project objectives.<sup>2 5</sup> There is little attention given in the project completion reports and the audit reports concerning mortality impact. On balance then, there is relatively little attention given to measuring the demographic impact of programs, and, where attention has been given, the conclusions are usually pessimistic.

The point made in the audit report quoted above is important. If reductions in fertility are the goal of Bank projects, then an analytic framework should be established for assessing project impact on fertility. Assessing the impact of projects carried out in a complex and dynamic environment is difficult. One needs an appropriate causal framework and a well defined time frame. Our instinct is that a careful analysis using the best techniques available would show the effects of Bank projects to be positive, measurable and (certainly in cases like Indonesia) significant. The complex technical task of assessing these effects goes beyond our mandate. The United Nations has published a series of papers outlining alternative approaches relevant to assessing the impact of Bank projects.

# d. Economic and Social Objectives of Development

The potential contribution of reduced fertility and population growth to economic and social development has been a major influence motivating the adoption of population and family planning programs and projects. After nearly twenty years of experience with Bank projects in this area, one may ask what has been the contribution of such projects to these general objectives of development.

> 2 4 Indonesia First Population Project: Project Performance Audit Report. May 28, 1985, page 45.

> 25 Ibid, page 10.

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With the exception of one study carried out in Indonesia, we have not seen retrospective research studies of the impact of population projects or programs. We have seen several very effective prospective presentations, e.g., for Senegal, concerning the possible consequences of rapid population growth. While many of the same problems outlined in the previous section would characterize research in this area, documentation of the empirical experience in different parts of the world would contribute to the development of a case for new programs. Better understanding of these issues may also improve support for these projects inside and outside the Bank.

# C. Summary of Project Effects

There seems little doubt that the Bank's population projects have made substantial contributions to the development of population policies, to the establishment of the physical and human infrastructure necessary to implement programs in accordance with those policies, and to the implementation of those programs. The exact magnitude of the effects is almost impossible to measure. It is our belief that the contributions are substantial, but we are also convinced that these efforts could have been larger if projects had been somewhat more flexibly designed and implemented.

On the measurement issues that tend to dog discussions of population project impact, we feel that it will never be possible to disentangle the causal web sufficiently to say with precision what were the contributions of different elements in the national program, much less those of different donor agencies. The same generalization can be made about programs in other sectors: education, health, agriculture, etc. Following our earlier assertion of the importance of a systems perspective in examining programs, we think that the best approach to assessing performance is to examine the activities of the donor and of the implementing agency to see whether they are consistent with observed or expected changes in contraceptive use or feasibility. This approach means that the evaluator should examine not only the final outcomes of project activity, but also the intermediate steps that are involved in achieving these outcomes. To this end, we think it is important to ask of the different major elements in each delivery system how it is functioning, what are its strong and weak points, and how it is linked with other elements in the system. Particular attention needs to be given to events at the periphery or at the interface between the client population and the delivery system.

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## V. **THE** PROCESS OF PROJECT DEVELOPMENT AND IMPLEMENTATION

In this section we review a number of aspects of project development and implementation. The focus is on issues that relate to the way that the Bank conducts its project work.

The sector reports provide a basis for project identification, preparation and appraisal. Once the project meets the Board's approval, is signed and made effective, a number of supervisory missions are undertaken at intervals of three to six months to help in monitoring and implementation. A project completion mission evaluates the project experience, and brings the project to a close. We have already discussed sector work in section II; thus in this section we focus on project development (identification, preparation, appraisal), supervision, and implementation processes. Towards the end of this section, we also raise issues regarding the broader Bank framework and its relationship to the PHN project process.

# A. Project Development

1. Mission Approach to Prqoect Development and the Resident Po_ulation Specialist Alternative

The Bank has been using a mission approach for project development and monitoring. The work of project development and supervision is currently undertaken by missions based in Washington. The mission pattern has some major disadvantages. Especially where the Bank is the lead agency in large and complex projects, the absence of a continuing Bank presence in the field of population creates difficulties. The absence of permanent representatives also means that the Bank is pooriy positioned to provide technical assistance. The mission model also has the disadvantage that mission visits are disruptive of the ongoing work of both national agencies and other donors.

While the Bank's work is predominantly mission-based, most other large donors employ a resident population specialist approach. It is important to assess the advantages and disadvantages of these two modes of operation and define circumstances in which it may be advantageous for the Bank to have a resident population representative.

In our field interviews a majority of program managers and nearly all representatives of other donor agencies endorsed the need for a resident population officer to expedite project development and implementation and to assure effective interdonor coordination. Indian officials, somewhat exceptionally, expressed satisfaction with the mission approach.

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We reviewed previous experiences with resident representatives in India, Bangladesh and Indonesia. The Indian officials did not recall any significant contributions made by the two resident population specialists stationed in Delhi in the mid-seventies; however, it should be noted that none of the officials with whom we discussed this subject were active in the ministry at that time.

In Indonesia, the first population specialist was remembered for a significant contribution to initial program design in the early seventies. It was observed that each phase in the program design requires a different set of skills: while the first project period need program design skills, the later phases demand administrative skills as the routine tasks of implementation became important. Currently there is a resident PHN specialist in Indonesia. The MOH and the MOP find him much more useful than does the BKKBN because the former agencies are still in the process of learning the Bank procedures and documentation requirements, and because the current representative's interests are more focused in the areas of health and nutrition than in population.

It is instructive to note the areas in which the resident representative was perceived as most helpful by the MOH and MOP in Indonesia. These included (1) collation of cost data and streamlining accounting procedures, (2) helping to draft the various documents required by the Bank, and (3) facilitating communication with Washington. The latter function of faci'itating communication with the Bank is also important to the BKKBN, but at the present stage of project development, they feel that the resident representative would be more effective in this role if he were given some concrete powers to deal with day-today problems. This opinion is also mentioned by the PCR for the second population project.<sup>2 6</sup> In Bangladesh, the appointment of a resident representative was considered extremely useful, especially in facilitating communication with the Bank and removing bottlenecks. However, his involvement in some of the policy reforms such as functional integration evoked both positive and negative evaluations. The comment on the resident representative in the recent (1986) Audit Report concerning the First Bangladesh Population Project is instructive: The Bank has made an enormous effort to supervise these projects, and an interesting feature of that effort was the establishment of a resident population office in the Bank's mission in Dhaka. The costs of this office were shared

> 26 PPAR Indonesia: Second Population Project, June 23, 1986,

p. 62.

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among the cofinanciers, and its performance has generally been regarded as outstanding. In retrospect, however, more delegation of autnority to the field could have substantially facilitated program administration and supervision. (page x) We do not advocate a single position on the resident representative issue. Our analysis points to a pragmatic need based policy. In general a resident representative will be useful when one or more of the following conditions obtain.

- When a country is developing the first PHN project.

- When project design and the environment are complex, as in Bangladesh.

- When institution-building is one of the key project objectives.

- When inter-donor coordination is of critical importance to the project success.

- When policy dialogue is perceived as a major precondition for program development.

Even where a resident representative is likely to be useful, care is required to recruit a person to suit the particular country context. A mismatch between the representative's skills and style and the country needs and political sensitivities could do more damage to the Bank's credibility than the option of not having a local population officer. Also the representative should avoid the temptation of substitut'ing for national counterparts.

There are several possible alternatives to the mission model. We have discussed the resident population representative approach at some length because of its controversial nature. However, our recognition of a flexible need-based approach would require development of a number of alternatives to ensure larger presence on the ground. One such alternative approach would be to share more of the responsibility with other donor agencies or cofinanciers, many of which routinely assign resident staff. A second would be to have more frequent, smaller and perhaps more specialized missions in countries where more of a presence is necessary. The Bank's resident missions are generally illequipped to provide backstopping to the PHN projects. There are of course exceptions, such as in Malawi, where the resident representative has previous experience working with the PHN.

# 2.__Reducina Delays

Project formulation takes anywhere from one to three years; the more common duration is about two years. In most cases, the Bank requires detailed specification of all the activities for the project period before signing the agreement. The USAID and the UNFPA generally sign agreements on the basis of a broad 55
definition of the project objectives and scope and leave the detailed specification of the various components to later stages. Apart from the need to work out projects in considerable detail in advance, pr-oject development can also be delayed due to sudden policy and leadership changes, complicated inter-donor coordination needs, and a lack of professional capabilities within the host country. Unlike other donors, especially the USAID, the Bank generally provides technical assistance through missions and relies heavily on country counterparts to formulate the project. This is not found to be adequate, especially in many African countries. The project preparation facility hlas helped to provide much needed technical assistance. Other mechanisms used in a few countries to hasten the project development process have been: (1) employment of long-term consultants, (2) project launching workshops to train local counterparts, and (3) appointment of a resident population representative for the first few years.

# 3. Lending Coefficients

PHN project development has become more efficient over time, as shown by decreasing lending coefficients from 1981 to 1985 (Table V-1). Although as compared to other sectors, PHN has historically high lending coefficients, the magnitude of the differences has been generally decreasing. This may be a function of the overall increase in Bank lending reported in Part III, use of the project preparation facility and other such mechanisms, and the increased representation in PHND of senior staff with extensive Bank experience. Despite an improvement in the efficiency of the project development process, it is still perceived by many program managers as too long and complicated.

Table V-1 Lending Coefficients (staff weeks) for Agriculture. Education, PHN and Urban Projects. FY1981-87

|Sector|FY1981|FY1982|FY1983|FYi284|FY1985|FY1986|FY1987|
|---|---|---|---|---|---|---|---|
|Agriculture|<br>147|176|133|138|150|128|136|
|Education|138|124|117|117|122|108|117|
|PHN|294|272|198|190|130|147|138|
|Urban|207|154|156|131|139|112|125|

Sources: A.R. Measham. Review of PHN Sector Work and Lending in Health, 198085, pg. 32; and letter from Lauren Chester.

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# 4. Learning_From the Past and Other Project Experiences

PCR and audit reports are two formal mechanisms which facilitate learning from the completed projects. The effectiveness of these mechanisms is undercut by delays in undertaking.audit reviews, and by the pressures inherent in the project cycle.<sup>2 7</sup> The need for the identification and appraisal of follow-up projects to be initiated before their predecessors are fully complete often leads to a neglect of learning opportunities. For example, in the Audit Report for the first Tunisia project, it is observed: The 1981 Health and Population Project of Tunisia had the advantage of having been preceded by a project with many lessons to learn. Yet, an identification of the new project was made before the evaluation of the first.<sup>2 8</sup> Thus,.there are major limitations on the ability of Bank projects to build on previous experience. Informal learning during the identification and appraisal micsions does take place, but it is often incomplete. Moreover, there are no formal mechanisms to ensure learning across countries and regions. As most staff members work in more than one country, some transfer across countries does take place. But at the same time such specialization tends to inhibit learning across divisions. The OED is expected to facilitate cross-country and cross-sectoral learning through publication of major findings from the audit reports and also by commenting'on the project briefs circulated by the divisions. We list below a few factors which seem to facilitate or inhibit learning from the past projects.

# Facilitating Factors:

- Involvement of country counterparts in preparing and evaluating projects.

- Continuity of mission leadership.

- Creation of local institutions, such as the Population Centers in India, which provide an additional mechanism for review and documentation of project experiences.

Ad hoc short reviews conducted by outside experts. A recent review indicates that a few such external reviews conducted 2 7The average delay between project completion and the publication of the PPAR has been 5 years (Table A-7).

> 2 8 Project Performance Audit Report: Tunisia First Population Project, Credit 238-TUN_ June 21, 1984_ page 18.

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in the past have proved extremely useful learning mechanisms.<sup>2 9</sup> The Kanagaratnam Mission to Kenya is one recent relevant example.

# Inhibiting Factors

- Frequent changes in the mission leadership or the top program management.

- Lack of follow-up mechanisms to learn about sustainability of project benefits after the project is completed.

- Massive base-line, mid-project and end-project field surveys which take too long to provide meaningful feedback at the right time. There is a need to simplify and shorten the methodology, instruments and analytic procedures for such surveys to ensure selective but timely feedback. Ocher methods of research such as case research, action research, focus group discussions, brainstorming, joint sessions with beneficiaries, etc., can also provide less rigorous but useful instruments of organizational learning.

- Project designs which are not flexible enough to allow midcourse correctiQns.

- Limited supervision time and tight visit schedules which do not allow open-ended wandering around to learn from the project implementation experience.

- Lack of broad-based participation in project formulation and evaluation from different levels of administration and different agencies. The PPAR for Egypt-I and the PCR for India-I mention inadequate involvement of country counterparts in project formulation. Even where there is an attempt to involve program managers, the project dialogue is confined to one or two ministries and that too only with top management. Even if the next project is in another location or another country, it would help to include one of the more perceptive members of the first project team in the formulation mission. For example it would be useful to have an Indonesian program manager attached to an Indian mission or vice versa.

- Lack of involvement of beneficiaries in project formulation process. The project design is not adequately influenced by client needs or the nature of worker-client transactions. A recent review of the community participation component in Bank projects concludes that some of the successful PHN

29Lauren Chester, "Monitoring and Evaluation Components in Completed Population Projects," April 1985, pp. 14-15.

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projects included community mobilization as a conscious strategy, but in general the initiative came from the project managers. The Bank's stance has been reactive iather than proactive in this area of project design.

# **B. Project Supervision** and Implementation

## 1. Bank Procedures for Supervision

Most of the program managers interviewed during field visits felt that the Bank procedures were cumbersome and thus caused delays in implementation. For example, the requirements of international tendering are looked upon by many program managers as problematic. One of our respondents from the OED also felt that many of the Bank procedures on construction and purchase of equipment are applied more rigidly by PHN projects than in some other sectors. He also observed that this may be due to lack of experience with Bank administrative processes among many of the PHN staff members and program managers. The PPARs for IndonesiaI, Egypt-I, and Bangladesh-I illustrate problems caused by such lack of familiarity with Bank procedures among program managers. We understand that an internal task force of the PHN is lookiag into the procedure simplification issues. Therefore, we have not analyzed this problem beyond mentioning the perception of the program managers. We should add that Indian program managers do not share this view. This may be partly due to their experience with the Bank and partly due to the fact that the Bank has accepted Indian government regular procedurds as adequate for project implementation.

# 2. The Nature of Supervisory Missions from the Country P,erspective

When a mission visits a country, there is a burst of activity and everyone concentrates on the Bank project. This momentum is lost once the mission departs and the national counterparts turn to other projects and programs. The mission returns, notes unfulfilled targets, and again the cycle is repeated. There is thus a need to develop mechanisms for followup between two visits. This can be done either by a resident representative or a steering committee specifically charged with the monitoring function and provided clear intermediate targets and activities.

Implementation guidelines have aroused mixed reviews. In India, the project managers found such guidelines extremely useful in guiding action between two missions. However, too rigid interpretation of such guidelines can lead to lack of flexibility in project implementation.

The timing of the supervision mission is not always well planned in advance. Many donor representatives observed that 59
they could not coordinate with the Bank missions. Also, Bank missions were sometimes viewed as having disruptive effects due to their unplanned and hurried style and short periods of stay. One such observer described it thus: "multiple individuals flying in and immobilizing large numbers of people, forcing quick decisions too soon in an unreal timeframe." This sentiment is also expressed as follows: "The numerous Bank missions to Egypt were seen by some Egyptian officials as a hindrance to this work. Egyptian officials complained that time and effort were spent with mission members, and this delayed their work."<sup>3 0</sup> There are also a number of countries where program managers perceived Bank missions as helpful in providing a forum for concentrated discussion, clarification of issues and removing short term bottlenecks. Intensive Bank supervision was one of the favorable factors in successful performance of the Population and Family Welfare Project in the Dominican Republic.<sup>3 1</sup> During the implementation of the Kenya-I Project, supervision missions were found "helpful in resolving problems and removing bottlenecks related to procurement, disbursement and project management."v32 However, while supervision missions are effective in routine activities, they do not afford majpr strategic reviews or a very close look at the periphery, where worker-client transactions take place. The PPAR for Indonesia-II points to the need for the supervisory missions to "spend more time in the field, where the impact of the program ultimately will have to be assessed."<sup>3 3</sup>

# 3. The Evaluation Component

Evaluation is the weakest link in the project process. Supervisory missions provide neither the time nor the incentives for the mission leader to give adequate attention to process evaluation. PCRs and audit reports are generally not available until long after the beginning of the next project. There is also no consistent methodology for evaluation. The problem of evaluation is compounded due to weak project designs, which do not detail evaluation procedures and measures. The PPAR for Indonesia-II gives a succinct analysis of this problem:

> 3 0 PPAR: Egypt - First Population Project (October 19, 1982)

p. 4.

> 3 1 PPAR (April 19, 1985) p. 33.

> 3 2 PPAR (July 2, 1981) p. 44.

> 3 3 PPAR (June 23, 1986) p. 18.

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Assessing the effectiveness of the Indonesian second population project remains difficult, as can be illustrated with a few examples. No specific target was mentioned in the appraisal report for the family planning and population training centers ... Some indication as to the type of training to be provided as well as output would have enabled a more objective assessment ... In the absence of baseline information or utilization data, the PCR could only comment that "the availability of project vehicles is reported to have greatly improved the provision of services in outlying rural areas." [PCR paragraph 3.05.] It is impossible to objectively evaluate such an assessment ... The bottom-line is that unless specific targets are set during preparation, population projects will remain difficult to evaluate. [pp. 16-17.] Some of the factors responsible for neglect of project evaluation are: lack of evaluation design and targets at the project formulation stage,<sup>3 4</sup>

# 4-. Supervisorv Coefficients

PHND projects have historically required more supervision than projects in-somewhat similar departments (see Table V-2). There is a downward trend in the coefficients, but, as we have indicated elsewhere, it is our impression that the nature of the tesk is likely to keep the need for supervisory visits relatively hiah.

# 5. Summary

In sum, project supervision is strong in terms of routine tasks, problem solving and removing bottlenecks in implementation. However, it remains inadequate in terms of strategic and innovative inputs, project evaluation, follow-up on suggested actions, inter-donor coordination, and in-depth analysis of program-client interface. The population projects may continue to require more supervision than other projects, due to rapid expansion of activities in Africa, complexity of inter34Even the PPARs and POCRs do not have uniform indicators to allow cross-project comparisons. Our examination of all the PPARs/PCRs showed that information on the ranking of projects by intensity and frequency of problems, types of problems, and institutional performance was not uniformly available for all the completed projects.

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## Table V-2

## Lending Coefficients for Agriculture, Education, PHN and Urban Projects, FY1981-85

|----------------------------------------------<br>Sector|-----------<br>FY1981|FY1982|FY1983|FY1984|__-<br>FY1985|---------------<br>FY1986|FY1987|
|---|---|---|---|---|---|---|---|
|----------------------------------------------|-----------------|||||__----------||
|Agriculture|<br>14|13|13|13|12|14|13|
|Educaticn|10|11|10|11|9|10|10|
|PHN|36|27|22|20|18|24|21|
|Urban|25|18|17|16|13|11|13|

Sources: A.R. Measham, Review of PHN Sector Work and Lending in Health, 1980-85, pg. 34; and letter from Lauren Chester.

sectoral population activities, and a need for a strategic shift in older projects from quantity to quality of ervices and from supply to demand generation activities. In arfz event, there is a real need to think of innovative ways in which supervision and monitoring time and quality can be improved. An alternative might be to design projects so that more of the supervision is handled by co-financiers or other donors, by local missions, as mentioned above, or by local representatives with more local authority. The recent Indian experience with local missions is one example of innovative methods.

# C. Coordination with Other **Agencies**

There is nothing in Bank procedures to inhibit interagency coordination within the project framework.<sup>3 5</sup> However, the style and process of coordination are important determinants of success in this area. For example, a predominant role by the Bank in inter-donor coordination may produce sub-optimal solutions, as the tendency is to find a compromise between various competing positions. On the other hand, too dominant a role in the national policy process tends to hinder donor coordination and collaboration. In Malawi, an overwhelming concern with pqlicy dialogue may have precluded care in inter-donor coordination. It is not necessary that the Bank always take the lead. It might be

> 35 However, project design may at times facilitate or inhibit interagency coordination. The Kenya Population Project specifically provides for a council to facilitate coordination with other departments and voluntary organizations. This has clearly helped to Increase cocrdination with other agencies, but at the same time it has weakened coordination between the council and the MOH.

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advisable to take a secondary position in some situations and allow other donors to take a lead.

A well articulated national plan or strategy is the best means of ensuring donor coordination. Kenya and Indonesia illustrate this proposition. While in Indonesia the local program leadership has articulated such a strategy, the Bank has played an important part in Kenya. The Indian government's strategy is to minimize the need for donor coordination by assigning different geographical areas to different donors. This seems to have effectively reduced policy influence by donor agencies. Some of the other donors observed that the Bank should take informal initiative in developing greater communication between donor agencies in India. Such communication can help learning from each other and developing common policy proposals. Given the political environment in India, this will have to be a very low key activity.

Distribution of tasks based on the relative strengths of various donor agencies could provide a useful strategy for donor coordination. In discussions with Bank staff, representatives of other donors and professionals in the countries we visited, the Bank is seen as relatively strong in terms of analytic capability and in terms of its ability to deal with high level policy issues and to make linkages beyond the population sector narrowly defined. It is seen as relatively weak in terms of technical assistance, institutional development, demand generation, and community-based activities.

Coordination among donors is an important element in the development of population policies and projects. The Bank's record in this area is mixed. One might visualize three different levels of coordination. The first would involve little formal coordination beyond consultations during missions. This seems to characterize most country situations. The second level of coordination would involve some joint planning such as having other donors participate on missions as was done in one mission in Malawi or participating in regular discussions among donors as seems to be the current practice in Kenya. A third level would be to arrange joint funding and overlapping staff functions. Cofinancing arrangements fit this pattern, but there might be other ways of coordinating with other donors that would work as well. Given the complementarity in the perceived skills among the different donor agencies, more shared projects may be advantageous. It is also possible that by coordinating in this fashion, staff time devoted to project identification and appraisal could be reduced.

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D. **The Impact of World Bank Procedures and Governing Rules on Project Development and Implementation**

# 1. Loans **vs.** Grants

In virtually all of the countries we visited the fact that the Bank works primarily through loans was seen as a disadvantage. In some countries the use of loans is seen so negatively that government officials working in the population field were concerned whether higher authorities would be willing to sanction any population activities. In all countries, officials felt that the Bank loan was a last resort. Part of the problem in this area is that officials in the ministries of health are relatively poorly informed about the terms of international finance, and they do not understand the "grant equivalence" of an IDA credit for example. Many of them and their colleagues in planning and finance still seem to feel that loans should only be for activities that involve a "real" product. There also seems to be a limited understanding of fungibility on the part of many country officials. In some countries where officials expressed reluctance to borrow for population or health programs to which they seemed fully committed, private sector banks were making loans for industrial projects. Increased education programs and marketing of the Bank's role in social sectors could help to overcome this set of perceptions.

# 2. The Relationship,between_PHN and the Rest of the Bank

The relationship between PHND and the rest of the Bank is complex and has not been a major focus of our inquiry. But it is clear that improvements in relationships or coordination of procedures would facilitate greater effectiveness in the population sector. Two examples illustrate this. There is a great deal of variation in the extent to which population (and other long term development issues) are highlighted in the economic work of the Bank. In Senegal, little mention is made of the population issue in the annual economic report, while in Kenya population is given considerable attention. While it is of course necessary for the Bank staff responsible for preparing these reports to be selective in the issues they choose to highlight, those choices will affect the work of PHND. A second illustration relates to the high level negotiations concerning the overall budget that a country will receive. in India, for example, there is an agreement about the overall amount that the Bank will lend, and individual sector agreements are made within that framework. In the Indian setting where the government has made a fairly firm commitment to spending in the population sector, there is as a result little incentive for responsible officials to increase Bank lending in the population area. The situation in Indonesia is different where the BKKBN's high international image has encouraged the government to push for 64
more loans in the population sector. Thus, both in terms of policy work and in terms of project development the larger set of Bank activities influence the productivity of PHND.

65
# VI. LESSONS LEARNED AND FUTURE STRATEGIES

The overall Bank performance in the population sector is commendable. There has been a considerable increase in the number of projects, amount of lending, and attention to new geographical areas, especially in Africa. The policy development in new programs has been a major strength of the PHN. There is a gradual shift from the physical infrastructure orientation of early projects to software aspects of institutional development, human resource development and program management. Similarly, over time, PHN projects have shown greater concern for quality of services and demand generation than for the traditional issues of reach and coverage. The project formulation and implementation process has become slightly more efficient and adaptive. We also feel that the strategic choiceq regarding priority attached to "key" countries, such as India, Bangladesh, and Kenya, and to the expansion of activities in Africa is basically correct.

A dynamic lending program in the population sector needs continuous readjustment and strengthening. Some of the areas where further strengthening is needed are the following:

- regional level mechanisms for policy development;

- * linkages between research and operations;

- quality and coverage of sector reports in terms of program effectiveness issues, NGO and private sector roles;

- project designs, in terms of innovative and adaptive orientation;

- involvement of other government departments, NGOs, and the private commercial sector;

- donor coordination strategies; softer aspects of institutional development, such as management processes, organizational culture and leadership training;

- widening the mix of staff skills in both research and operations divisions in the areas of political analysis, ID, management, communication, and community diagnosis.

Also, there is a need to translate the high priority attached by top management to the population sector into a consistent level of support from all regional departments and country economists.

In this last section we highlight some of the key findings from past experience and project some of the problems and opportunities that may be associated with the effort to expand lending in the population sector. While beginning with a brief outline of the task, we organize the subsequent discussion roughly in the order of the earlier presentation, beginning with a discussion of policy dialogue and sector work.

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# A. **Analysis of the Nature of the Task**

Needs in the population sector vary strong._-, from one country or one region to another. The nature of the task varies according to culture a:id organizational patterns and to the stage of development. Most of the African countries are at an early stage of policy development. Thus the main tasks in Africa are the following:

- t political commitment and policy development institution building for policy development and program planning

- demand generation with special reference to family size and spacing norms

- demonstration projects

The main tasks in Asia are much more likely to involve the following:

- policy analysis for a strategic shift from coverage of services to quality of services, and from family planning services to broad-based intersectoral demand generation activities

- assisting with the improvement of management and quality of services

- finding ways of reaching diverse audiences of potential clients

- dealing with the private sector - both NGOs and the for-profit private sector

The Middle East and Latin American regions will have their own set of priorities. The Bank is to be commended on its attempts to differentiate its activities in different parts of the world. As we have mentioned earlier, more efforts in this direction are needed.

# B. The Overall Influence of the Bank **in** Policy Matters

One of the great assets that the PHND staff has in its population work is the high respect that the Bank has in general. Because of the magnitude of the assistance the Bank offers and because of the high quality of its staff, bank representatives have access to senior level administrators and policy makers.

The Bank has used a variety of mechanisms to develop population policies in developing countries. In general, policy development has been one of the strong aspects of the Bank's activities. However, the Bank has been relatively more successful in courtries at the beginning of the population program development than in more mature programs. Similarly, its record in Africa is much better than in Asia or the Middle East. It is difficult to generalize about the factors which impinge on 67
policy development activities, since the country context is very important. Nevertheless, those project teams which employ a combination of mechanisms such as sector work, region support, policy dialogue at political levels higher than the MOH, dissemination of research, and flexible project design to take advantage of new opportunities are more successful than those which rely exclusively on one or two mechanisms. Similarly, more mature programs require sophisticated policy analysis on specific policy issues rather than general sector analysis. More analysis of the actual experience of programs is an important element of policy analysis for mature programs. Such variation in the environment of policy work requires continuous learning from a variety of contexts.

One way such skills can be developed is to systematically share experiences within the division and across divisions on a regular basis. More sharing of experience with project development staff in other multilateral and bilateral donor agencies is also appropriate.

We feel that greater investment of staff time and resources may be needed in non-project activities such as policy and programmatic research, regional meetings of policy makers and program managers, and most of all continuing high level support for population work from the economic and regional departments. All of these activities will reduce the "efficiency" of staff involved in project development and implementation, but they are likely to greatly enhance their effectiveness.

Sector work has improved over the years both in quantity, quality and scope. Sector work has also been effectively used for policy dialogue, especially in Africa. However, the link between sector work and project development is not well established. We feel that the future strategy should aim at continuing the momentum on sector work, building better linkages between sector work and projects, and undertaking specialized sub-sector studies in more mature programs. Also, there is need to improve the quality and coverage of sector reports in terms of program effectiveness issues, and the NGO and private sector roles in national programs.

The Bank's capabilities and analytical base are weak in the areas of institutional development and NGOs. Unlike institution building, the area of NGOs is also a new field which may pose both opportunities and constraints. The Policy and Research Division should collaborate with researchers in other Bank units, especially the public sector management unit, urban and education units. Research on NGOs should address three priority areas: (1) internal management and organizational effectiveness of NGOs; (2) government policies and funding procedures; and (3) methodologies for scaling up successful NGO projects.

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# C. **Needed** Changes in Projects

The work that needs to be done differs from one region to another, from one country to another, and even from one potential beneficiary to another within countries. For this reason there is not likely to be a universal approach to project design and implementation that can be used in all places. If we were to pick a single weakness in the project work of the Bank, it is that there is not enough diversity in the mix of activities that make up projects, in the organizational structures through which they are implemented and in the way that they are supervised by the Bank. The most common pattern is a project run through the Ministry of Health with little regional variation or autonomy, only small roles for NGOs, the private sector or other ministries, a substantial element of construction and a general neglect of demand generation, and a poor appreciation of events or relationships at the periphery. Within this modal project, responsiveness to changing needs is difficult, and, as a result, opportunities for creative modification of projects are often overlooked.

# D. The Bank's Role in the Development of NGOs

In the past, the Bank has mainly dealt with national governments. NGO involvement in the Bank projects has been minimal. One of the early projects to experiment with the NGO involvement was the IPP-I, India, in the state of Karnataka. However, this was not followed up in the second project, but it is being revived in the third project. During most of the intervening period NGOs were not given a major role in Bank activities. Recently, the Bank has started giving serious consideration to its work with the private sector, and initiated a number of activities to build bridges between the public and the private sectors. This is a welcome development and we strongly endorse it. However, it is still at a very early stage and needs flexible financial support for research, regional meetings and conferences, and small grants to intermediate organizations.

The Bank should increase its resource commitment to research and sector work on NGOs and their interaction with public programs, explore possible ways in which it can utilize intermediary organizations such as the IPPF or even other donor agencies with more flexible funding procedures, and encourage Bank projects to support NGO activities as in Kenya. While the Bank may not be able to provide direct funding to national NGOs, its analytic and communication activities should provide the intellectual base, policy environment, and institution-building support for NGOs.

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# S. Relations with Other Donors

The Bank has a complex relationship with other donors. In some sense, it is competitive with other agencies both at the international and the national levels. In another sense, it is highly dependent on other donors to provide information during missions, to cover aspects of programs with which the Bank is not well equipped to deal, provide grant funding where loan funding is unacceptable, etc. Both at the country and at the headquarters levels, much could be done to improve relationships and to facilitate coordination. In many of the countries that we visited, Bank missions are seen by other donors as disruptive, parasitic and sometimes arrogant. At the headquarters level, leaders of other donors have suggested that the Bank has not always demonstrated initiative for increased coordination or even sharing of information. This situation may have improved in recent years, but this is an important area for attention. As the Bank's presence in population increases, relationships with other donors will become increasingly important.

# F. The Mix of Skills among the **Bank Staff**

The Bank staff seem to be stronger in some areas than in others. Areas of strength are formal analytic techniques, the understanding of decision making at high levels and some technical skills such as budgeting. There seems to be less skill in areas like IEC program development, implementation analysis, and institution building. The Research and Policy Division also reflects this unbalanced skill composition. For a closer relationship between the research and project development, the Research and Policy Division needs more sociological and institutional analysis skills. There is a need to recruit professionals with rural sociology/organization theory/ institutional management backgrounds, and to hold training workshops for the operational staff members.

# G. **The Efficiency of Bank Work in the Field of Population**

We are convinced that the population sector differs from other major sectors of Bank lending in important respects. As a result, supervision ratios and other indicators of the costs of Bank lending in this area are likely to remain less favorable than they are in other sectors. The Bank's work is also likely to be facilitated by the devotion of relatively large amounts of resources to sector work, policy dialogue, research and other activities that are not part of lending per se. Also, the use of some funds outside of the conventional lending mode may increase the Bank's effectiveness in areas such as work with the private sector.

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# H. What **Are** the Prospects for Increased Lending?

Bank lending for population has increased markedly during the past five years. Available funding for at least two other major donors, USAID and UNFPA, seems likely to stagnate or even decline during the next few years. Demand for donor funds in the population sector is likely to increase significantly both among countries with continuing programs and in the countries of Africa that are just beginning to undertake population programs. The amount of lending that countries will want depends on many facto-s. Many of those factors can be influenced by the Bank through its sector work; through more systematic efforts to educate national leaders about the economics of borrowing in this sector; through better coordination with other donors and through better project design and supervision. A willingness to try new approaches, as in the case of the funding to IPPF for NGO support in Africa, will be an important complement to conventional lending. In short, the prospect for increased lending for the population sector is high, but the overall impact of the Bank in this sector will be greatly increased through flexibility and imagination.

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VII. RECOMMENDATIONS The Bank's overall performance in the population sector is commendable. There has been a considerable increase in the number of projects. the total amount of lending, and attention to new geographical areas. especially in Africa. The emphasis given to policy development in countries initiating programs has been a major strength of the PHN. There has been a gradual shift from the physical infrastructure orientation of early projects to the software aspects of institutional development, human resource development and program management. Similarly. PHN projects have begun to show greater concern for quality of services and demand generation than for the traditional issues of reach and coverage. The project formulation and implementation process has become slightly more efficient and adaptive. We also feel that the strategic choices regarding priority attached to "key" countries, such as-India, Bangladesh, and Kenya. and to the expansion of activities in Africa are basically correct. And yet fertility is still high in many countries, and family planning programs, though effective in reducing fertility in some, are still weak in others. There is clear need to further strengthen Bank efforts in the future.

The next several pages contain recommendations for consideration by the Bank in the formulation of plans for the next cycle of population projects. Here we concentrate on those issues which we regard as having highest priority. Recommendations concerning other issues are often implicit in the findings detailed in the main report. Several preliminary comments are important before detailing specific recommendations. First, by our original charge the primary focus of our work has been on sector work and projects, and questions of the internal workings of PHN are largeLy beyond the purview of this report. Second, the Bank has announced changes in structure to be implemented in the near future, and these changes will affect the implementation of our recommendations. Finally. the recommendations which follow are interrelated, and the staff of PHN need to keep the larger pattern in mind as they deal with any individual recommendation. For example. it our recommendation that the Bank continue to expand the role of NGOs in its projects is accepted, there will be implications for the agenda of research and sector work. Our recommendations follow the general order of the report.

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# **POLICY, SECTOR WORK AND RESEARCH**

1. POLICY DIALOGUE: Perhaps the single most effective element in the Bank's work on population is the policy dialogue that links population issues with other aspects of development. It is our impression that this linkage has been made strongly in most countries, but there are still places where the Bank's economic officers have been reluctant to deal with population or have given it low priority. We recommend that the senior officers of the Bank and the country-economists continue to_give and where possible increase_the priority given to,population issues in their dealings with policy makers in borrowing countries.

2. SECTOR WORK: In a field such as population where basic technologies are still poorly understood, sector work has a particularly important role. PHN has devcted considerable resources to the preparation of sector reports which have taken a variety of forms. While broad sector reports will continue to be important in new and emerging progranms, more established and mature programs will benefit from indepth analyses of selected policy or program effectiveness issues. We recommend that_continued priority be given to population_related sector work. that greater attentIon be given to issues relating_to program effectiveness, the role of nongovernmental sectors and community perrspectives; that ways be found to share the results of this analysis more widely_and that, where app.ropriate,_as in parts of Africa, the sector_analys!s be given a regional orientation.

3. RESEARCH: In a situation in which the dominant existing technology for reducing fertility,has had limited success and the underlying problems of high population growth are unresolved, the role of research is central. The Bank, by virtue of the skills of its staff and the nature of its role among institutions, is well positioned to make a central contribution to research. This may be accomplished both through in-house research and promotion of research by other organizations. and through projects. We recommend that the Bank increase the resources devoted to research on issues related to population; that. in order to increase the integration between research and operations, it draw some of the additional resources from the divisions with line responsibility (possibly on a temporary basis); and that it continue the recent trend of orienting research towards issues of programmatic significance such as finance (which has already received considerable attention), program-client transactions, the role of NGOs, demand generation, institution building and management.

# PROJECT DESIGN AND IMPLEWNTATION

In the body of the report. we have discussed prob' 'is of project design in detail. A central premise of that discussion was that t-ach project needs to be designed around a set of specific circumstances. Nonetheless, there are a few general orientations that may provide helpful guidelines in undertaking new projects. The most important of these follow: 4. DIVERSIFICATION: Durinlg most of the last decade the central strategy has been to integrate population projects with health. To the extent that this limits projects to the heatlth ministry. this orientation is excessively confiniing. We recommend that the Bank seek watys of strengthening its linkages with agencies _73_
other than ministries of health, especially those _in the pzivate_sector, both forprofit and,_private_voluntary organizations] and other governmental agencies.

5. REORIENTATION: Throughout this report we have stressed the coip.lexity of the systems within which population related programs must be organized. Inevitably in these complex environments, some issues have received more attenticon than others. Construction, equipment, training and management at the central government level are examples of program dimensions that have received disproportionate attention while institutional development. [EC and "management at the periphery" have been relatively neglected. We recommend that project desig and implementation give relatively more attention to_the_ institutional development. sustainability. IEC and the client transactions components of projects.

6. SIZE AND COMPLEXITY: Project size and complexity vary enormously among projects. Nonetheless there is a tepdency towards larger and more complex projects. These projects have the advantage that they provide a framework within which a large number of elements can be integrated. but almost by definition they also constitute a larger management task both for project supervisors and for national counterparts. There is also a related problem that large and complex projects are difficult to change in the face of new circumstances. When larger, complex projects are necessary, it may be useful to treat components as smaller subprojects, and phase them in over time. We recommend that gjretater emphasis be placed, where appropria,te. on smaller less complex protects and that proJect design be flexible enough to accommodate new developments.

7. EVALUATION: Because of the complexity of projects and the environment in which they are implemented, it may never be possible to evaluate their effects adequately. We feel. however. that evaluation can be improved and more adequately integrated with operations. We recommend that the Bank adopt a systems approach to the evaluation of projects and,that evaluation be undertaken on a more regular basis to avoid the delays that_have been experienced in the past.

# OTHER ISSUES

8. THE MISSION APPROACH: In all stages in the rroject cycle the Bank has relied on the use of missions, composed of Bank staff and some consultants. which work intensively with national counterparts on a variety of tasks related to the development and implementation of projects. These missions have become the Bank's primary vehicles for technical assistance, project coordination and supervision. This pattern is strongly established in the Bank. but it has some disadvantages in the area of population. We recommend that the Bank continue to seek ways of supplementing the current pattern of missions with alternative arrangements that will provide _a more continuing presence in the countries where projects are being prepared or implemented.

9. COORDINATION WITH OTItER DONOR AGENCIES: Earlier reviews of the population sector suggest that coordination with donor agencies has been a long standing problem. It should be stated from the beginning that the problem is structural and is unilikely to have a permanent solution. In many respects donior relations seem to have improved **in** recent years, btit thtere are still many ways in which improved cooperation among donors would beniefit individual projecLs and country pr'ograms.

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increased efforts in this direction become particularly importan'. given the projected increases in population lending. We_recommend that the Bank make increased efforts at both the country,and the international levels to improve coordinat,ion and,,cooperation with other international donor and imnem n,ti g agencies.

10. THE MARKETING OF LENDING FOR POPULATION: The Bank by its charter must work primarily through lending. Although the businesslike manner of ti.e Bank is appreciated by some, the restriction of the Bank to lending puts it at a disadvantage in the eyes of most potential borrowers. The issues involved in different modes of finance are not widely understood by managers in the population sector or even, in many cases, by government officials in finance ministries. There is. for, example, often confusion over the differences between IDA and IBRD credits. There is also still some feeling that loans should not be used for "soft" sectors. We recommend that the Bank undertake special efforts to educate governiment leaders c(fncerMtlilg the issues involved in the decision to use loans to finance population projects.

There are several areas of concern which cut across the recommendations presented above.

LEARNING: The Bank's population lending activities will be greatly enhanced if more efforts can be made to learn from the experience of previous projects in the same country and from similar efforts in other countries. The most effective evaluations of Bank projects are circulated years after the projects are completed and the new generation of projects have been initiated. Of course, less formal efforts do take place as a part of the process of project supervision, but they are not enough by themselves. Efforts must be made to shorten this cycle so that systematic learning can take place more rapidly.

INSTITUTION BUILDING: The development of strong institutions capable of defining and implementing effective programs is at the heart of the Bank's population program, yet the record in this area is not strong, and we feel that the Bank should be seeking ways to strengthen its ability to help develop institutions.

THE SKILLS OF BANK STAFF: We have not done a systematic survey of the current skills of Bank staff, but it seems clear that the implementation of recommendations concerning sector work, research and projtst design will involve a higher demand for skills that are currentLy poorly represented among PHN staff. Thus there may be a need for either some retraining of current staff or for the selective recruitment of new professionals with the required backgrounds.

The recommendations and observations presented above are based on the detailed population lending review. By the nature of our assignment, with the focus on projects and sector work, the two documents cannot provide a complete view of all aspects of PHN's work, but we hope that this review will be one element In the continuing effort to improve the quality and the quantity of the Bank's involvement in population.

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