Policy Research j WQRKIsG PAPERS Population, Health, and Nutrition Population and Human Resources Department The World Bank April 1992 WPS 890 Population, Health, and Nutrition Fiscal 1991 Sector Review Denise Vaillancourt Janet Nassim and Stacye Brown To strengthen efforts to alleviate poverty and to develop man- agement and institutional capacity, the Bank should improve the skills mix of its population, health, and nutrition staff, provide better standards and guidelines for analyzing and addressing institutional and management issues, and ensure that enough time is spent on institutional and management issues. Policy Rescarch Working Papcn disseminate the findings of work in progress and encourage the exchange of ideas among Bank staff and all others interested in development issuc Thesepapers, disuibuted by Lhe Research Advisory Staff,carry thc names of thc authors, reflect only theirviews. and should beused and cited accordingly. Thc fundings, interpretations, and conclusions anr the authors own lheyshould not be attributed to the World Bank, its 3oard or )insctors, its management, or any of iLs membcr countries Policy Research Populatlon, Health, and Nutrition I WPS 890 This paper - a product of the Population, Health, and Nutrition Division, Population and Human Resources Department - is part of a larger effort in the department to address management and institutional issues in the PHN sector. Copies of the paperare available free from the World Bank, 1818 H Street NW, Washington, DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (April 1992, 65 pages). Growth in both number of projects and amount of The Bank's ability to strengthen institution5s. lending has been a notable feature of the Bank's especially those nceded to alleviate poverty, are support to the population, health, and nutrition (PHN) constrained by the number and the skills mix of PHN sector since fiscal 1981, when the Bank first began staff, by the absence of standards and guidelines for lending for health. The proportion of total Bank analyzing and addressing institutional and manage- lending to the sector increased from 4.5 percent in ment issues, and by too little timc to spend on fiscal 1990 to 6.9 percent in fiscal 1991 (from 4.1 institutional and management issues. Therzfore, the percent to 5.8 percent, if lending to non-PHN cornpo- sector review recommends: nents is excluded), surpassing targets set by the Bank's senior management for growth in the sector. Improving the sector staff not only in numbers but in access to guidelines and training; making more In September 1990, President Conable expressed use of in-housc management and institutional the Bank's determination to provide greater support development expertise; using more consulting for primary health care - and set a goal of increasing specialists; and increasing thc number of management lending for primary health care from about 3 percent and institutional development experts in divisions to about 5 percent of total Bank lending in the next working on the PHN sector. three to four years. This goal was exceeded fiscal 1991: lending to primary health care for that year * Revising Bank priorities and practices to cnsure amounted to US$1,220 million, or 5.4 percent of total that enough time is spent on supervision and on Bank lending. upstream diagnostic work, and that management rigorously reviews the management and institutional The momentum in actual and forecasted growth development content of lending and sector work. in PHN lending is attributable to several factors, including the high priority assigned to human * Grounding PHN policies in a macroeconomic resource development (as a key component of and multisectoral framework oriented toward growth economic reform and development objectives) and with poverty reduction, together with a sound strategy the Bank's strong commitment to the alleviation of for building institutions and the capacity to implement poverty, which requires providing basic social and manage policy. This means country operations services to the poor. divisions have a critical role in helping key national decisionmakers understand and internalize objectives The theme of this year's annual sector review of poverty alleviafion and institution building. blends two special topics: poverty alleviation and the development of management and .nstitutional o Seeking more creativc use of Bank instruments capacity. Based on a review of project experience, through a review and assessment of the best use of both within and outside of the PHN sector, this report lending instruments for PHN sector interventions; distills lessons that should assist lask managers in the more innovative identification and financing of local design and implementation of interventions to expertise; and greater effort to encouragc the ex- develop poverty-sensitivc management and institu- change of experience and ideas among devcloping tional capacity in the PHN sector. countries. ThePolicy Research Working Paper Sericsdisseminates thc findings of work under way in the Bank. An objective of the scrics is to get these fimdings out quickly, even if presentations are less than fully polished. The findings, interpretations, and i conclusions in these papers do not necessarily represent official Bank policy. Produced by the Policy Research Dissemination Centcr CONTENTS page EXECUTIVE SUMMARY ...................., i 1. INTRODUCTION: PURPOSE AND SCOPE OF REVIEW 1. II. OVERVIEW ...............................................,,. . 3 A. Lending . 3 1. Growth in the Lending Portfolio . 3 2. Regional Distribution and IBRD/lDA Commitments ....S................ S 3. Cofinancing . 6 4. Project Funds by Expenditure Category ......... 7 B. Sector Work . 7 C Supervision and Project Evaluation . 8 D. Population, Health and Nutrition Content of Projects . 8 III. SPECIAL THEME: INSTITUTIONAL DEVELOPMENT IN SUPPORT OF A POVERTY FOCUS FOR PHN SECTORS .11 A. Introduction .11 1. Poverty .11 2. Management and Intitutional Development .11 3. Choice of and Approach to Special lbpic .11 B. Lessons Learned .12 1. Lessons of Substance .12 2. Lessons of Design and Process and Some Useful Tbols .16 C. Evaluation of FY91-Approved PHN Operations Against Lessons Learned .18 1. Overview .18 2. Innovative Categories of PHN Operations .19 3. Issues .20 IV. PROSPECTUS .23 A. Future Work Portfolio .23 B. Conclusions and Recommendations ..23 1. Expanding Bank Expertise in Institutional Development .23 2. Changing Priorities and Practices in the Bank .24 3. Expanding the Role of Country Operations Divisions .25 4. Making Creative Use of Bank hIstruments and Resources .25 5. Other Recommendations .26 a CONTENTS (Contd) Page TEXT TABLES: 1. BIends in Lending to the PHN Sector, FY89-91 ................................ 4 2. Sectoral Composition and Funding Characteristics of PHN Portfolio, FY91 .... ....... 5 3. Cofinancing from Official Sources in PHN Projects, FY90 and FY91 ..... ........... 6 TEXT FIGURES: 1. Lending for the Population, Health and Nutrition Sector, FY80-91 ..... ............ 3 2. Sectoral Compostion of PHN Projects Approved in FY91 ......................... 4 3. Regional Distribution of PHN Lending, FY91 ................................. 5 4. Breakdown of Tbtal Project Costs by Expeneiture Category ........................ 7 ANNEXES: 1. Statistical Annex . 29 TIbles: 1. FY91 PHN Portfolio by Sectoral Compostion .31 2. Primary Health Care Component of PHN Lending, FY91 .32 3. PHN Lending Volume, FY80-91 .33 4. FY91-Approved PHN Projects: Funds Components .34 5. PHN Sector Reports Completed by Region, FY82-91 .35 6. PHN Sector Reports Completed in FY91 .36 7. OED Reports on PHN Sector, FY91 .38 8. Lending for Population Projects and Components by Region, FY86-91 .39 9. PHN Projects with Population Components, FY91 .40 10. Nutrition Components in Structural and Agricultural Adjustment Operations, FY91 .41 Figures: 1. PHN Projects under Supervision .43 2. Total Project Resources for Nutrition in Bank-Assisted Operations, FY81-91 . 44 3. The Bank's Nutrition Lending, FY81-91 .44 4. World Bank Lending for Population, FY80-91 .45 2. Lo3n and Credit Summaries of FY91-Approved PHN Operations .47 3. Bibliography ....... 61 AbbrevlatPons and Acrotms AF2PH East Africa Department, Population and Human Resources Operations Division AFIPN Africa lechnical Department, Population, Health and Nutrition Division AFISP Africa lIchnical Department, Poverty and Social Policy Division AIDS Acquired Immune Deficiency Syndrome ARIS Annual Review of Implementation and Supervision ASR Annual Sector Review COD Country Operations Division EDI Economic Development Institute EM3 Europe, Middle East and Nonh Africa Country Department III EMENA Europe, Middle East and North Africa Region EXTIE International Economic Relations Division IBRD International Bank for Reconstruction and Development IDA International Development Association IEC Information, Education and Communication LAC Latin America and the Caribbean Region MIS Management Information System NGO Non-governmental Organization OED Operations Evaluation Department PCR Project Completion Report PER Public Expenditure Review PHN Population, Health and Nutrition PHR Populalion and Human Resources Department PHRHN Population, Health and Nutrition Division of the Population and Human Resources Department PIR Public Investment Review PIU Prcject Implementation Unit PRE Policy, Research and External Affairs PRS Sector Policy and Research PRSVP Office of the Vice-President for Sector Policy and Research SAR Staff Appraisal Report SOD Sector Operations Division TD Tbchnical Division WDR World Development Report WID Women in Development EXECUTIVE SUMMARY Overview olFY91 Sector Operations 1. The volume of lending in the Povulation, 2. Of the twenty-eight projects approved during Health and Nutrition (PHN) sector showed contin- the fiscal year, eighteen are "pure" PHN projects and ued and significant growth in FY91. Lending to ten are social development projects -- multisectoral twenty-eight projects totaled $1567.6 million, com- operations encompassing the PHN and education pared with commitments of $933.4 to eighteen sectors and, in some cases, other sectors, as well, projects in FY90, which, in turn marked a substantial s-ch as agriculture, water supply and sanitation, increase in both number of projects and lending other basic infrastructure and income generation volume over FY89. In fact, growth both in number activites for the poor. The ten social development of projects aind amount of lending has been a notable projects received $464.8 million of IBRD/IDA feature of the Bank's support to PHN since FY81, support (30 percent of overall PHN lending) of when the Bank first began lending for health (Figure which an estimated $207.4 million wil support PHN 1). components. Lending for "pure" PHN projects and for the PHN components of the social development Figure 1: Lending for the Population, Health and projects amounts to $1.3 bitlion, or 83 percent of Nutrition Sector, FY80-91 overall lending to the sector. 3. The growth in PHN lending has surpassed 30Number o Pojects targets set by the Bank's senior management on a 30 28 number of occasions. In November 1989, President 2 6 Conable, in an address to the Annual Meeting of the 20E la International Planned Parenthood Federation, 20 t8 g pledged to increase PHN lending to $800 million 1. 1* annually during the period FY90-92; lending for the 10. 7 7 total PHN sector and for "pure" PHN reached $933.4 a 4 4 2 m E milion and $845.1, respectively, in FY90, and o- $1567.6 and $1,300.2 respectively in FY91. The 80 81 82 83 84 86 80 87 88 8e 90 91 Bank's 1990 "Review of World Bank Programs and Fs8cal Year FY91 Budgets' estimated that PHN lending would - PHN PROJECTS EMSOCIAL DEV. PROJECTS increase from an average of 3 percent of Bank lending in FY89-90 to 4 percent in FY91. The 1800 Mill lons of USS proportion of total Bank lending to the sector 1600 166 increased considerably -- trum 4.5 percent in FY90 1400 to 6.9 percent in FY91, or from 4.1 percent to 5.8 1200 percent, if lending to non-PHN components is 1000 934 excluded. More recently, on the occasion of the 800i World Summit for Children in September 1990, eoo- 420 660 President Conable expressed hBank's determina- 400 244193 304 tion to provide greater support for primary health 200 143 120 3 o- 0 36 I 8" care and set a goal of increasing lending for primary. S0 8t 82 83 84 88 S0 87 88 89 90 es health care from about 3 percent to about 5 percent Fiscal Year of total lending within the next three to four years. _PHN PROJECT8 80CIAL OEV. PROJECTS InFY91,some90percentof "pure" PHNallocations, or $1220 million, supported primary health care, accounting for 5.4 percent of total Bank lending. ii PHN 1991 Sector Review 4. The future PHN lending program looks additional funds for its PHN and social development strong. The large Increase achieved in FY91 proba- projects was sigr.ificantly higher in FY91 than in bly will be followed by a decline in FY92 in the FY90. In FY91, cofinancing more than doubled the number of projects and the volume of lending. resources available to those PHN projects that were Projected FY92 levels, however, still exceed those cofinanced. The proportion of PHN sector projects achieved in FY90, both in terms of the number of receiving cofinancing from official sources (61 operations and the volume of lending. Furthermore, percent) was higher than the overall Bank share (53 these levels would surpass senior management's percent); in FY90, the shares were equal (56 per- target of $800 million in lending to the PHN sectors. cent). Social development projects attracted more Continued growth is projected for FY93 and FY94. cofinancing than those projects focussing exclusively on the PHN sectors. In addition to official cofinan- 5. The momentum in actual and forecasted cing arrangements, Staff Appraisal Reports (SARs) growth in PHN lending is attributable to a number document increasing coordination with donors of factors. Human resource development is accorded overall. very high priority, in the context of overall economic reform and development objectives, by both the Bank 9. Integrated Strategies. The increasing integra- and national policymakers. Furthermore, the World tion of PHN into country strategies, noted in the Development Report (WDR) 1990 and subsequent FY90 sector review, has continued. A growing operational strategies reflect the Bank's strong number of projects address PHN and other compo- commitment to the alleviation of poverty, a key nents together, and sector work is preparing the component of which emphasizes the provision of ground for dialogue and operations in integrated basic social services to the poor. human resource and social sector activities. Many projects now involve multiple line ministries and 6. PHN lending and sector work undertaken require significant coordination among the different during the year has been responsive to the Bank's parts of the governm-nt. While these projects emphasis on human resource development and on maybe more complex, they promise long-term pay- poverty. Highlights follow: offs. The involvement of central ministries, such as planning and finance, seems to elicit from those 7. Diversity in sectoral content and lending instru- ministries an improved appreciation of and, conse- ments. In addition to the increasingly multisectoral quently, stronger commitment to social programs. nature of PHN operations, discussed briefly above, diversity is evident in the funding mechanisms 10. NGOs. The involvement of NGOs in the employed in FY91-approved operations. Seven (or design aLd implementation of PHN operations is on 25 percent) of the twenty-eight operations are the increase. In nearly all 28 of the PHN operat:ns designed as sector funds, wiiich support subprojects approved during the fiscal year, NGOs are assuming prepared in-country by communities, local govern- important roles in prceect implementation. 'lb a ments and non-governmental organizations (NGOs), lesser but still significant extent, NOOs are partici- among others. These funds are managed by the pating in the design of projects. Borrower, which has primary responsibility for the solicitation, review, appraisal, approval and supervi- 11. Health. The main thrust of health operations sion of subprojects. In addition, the first-ever PHN has been on extending access to quality primary sectoral adjustment operation (Togo Population and health care. Within the primary health care objec- Health) was approved this year, along with one tive there has been considerable emphasis on mater- emergency recovery operation (Yemen) prepared In nal and child health services as well as on the Ac- response to urgent social sector needs generated by quired Immune Deficiency Syndrome (AIDS) pan- the Gulf crisis. demic. Nutrition and population projects also support important components of primary health 8. Cofinancing. The Bank's leveraging of care. PHN 1991 Sector Review iii 12 Populaton. Thirteen projects in the FY91 ment/institutional development, chosen by the lending program provide direct support to family Population, Health and Nutrition Division of the platnirtg -- up from eight last year. Lending volume Fopuiation and Human Resources Department rose as well, doubling from $169.3 million in FY90 (PHRHN) in close consultation with PHN colleagues to $340.3 million in FY91, with much of that in- in operations. crease attributable to the Bangladesh project, which was. advanced from FY92 during the fiscal year. The 15. A review of project experience both within $340.3 million is a conservative estimate of direct and outside of the PHN sector reveals four condi- lending to population, and represents about 25 tions that have a strong influence on the success and percent of the S1.3 billion committed to "pure' PHN sustainability of PHN operations: (1) enabling policy projects and components. In addition to the provi- and pol'tical environment; (2) sound organizational sion of family planning services and their integration structure; (3) adequate management capacity, and (4) into basic health services, support is also provided to adequate and reliable financing of essential sector policy and program development with a strong activities over the long term. Tle main approach to emphasis on building national capacities in these the special topic was to review lessons learned from areas. Bank implementation experience, with a view to identifying what management/institutional issues 13. Nutrition. Bank support of nutrition is clearly should be addressed in PHN sectors in order to manifest in the large growth In the numbei of assist national governments to bring about these four operations, which support nutrition activity. Esti- conditions for successful and sustainable activity. mates of overall project resources for Bank-assisted While the ASR presents both lessons of substance nutrition activities have risen in the past three years (what to do) and lessons of design and process (how from $54.8 million to $337.7 million to $470.4 to do it), it does not provide a complete set of million. As with population, the Bank, itself, may guidelines for task managers and management. sometimes finance only a modest share of total Rather it represents an initial attempt to address a project resources for nutrition, while raising substan- difficult yet crucial dimension of PHN work, which tially more funds from other agencies. In addition to has thus far received modest attention. PHRHN is nutrition assistance provided through sector opera- considering a more thorough review and analysis of tions, nine of sixteen adjustment operations approved management/institutional development experience in in FY91 address nutrition. Projections for FY92-94 PHN, both inside and outside of the Bank, which lending for nutrition projects, and projects with would eventually culminate in the production of such significant nutrition components, continue the guidance. upward trend. At $1.2 billion this lending would more than double Bank lending for nutrition during 16. Lessons of Substance. Both the institutional the period FY89-91. Nutrition assistance is increas- and organizational framework and the capacity for ingly addressing micronutrient malnutrition. Despite policy formulation and implementation need to be additions to the technical nutrition staff this year, the strengthened for more effective and efficient PHN Bank needs to increase further its institutional activity. In summary, six dimensions of institutional capacity to respond to the growing demand and strengthening should be considered when developing opportunities for nutrition interventions. and implementing a PHN operation, particularly one with a poverty focus: (1) optimal use of institutional Special Theme: Institutional DevetoDment in Support resources; (2) forming and strengthening local of a Poverty Focus organizations; (3) intersectoral coordination between poverty-oriented institutions; (4) appropriate decen- 14. The theme of this year's Annual Sector tralization of health sector authority and responsibili- Review (ASR) is a blend of two special topics: (1) ty, (5) sound organization of service delivery and poverty, chosen by the Office of the Vice President promotional activities; and (6) strengthening of key for Sector Policy and Research (FRSVP) for inclu- components of the institutional frameworkl The sion in all FY91 Sector Reviews. and (2) manage- following dimensions of management capacity for iv PHN 1991 Sector Review policy analysis and implementation need to be adjustment operations; and (4) emergency recovery strengthened: (1) qualitv and availability of informa- operations. Their comparative advantages are tion; (2) skill in policymaking, planning, program- discussed in the review. ming, and budgeting to ensure the translation of well-articulated, appropriate policy into .implement- 19. Issues. While the FY91 portfolio of PHN able programs and projects; (3) the availability, projects pays great attention to poverty and institu- distribution and management of resources (physical, tional issres--many with ingenuity and creativity--it human and financial); and (4) sound project and still reveals some variance in the depth, breadth, and program management. quality of PHN analysis and interventions aimed at strengthening institutions and management capacity. 17. Attention to the following process factors The notably increased policy orientation of PHN should increase the effectiveness and efficiency of operations is not always accompanied by fully ade- efforts in the PHN sector to improve the promotion quate capacity building efforts to permit national and delivery of basic services to poor and vulnerable institutions to assume responsibi!ities and implement groups and to develop inLstitutional and management activities generated by such operations. The ASR capacity in support of that objective: (1) sufficient has distilled a wide array of documented experience analysis of institutional, organizational and socioeco- and wisdom in the Bank into a matrix of lessons or nomic culture preceding project preparation; (2) principles, which give direction in this regard. The flexibility in project design and implementation; (3) quality and effectiveness of Bank efforts to strength- deliberate attention to political, institutional and en institutions, particularly with a view to facilitating financial sustainability at all stages of a project; (4) the achievement of poverty-alleviation objectives is project management arrangements that ensure constrained by three major issues: smooth implementation and encourage institution building and sustainability; (5) improvements in the (a) number and skills mix of PHN Staff; quality of supervision work; (6) increased use of (b) absence of standards and guidelines for qualified local expertise in all aspects of the Bank's analyzing and addressing institutional wek; (7) greater community participation; and (8) and management issues; and improved planning and management of technical (c) lack of suffcient time to spend on insti- assistance. tutional and management issues. 1& Overview. The FY91-approved portfolio of Recommendations PHN operations has.a strongpoveny focus: twenty-six of the twenth-eight projects support the provision of 20. These constraints can be significantly alleviat- basic services to targeted poor and vulnerable seg- ed by implementing the following suggestions. First, ments of the population. The two remaining pro- Bank expertise in institutional development should jects, which support the hospital sector in countries be expanded by: (1) improving the capacity of exist- where access to basic services is universal, emphasize ing sector staff (increasing not only their numbers efficiency and equity issues. Vitually all FY91 but their access to guidelines and training); (2) operations support sist4ution development and increasing the use of in-house management and improvements in management capacity. A predomi- institutional development expertise; (3) increasing nant feature of such assistance is support of decen- the use of consultant specialists in this area; and (4) tralization policy in the PHN sector by strengthening increasing the number of management and institu- lower-level planning, decisionmaking and financial tional development experts in divisions working on management; encouraging community participation; the PHN sector. Second, priorities and practices in and redefining and limiting the role of central the Bank should be revised to ensure adequate time government. Four innovative categories of PHN spent on supervision and on upstream diagnostic operations were evaluated against these lessons and work, and to ensure a rigorous review by manage- found to be quite responsive in various ways: (1) ment of the management/institutional development sector funds; (2) social swetor operations; (3) sector content of lending and sector work. PHN 1991 Sector Review v 2i. Third, the full potential of PHN policies and Interventions to contribute to institution building and poverty alleviation can be realized only when policies are grounded in a macroeconomic and multisectoral policy framework oriented towards growth with poverty reduction, accompanted by a sound strategy for building institutions and the capacity to manage and implement policy. This means that countly operations divisions have a critical role in assisting cey national decisionmakers to understand and internalize poverty alleviation and institution-build- ing objectives and to plan and prioritize sector interventions and allocate resources accordingly. 22. Fourth, more creative use of Bank instruments and resources should be sought through: (1) a review and assessment of the optimal use of lending instru- ments for PHN sector interventions; (2) increased innovation in the identification and financing of local expertise; and (3) increased efforts to encourage the exchange of experience and ideas among developing countries, over and above the notable efforts of the World Bank's Economic Development Insititute (EDI). CHAPTER I. INTRODUCrION: PURPOSE AND SCOPE OF REVIEW 1.1 The objectives of this Population, Health and agreed with Operations colleagues that the issue Nutrition (PHN) Annual Sector Review (ASR) are would be dropped from this years sector review in (a) to provide an overvlLt of the FY91 work portfo- favor of a more tncused exercise. Iio, including ,tistics on the volume and mix of lending and sector work and a brief discussion of salient features and trends, and (b) to address in some depth the special topic of institutioial develop- ment for poverty alleviation.* 1.2 This report covers three components of the PHN work portfolio. First, the vortfolio of FY91- approved knding opelations considered in this review comprises the twenty-eight projects officially catego- rized as PHN sector, including a number of multisectoral operations that include relatively small PHN components. While the PHN secor lending work undertaken during FY91 actually encompasses a larger sampling of projects (i.e., those at the preparation, appraisal, and negotiation stages at the end of the fisal year), resources did not permit a rigorous review of all projects developed during the fiscal year. Second, the review provides statistics on sector work, but no critical analysis; such a review is under consideration. Third, the coverage of the ninety-seven projects under supervision is limited to some basic statistics on the size and composition of the supervision portfolio. The Seventeenth Annual Review of Implementation and Supervision (ARIS), currently underway, will provide a thorough review of supervision work This report did, however, take great care to incorporate into the lessons learned matrix the findings of the Sixteenth ARIS and of all seven Project Completion Reports (PCRs) produced during FY91. 1.3 r.. years Annual Sector Review guidelines, prepared oy the Office of the Vice-President for Sector Policy and Research (PRSVP), explicitly noted that reviews of research and poly work were not to be included, as had been the case in the past. * The review team (Denise Villancourt, Jane Such a review is being considered as a separate Nassim, and Stacy. Brown, PHRHN) consulted eercise and would, more appropriately, be undertak- about forty operations staff on the process and en by Operations. Also, while the teholg topic substance of this exercls. These consultations heavily proposed in the PRSVP guidelines was widely influenced the choice of the special theme as well as considered to be important, it was discussed and the overal approach to the review. CHAPTER It. OVERVIEW A. Lending Figure 1: Lending for the P^;sulatlon, Healah and A4utrition Sector, FY80-91 1. Growth in the Lending Portoli_ 2.1 FY-I saw continued growth in the PHN 3 Number of Project* activities of the World Bank. Lending to twenty-eight 30 24 projects totaled $1567.6 million, compared with 2 6 - commitments of $933.4 to eighteen projets in FY90, 2 18 which, in turn, marked a substantial increase in both numbnr of projects and lending volume over FY89. 11 1E In fact, growth in both number of projects and so r 8 8 amount of cnd.ng has been a notable feature of the 6 , 2 Bank's support to PHN since FY81, when the Bank o first began lending for health (Text Figure 1). The 80 SI 8 83 84 86 86 87 88 8a9 90 G Bank's restated commitment to the reduction of Fiscal Year povertyandits rapidly growingemphasison human PHN PROJECTS i0OCIAL DEV. PROJECTS resource development have stimulated this growth, Milli10 f Use which has been particularly marked in the past four 180G - to rive years. In addition, the 1987 reorganization of 10 0 . .66 the Bank, which combined PHN with education in 1400* integated Population and Human Resource (PHR) 1200 divisions, also led to expansion in PHN operations 18000- t34 and In social development projects that include PN 600 e -o and education sector components and, in many cases, 400 244420 304 others as well. Annex 1, Ibble 1 lists the twenty-eight 200 143 t20 64 PHN projects approved during FY91 ..nd provides a o868 breakdown of IBRD/IDA amounts by sector--PHN, F38cal Year Education, and others--which highlights the MrHM PACE? M3OCIAL 0EV. PROJECTS multisectoral nature of the social development procs^. __ 2.2 Social development projects arose as a distinct Figure 2 gives an overview of the sectoral composi- feature of PHN work in FY90 when there were six tion of the FY91 PHN projects. such projects. In FY91 there were ten, with lending amounting to $464.8 million, or 30 percent of overall 2.3 The proportion of total Bank lending to the lending to the PHN sector. The review team estimat- PHN sector increased considerably in FY91--from 4.5 ed the value of the PHN components of social percent in FY90 to 6.9 percent in FY91, or from 4.1 development projects at $207.4 million, representing percent to 5.8 percent if knding to non-PHN compo- 45 percent of loans and credits for that type of nents is excluded (Ilx lIble 1). PHN lending has project. Lending for 'pure' PHN projects and for the grown in both absolute and relative terms, in re- PHN components of the social development projects sponse to senior management's commitment. to mounted to $1.3 billion, or 83 percent of overall increase PHN activities. This commitment has been lending to the sector (Annex 1, lable 1). expressed on several occasions. In November 1989, President Conable, in an addtess to the Annual Meeting of the Internationai Planned Parenthood 4 PHN 1991 Sector Review Federation, pledged to increase PHN lending to $800 detailed information on the growth of the sector is million annually during the period FY9O-92. The given in Annex 1, lhble 3.) Bank's 1990 "Review of World Bank Progms and FY91 Budgets' stated that it expected PHN lending lhble 1: lVends in Lending to the PHN Sector, to increase from an average of 3 percent of Bank FY89-91 Figure 2: Sectoral Composition of PHN Projects Approved in FY91 ls. 2MSLRidll Aemots in S Hi Regon r089 FY90 FY91 . , . ~~~~~~~~~~~~~~~~~~~~~~~~~~............... .........I..... ...........I........ SEACt No. APaW. No. Rount No. AFRICA III.0 1'.) 732.7 (8) 432.8 (12) PHN 1300.2 ASA 80.0 (4) 192.5 ? 507.5 (5) EDUCATION 58.7 fICECA s0.0 (2) 119.0 (2) 2?0.0 (6) INFRASTRUCTURE 110.2 SAc 99.0 (1) 389.2 (6) 337.3 si) 'MTER 6.3 TOTAL 530.0 (11) 033.4 (18) 1567.6 (a8) INCOME GEN. 8Q.3 AGRICULTURE 2.9 - - - - - - lb. PHt Ledirng as a Percent of Totat Rank Ltiring TOTAL 1567.6 ..o rYb . . . . rY9; ltegion FY89 FY90 FY91 Pure Totes Pure Total Pure Totat _PN PHt Po pit PNY PKM AFRICA 2.1 2.1 4.3 5.9 12.3 12.8 AgrIc~ulturo 0.2'b_ PHN a2 9$ kASIA 3.7 3.7 3.0 3.0 6.3 6.8 lntragtruCturO 7.0$ $ fIEUA 2.1 2.1 2.7 2.7 1.9 4.4 LAC I.r 1.7 6.1 6.5 5.6 8.4 Education 3.7% ................................................ Income 5.7% TOtAL 2.6 ?.6 4.1 4.5 5.8 6.9 Water 0.4% Note: QPur* PNe- reters to PHU only Projects and PHU ctmpnents of Social Dovelopomnt Projects. Total PuN emooseg (l lling for rttro PtU sector, (In USS millions) i.e. incuding non-PHoI contonta. 2.4 The portfolio of FY91-approved operations, lending in FY89-90 to 4 percent in FY91. Both of reveals increasing divetsity in both the sectoral these targets have been exceeded. More recently, on content and the lending instrument used (lbx 'able ihe occaslon of the World Summit for Children in 2). Eighteen of the twenty-eight projects (64 per- September 1990, President Conable expressed the cent) are devoted entirely to the PHN sector, of the Bank's determination to provide greater support for remaining ten social development projects, four (14 primay health care and set a goal of increasing percent) support PHN and education sectors only lending for primary health care from about 3 percent and six (22 percent) support PHR and other sectors to about 5 percent of total lending within the next as well, such as agriculture, water supply and sanita- three to four years. Some 90 percent of "pure" PHN tion, other rural infrastructure, and income genera- allocations, or $1220 mllion, supported primary tion activities for the poor. Diversity is evident as health care in FY91, acoounting for 5.4 percent of well in the funding mechanisms employed. Seven of total Bank lending (see Annex 1, ibble 2 for detalls). this yeares operations (25 percent) are in the form of PHN p-o,ts approved during the year have also sector funds, which support subprojects prepared in- been found to be highly responsive to the Bank's country by communities, local governments and non- poverty alleviation objective (see Chapter III). (More gwrernmental organizations (NMOs), among othes PHN 1991 Sector Review 5 These fuads are managed by the borrower which has FY91 projects supported PHN and socal develop- responsibility for the solicitation, review, apprisal, ment activitdes In Africa; six projects were approved approval and supervision of subprojecs. In additon, in the Europe, Middle East and North Africa a number of other traditional projecs provide for (ENENA) region and five each in the Asia and the small sector funds to support such Innovative activity Latin America and Carlbbean (LAC) regions. In which serves as a complement to other components. terms of loan and credit amounts, 32 percent of total A list of all sector funds is provided In Annex 1, PHN sector lending was committed to Asia, 28 Ibble 4. In aiditlon, one project (rogo), represent. percent to Africa, 22 percent to LAC and 18 percent ing the flrst-ever PHN sectoral adjustmt operation, to EMENA (lbxt Figure 3). In FY90, sodal develop- will provide balance of payments support In three ment projects were a feature of the lending programs tranches in fulfMllment of a number of sectoral inAfrlmaandLAConWlInFY9lallregions hadat reform measures. Ths year's portfolio also includes least one such project: four in LAC, three in Africa, one emergency recovery operation (Yemen) In two in EMENA, and one in Asia. response to urgent social sector needs generated by the Gulf crisis. The comparative advantages of the variety of sectoral and financing characteristics of Figure 3: Regional Distribution of PHN Lending, this years portfolio of projects are discussed in some FY91 detail in Chapter Hm AFRICA 12 Ikbie 2: leczoral Composition and Funding r43W% Characteristics of PHN Portfolio, FY91 ASIA 6 18% LAG 18% .. _ _____ _ __ ...... _EMENA 8 ?rSdleloauL sector naa ot,.r 2 1% ._N,L-qa,r, _. "'' -- ._ !} .;- Number of t'rojbcts aoly Xad4q9ccr-SIL NIgeria P.-ZtL (i) NSI*VL- SIN RZntL _ _ AFRICA 432.8 UmIabJt-t ASIA 607.6 28% Saaqlad.sh-StL 32% madla-SIL IWlOMOLOI-SZL Tun&*A& (R@apOI -tL9 22% Neaaco-SIL EEA . ... _ __...... _ _------ Amounts------ E CL SeLas014-fSL Lending Amounts PX1 VtmSIMU-S.. L ;; (In US$ Millons) _ ~~~~. ...... ............ .............. ...... S tOd Or tsri M_tOW - Iinn Laon SA Sctr erstw uxaafi, S taL l= e uaLoan Afmha n project laqe than S100 mflon, . . . . . . . ~~~~wherma thtee of the five Asia projects were larger than trat, as were two of the re ee LAC projects, and one of the six in ENA. These large projects ac counted for 57 percent of PHN lemding volume. ee 2ReDianadl RDM 4CoMM i aveage size of IBRD/IDA allocations for PHN operaSot in FY91 r $56 millon; for the four 2.5 'Me Atifca Region developed the lugt regions the averagd size p s l1are5 thla on for Asia, number of projects in FY91, though lending volume S67.5 mionforAcut for EpCe PHN mlning lme A, was greatest in Asia. 'Nelve of the twenty-eight and $36.1 mfllon for Africa 6 PHN 1991 Sector Review 2.6 The proportion of PHN projects that receive munity, however. The social development project IDA funds is larger than the Bank-wide average. appraisal reports, in particular, refer to coordination Overall, 59 percent of the total amount of Bank in support of larger country social programs, of lending to PHN operations in FY91 was comprised which the Bank project often constitutes only a part. of IDA funds, compared with 28 percent for all Bank projects. The proportion was greater for social Tible 3: Cofinancing from Official Sources in development projects (73 percent) thdn for "pure' PHN Projects, FY90 and FY91 PHN projects (53 percent), as befits the former projects' important role in poverty reduction. (Annex 1, Ibble 1 itemizes the IBRD/IDA allocations.) 3s. Cotfirned Projects FY90 FY91 3. Coflnanc ................ ......... go. of Total N0. No. of Total LO. Coflraced of PHU Cofinared of P,Ig 2.7 In FY91 the number of cofinanced projects Region Projects Projects Projects Projecto increased with the overall growth in the number of 8FRICA 7 a 9 12 PHN sector projects, though the proportions re- ENEA 0 2 3 6 mained the same as in FY90. The regional distribu- LAC 3 6 3 5 tion of cofinanced projects ums, however, more .. .... ... .... All R8gior 10 18 17 28 balanced in FY91. Every region had some cofinanced .....................28 projects in FY91, whereas in FY90, Asia and EMENA had no cofinanced projects (Text Tble 3). 3b. Addition ity The Bank's leveraging of additional funds for its Ovrall; Additionetity In Cofmr4oed PHN and social development projects was significant- Additloo lity Projects 18) ly higher in FY91 than in FY90 according to both Regio F90 FY91 F;90 FY91 measures of additionality--the amount donor co- . -.-.-.-.-.-.-. l AFRICA 4.2.? 39.3 60.3 S9.1 financing (not recipient governments) adds to the ASIA 07 S 0.0 112.0 Bank's lending .'or all PHN projects (overali EIEUA 0.0 1380 040 1 89 1 additionality) and the amount cofinancing adds only . .. 4 ......... to the projects that are cofinanced. In FY91 co- All Peeo 1S.4 36.0 S6.? 110.2 financing more than doubled the resources available to the cofinanced projects. The proportion of PHN sector projects receiving cofinancing from official sources (61 percent) was higher than the overall Bank share (53 percent); in FY90 the shares were equal (56 percent). 2.9 An interesting feature of the FY91 lending program is the involvement of in-countrycofinanciers 2.8 Other donors contribute more to the financing in addition to central government or, in one or two of social development projects than to 'pure' PHN cases, in place of central government. In three of the projects: overall additionality is 113 percent in social Africa projects and in one Asia project, state govern- development projects and 33 percent in PHN-only ments and public agencies are cofinancders. In many projects. IX the cofinanced social development projects the beneficiaries are also contributing: this projects, additionality is 153 percent; in the PHN- is occurring in six Africa projects, two LAC projects only projects it is 83 percent. The social development and one Asia project In the Korea Health Technolo- projects, supporting a broad range of social invest- gy I project, the private hospitals that are the project ments, appear to offer an attractive means of com- beneficiaries are financing 26 percent of total project bining assistance. Official cofinancing of Bank- costs while the government is making no financial assisted PHN and social development projects reveals contribution. In all other projects the amounts only part of the growing collaboration between the committed by the beneficiaries are quite small, since Bank and other agencies in the official donor com- they are, in most cases, the municipalities, NGOs, PHN 1991 Sector Review 7 and local groups that will be presenting proposals for rately in this analysis because it has been categorized project funding. In general the contributions are in both as an investment and as a recufrent cost by the form of matching grants, and their significance different projecs within and across regions. While lies less in their size than in their implications for drugs are recurrent In natu:e, in that supplies need greater local involvement in project design, imple- to be replenished on an ongoing basis, the purchase mentation, and sustainabDlity. of an initial stock of drugs through a project, which will be replenished ultimately through cost recovery 2.10 On average for FY91, the Bank is financing 46 and/or other means nationally, is sometimes catego- percent of total project costs in the PHN sector. rized by task managers as an investment cost. Average project costs were higher in the socdal development projects than in the "pure" PHN proje- Figure 4: Breakdown of ibtal Project Costs by cts--$131 million versus $119 million--though Bank Expenditure Category loans were lower on average to social development projects--$46 million versus $61 million--another indication of the additional leverage gained in cofinancing from all sources in the social develop- Project Cost Categories ment projects. Summary Accounts 4. Project Funds by Expenditure Catezorv . S 402 2.11 As shown in Figure 4, investment costs weie j _Dev. 70 percent of total projea costs, and recurrent costs 33.1 were 30 percent, including the costs of drugs, contra- I9C.2a 74074 SI'. ceptives and therapeutic nutrition. The greatest share ............... v (about two-thirds) of investments financed under 117.9 ., 7i7 FY91 projects was fcr equipment, furniture, supplies, . U9 and civil works. While not calculated in detail by the 8&6 ASR team, a large proportion of these investment costs are for the rehabilitation of existing facilities (in US$ millions) and for replacement of equipment which have been allowed to deteriorate. This phenomenon is reflec- Note: Data derived from 19 of the 28 FY91-ap tive not only of the need for improved management proved PHN projects for which detailed break of maintenance activities but also of the lack of down of total project cost was available (18 recurrent financing to support such activity. Securing "pure" PHN projects and the Mali Health and adequate levels of recurrent financing for proper Water project). maintenance of buildings, vehides and equipment is surely a more cost effective alternative for providing needed inrastructure for the promotion and delivery of health services. The Bank, both in its policy on recurrent cost financing and in its PHN project B. Sector Work designs, should be more supportive in providing needed assistance in this regard. 2.13 Thirty-threc pieces of sector work reached at least the white-oover report stage in FY91, the same 2.12 Three-quarters of the non-drug recurrent cost level of output as in FY90 (Annex 1, lhble 5). component, which represented 24 percent of total TWelve of these reports were completed in final grey- project costs, was for salaries and allowances. The or red-cover form. (Annex 1, bkble 6, provides "drugs" cost category, which includes drugs, contra- details.) lWenty-four of the reports were produced ceptives and therapeutic nutrition, made up 6 per- by the PHR divisions, the balance by the country cent of total project costs; it is accounted for sepa- divisions, a few other sector divisions and one by the 8 PHN 1991 Sector Review TIbchnical Cooperation Unit of the Europe, Middle the five projects reviewed in this exerc aises con East and North Africa Country Department m cern, four of thowe projects were considered to be (EM3), which reviewed the organization and func- sustainable. The projects were among the first health toning of the Ministry of Health of Saudi Arabia. and nutrition operations of the Bank; and the About half the reports treat PHN in the context of process of their review and evaluation has indicated broader human resource, poverty alleviation, and that a review of criteria for rating success of PHR social sector issues or, particularly in Africa, in projects may be in order. relation to women in development issues. 2.17 One OED report issued in FY90 with impor- 2.14 The reviews, which focused exclusively on the tant implications for Operations was the review of PHN sector (or subsectors), were undertaken most the Bankes work to date on population, based on often in countries where the Bank is at an early stage eight country case studies. The report found justifi- of involvement (e.g., the PHN sector report in Lao cation for the Banks greater focus (since its reorga- PDR), or where it has had to adapt to changing nization) on coherent macroeconomic and govermnent policy (e.g., the *New Directions in multisectoral strategies at the country level and for Family Planningf report in the Philippines). In the poverty focus of its worL Although several of the health, several reports dealt in some detail with the famly planning programs studied were able to raise technical issues of health financing and health contraceptive prevalence levels even under unfavor- planning, questions of growing concern. In nutrition, able socioeconomic conditions, the report stresses an increasing number of reports assessed needs and the limits to such an approach. It argues that project interventions in the broader context of food secuity impact would have been greater had family planning concerns. IWo important areas of population sector programs been developed in combination with work were (a) policy development and the institu- reinforcing social programs that produce conditions tional framework necessary for program implementa- favoring the emergence of preferences for smaller tion, and (b) the use of alternative channels for family size. The report cites the ase of Indonesia, bmily planning services-- NGOs and, to some extent, where parallel investments in education helped to the commercial sector. Secor work will remain at create the condidons for fertility decline and the much the same level of activity in FY92 and FY93. increased demand for family planning services. Another important conclusion of the OED report Is C Supelion and Project Evaluatlon that greater financial resources from the Bank would not necessarily have Improved the programs' impact; 2.15 The PHR divisions are currently responsible rather, non-financial assistance in the form of more for a heavy supervision workload (Annex 1, Figure sector work, more focus on software than hardware, 1). Ninety-seven projects, representing commitments a more pro-active role in some countries, and more of nearly $4.5 billion, are being implemented. Nearly collaboration and coordination with other donors, half these projects are in the Africa Region. (The would have been useful oDmplements. Operations is implications of this workload are discussed in more already moving in the dections, and the report detail in Chapter IV.) confirms the soundness of these approaches. 2.16 Seven project completion and audit reports D. PopulatIon, Health and Nutrulton Content of were produced during FY91 (Annex 1, Ihble 7). Projec Several of them--the ibmil Nadu Integrated Nutri- tion Project, in particular-distill the lessons of 2.18 The increasing integration of PHN into experience in ways that have wide applicability. country strategies, which was noted in the FY90 These completion reports were used by the Opera- sector review, has continued, and the Staff Appraisal tions Evaluations Department (OED) in its 1990 Reports (SARs) document increasing coordination Reiew of Project Performance Results: Human with other donors as welL A growing number of Rsources Pojets. Although the unsatisfactory rating projects address PHN and other components togeth- for achievement of original objectives for three of er, and sector work is preparing the ground for PHN 1991 Sector Review 9 dialogue and operations in integrated human re- of primary health care, and, so, share that emphasis, source and social sector activities. Many projects now seeking to address the needs of young children and involve multiple line ministries and require signifi- women and to integrate ard coordinate those servic- cant coordination between the different parts of es with other basic health services for greater effi- government (see Chapter 111). While these projects ciency and effectiveness. Thus the Bangladesh, may be more complex and risky, they promise long- Indonesia, and Pakistan projects aim at more effec- term payoffs as previously excluded ministries, tive integration of family planning with maternal particularly central ministries, such as planning and child and health services than has previously been financing, are drawn toward a stronger commitment the case. The India Integrated Child Development to social programs. The involvement of NGOs is on project is strongly focused on nutrition, the Sri the increase. In nearly all twenty-eight of the PHN Lanka Poverty Alleviation project includes a nutri- operations approved during the fiscal year, NGOs are tion fund aimed at improving the health of mothers assuming important roles in project implementation. and children, and the Honduras social development lb a lesser, but still significant extent, NOOs are project includes pilot nutrition activities. participating in the design of projects, as well (Gha- na, Pakistan, Venezuela, for example). NGO in- 2.22 Population. Thirteen projects in the FY91 volvement is particularly significant in projects with lending program provide direct support to family sector funds, where their role in eliciting from planning--up from eight last year. Lending volume communities and in preparing, themselves, subproject rose as well, a doubling from $169.3 million in FY90 proposals is certain to result in the design and to $351.0 million (Annex 1 Tbble 8 and Figure 4). support of PHN activity which is responsive to the Most of the increase comes from the Bangladesh needs of local populations and which is likely to be project ($61.5 million for population), advanced from sustained. the FY92 program; next year's program will be corre- spondingly reduced. Attribution of commitments to 2.19 The integration of PHN into broader human population in Bank PHN projects has always been resource operations, was a welcome development, but difficult, but it has become increasingly so with the not all projects need be multisectoral though plan- integration of PHN and other components. The ning must take place in a broader context. Indeed, as $351.0 million FY91 total is a conservative estimate the sectors mature, specialized projects addressing of direct lending and represents about 25 percent of specific needs may become increasingly important. the $1.3 billion committed to "pure" PHN projects and PHN components of social development pro- 2.20 Health. In health there were three such spe- jects, and over 50 percent of lending in PHN projects cialized projects in FY9': the Korea Health Technol- that include Bank assistance to population (Annex 1, ogy project, which seeks to expand the diagnostic and Tbbles 8 and 9). treatment capabilities of hospitals by upgrading equipment; the Algeria Pilot Public Health Manage- 2.23 Cofinancing also made important contribu- ment Project, which tests management tools for tions to family planning projects. The Bank made no replicability nationwide; and the linisia Hospital direct contribution to family planning in the Zimba- Restructuring Support Project, which addresses bwe Family Health project, but raised $17.7 million issues of management capacity and service quality in for population from other donors. In the Bangladesh the context of policy reform in the sector. The main family planning program, the Bank's allocation of thrust of health operations in FY91, however, has $61.5 million of its assistance to family planning been on extending access to primary health care represents 34 percent of the IDA credit, but the total services in the context of poverty reduction. project ($600 million), commits over 60 percent to population. The Nigeria Population project will do 2.21 Within primary health care, there has been much to promote a strong institutional framework considerable emphasis on maternal and child health for policy and program development, at both nation- services as well as on the Acquired Immune Defi- al and local levels, while building national consensus ciency Syndrc-Ae (AIDS) pandemic. Nutrition and on the importance of reduced fertility for national population projects support important components and individual progress. The Pakistan Family Health 10 PHN 1991 Sector Review project foliows several years of difficult reexami- 2.26 lbn projects apprved In FY91 contain nation of the country's program and uncertain micronutrient components, including the pioneering government commitment. There, too, integration of Mali project for Iodizing water by equipping pumps fimify planning into a broader array of serices de- with an iodine module. 'he Bankes support for signed to inprove health is seen as the most effective micronutrient projects has grown considerabl, way to stimulate the demand for family planing that projecs under preparation demonstrate Bank inter- provides the long-term conditions for program est in fortfication programs. Although there were success. additions to the technical nutriton staff this year to handle the grwng nutridon programs, the Bank 2.24 Nutn. Bank support of nutridon is clearly continues to rely heavily on consultants for fieldwork manifest mx the large growth in number of opera- assinments. The Bank needs to increase institudon- dons, which support nutrition activity--from thirteen al capacty to respond adequately to growing de- in FY89 to eighteen in FY90 and twenty-eight In mands and opportunities for Bank-assisted nutrition FY91, and in lending for nutrition (including PHN, operations. education, Women in Development (WID) and food security operatlons)--from $33 million in FY89 to $200.9 million in FY90 and $252.7 million in FY91. Estimates of overall project resources for Bank- assisted nutrition activities have risen in three years from $54.8 million to $337.7 million to $470.4 million (Annex 1, Figures 2 and 3). As with popula- tion, the Bank may sometimes finance only a modest share of total project resources for nutrition while raising substantially more funds from other agencies. (For example, because of the nature of nutrition operations, large portions of overall project costs are sometimes met by food aid agencies). 2.25 These figures for nutrition do not reflect adjustment operations, which gave considerably more attention to nutrition in FY91. Venezuela's targeted food and nutrition progams went up more than sevenfold in conjunction with adjustment opera- tions--from $102. million in 1989 to $761 million in 1991. And a significant portion of the Agrficultural Adjustment Project for Mexico ($400 millon loan plus $200 millon from the Inter-American Develop- ment Bank was directed to nutridon. Overall, nine of sixteen adjustment loans approved in FY91 address nutrition; four include specific nutrition actions as conditions for tranche release and three led to sizeable sodal funds to improve nutrition conditions. Three of the four agriculture sector adjustment operations include nutrition activities, and in two of them nutrition actions are a condition for tranche release (Annex 1, 'bble 10). Projections for FY92- 94 lending for nutrition projects and projects with significant nutrition components point to a continua- don in growth. CHAPTER HI. SPECIAL THEME: INSTlTUTIONAL DEVELOPMENT IN SUPPORT OF A POVERTY FOCUS FOR PHN SECTORS A Introducwn tions departments) and In the counuries (planning and finance ministres and heads of state). All 3.1 7Wo special topics were selected for this yeares sectoral interventions need to be prioritzed within a sector review: (1) poverty, chosen by PRSVP for well-arIculated set of macroeconomic and multisect- inclusion in al FY91 sector reviews and (2) manage- oral polcies that are oriented toward growth with mentAnstitutlonal dwelopment, chosen by PHRHN poverty reductlon Without this kind of framework, in close consultation with PHN colleagues in opera- the potential of the PHN sector (and others) to dons. A brief overview of each topic and its rele- contribute effectively to poverty alleviation will not vance to the PHN sector is presented here, followed be fully realized. by an introduction of this report's chosen theme, which blends the two special topics. 2. Manawment and Instiutdonal Development 1. &env 3.5 There is a strong, well-documented, positive correlation between project sustainability and institu- 3.2 The World Development Report (WDR) 1990 tional development. The FY90 PHN sector review reflects the Bank's strong commitment to the allevia- noted an increasing appreciation in Bank investments tion of poverty as a central development objective in PHN of the importance of developing institutional and top priority. RDR 1990, and the subsequent capacity and management skills and practices, but policy paper, *Assistance Strategies to Reduce some variance in the effectiveness with which differ- Poverty," articulate a two-pronged strategy for ent operations have addressd this issue. The need sustainable poverty reduction: (1) the generation of for strengthening Institutions and management income-earning opportunities for the poor, and (2) capacity Is espedally acute when poverty and equity the provision of basic social services to the poor to issues and objectives are addressed through PHN enable them to seize those opportunities The sector actvtities. To meet the PHN needs of poor and strategy also calls for providing a social safety net for vulnerable groups, developing country institutions vulnerable groups who are unable to take advantage must be capable of: cross-sectoral and inter-agency of income earning opportunides. Tbis strategy communication and collaboration; more effective intensifies the emphasis on PHR sector activities as targeting, monitoring, and evaluation, which require key investments in the development of any country a strong Management Information System (MIS) and and presents further challenges to the PHN sector. research capadty, understanding and responding to the demands of the poor, and greater community 3.3 Addressing poverty through PHN interven- involvement, to name only a few priorities. tions certainly means expanding access to basic services and targeting programs for the poor and 3. Choice f and ADporah to Special Topic vulnerable groups, in particular. It also means addressing broader sectoral issues--improving the 3.6 Thespedaitheme,"Institutional Development quality and efficency of services, reallocating public in Support of a Poverty Focus for the PHN Sectors," expenditure,decentralzingdecision-makingresponsi- touches on issues of concern to all of the Bank's bility, encouraging greater NOO and community regions. In its treatment of this theme, this review involvement, and exploiting the role of the private emphasizes popular partidpation in the desig and sector to liberate public resources for basic and Implementation of PHN activities, as a key to suc- preventive serices and carefully designed cost- recov- vessfully providing basic servces to the poor. ery programs. 3.7 One overwhelming message received from 3.4 The objective of poverty alleviation must be Operations during the consultative process of this understood and internalized at the country (macro- exercise was the need to take better stock of lessons economic) level-both in the Bank (country opera- learned to enlighten the design of future operations. 12 PHN 1991 Sector Review Section B of this chapter provides a distillation of allocations that are filly reflective of sound policy lessons learned from myriad Bank reviews (see and strong political support, adequate and equitably bibliography in Annex 3), from seven PCRs and designed cost-recovery programs, and improved other reviews of PHN program experience undertak- availability, coordination, and use of external aid. en during FY91 (Annex 1, lhble 7), and from the insights of task managers of FY91-approv,-4 opera- This section provides insight based on lessons tions. Section C reviews FY91-approved PHN learned as to what managementfinstitutional Lssues operations as they relate to those lessons learned. PHN sector operations must focus on in order to While the ASR team reviewed many documents in assist national governments to bring about these four preparing this sector review, time did not permit a conditions for successful and sustainable activity In comprehensive review and analysis of Bank experi- the PHN se vs. These lessons are drawn largely ence relevant to PHN sectors. from the I et. implentation eapeince, particu- larly but nt ;xclusively in the PHN sectors, as B. Lessons Learned documented in the in-house reviews cited earlier. They also reflect the experience and perspectives of 3.8 The review of PHN project experience (Annex Bank staff consulted during the ASR exercise. 1, Thble 7), two OED studies (1985 and 1989) on Where available and appropriate, references are project sustainability, and the Sixteenth ARIS, made to documents, which would provide furnher reveals four conditions that have a strong influence guidelines and/or insight on how to approach these on the sucoess and sustainability of PHN operations: issues. *Enabling policy and political environment, 3.9 Section B.1, below, presents some lessons of which includes (1) macroeconomic and muitisectoral substance, which give some indication of what to do pollcies that are oriented toward growth with poverty about thee various components of reduction; (2) strong political commitment to poverty management/institutional development issues. programs despite the weak political and economic Section B.2, which immediately follows, presents a position of the poor, (3) policies that encourage number of lessons of design and process and notes private sector development, decentralization, institu- some useful tools, al of which might give some tional pluralism, and popular participation; and (4) guidance on how to address management/institutional PHN policies that emphasize the provision of basic development issues more effectively. These sections services to the poor and vulnerable segments of certainly do not provide a complete set of guidelines national populations. for task managers and management. Rather, they are an initial attempt to address a difficult yet crucial eSound organiutonal stucture, which would dimension of PHN work, which has thus far received encourage the involvement of the many institutions, little attention. PHRHN is considering, however, agencies, and community groups that could partici- developing the preliminary work undertaken in this pate in PHN sector development. ASR into a more thorough review and analysis of management/nstitutional development experience in *Adequate management capacity of all contri- PHN, both inside and outside of the Bank, which butors to PHN sector development, which would would eventually culminate in the production of such permit appropriate planning, programming, design, guidance. implementation, nmonitoring, and evaluation of sector activity, as well as the optimal use of human, finan- 1. Lessons of Substance cial and capital resources. 3.10 Tne lessons of substance presented here are eAdequate and reliable finandng of esntial organized around two main categories: institutional sector activities over the long term, which would be and organizational framework, and management aehieved through investment and recurrent budget capacity for policy formulation and implementation. PHN 1991 Sector Review 13 a. Insitutional and Organzanonal Framewwork the poor, whose disadvantages have made them virtually powerless to improve their situations. PHN 3.11 A sound institutional framework is critical to experience corroborates these findings: according to the efficient functioning of PHN sector activity. The review work undertaken during the year, US the following six dimensions of institutional strengthen- achievements of Indonesia's population program and ing should be considered when developing and imple- India's lkmil Nadu Nutrition project are largely mentir.g a PHN operation, particularly one with a attributable to well-organized community involve- poverty focus. ment in promoting and managing basic services. 3.12 Ophimal Use of Instituond Zrsouces. The 3.14 Intsectwal Cordinon Between Povety. institutional framework for In-country PHN activity OMknted Instauion& Intersectoral coordination Is should encourage involvement of the various poten- crucial to the efflciency of PHN sector actviy, but tial actors in the sector according to their compara- achieving it is a formidable management challenge. tive advantages. While there are notable exceptions, Strate4les for population, health, nutrition, and in many developing countries the public sector poverty alleviation each require the input of a carries out the planning, financing and delivery of number of line ministries. OED's review of Bank PHN services. Significant gains in quality and effl- population assistance in eight countries$ cautions ciency could be realized if the private commercial that such essential contributions will not be forth- sector, NGOs, oDmmunity organizations, universities, coming unless deliberate efforts are made to ensure national and regional institutions specializing in coordination, collaboration, and accountability. One training, consulting, aud research, and other groups need is for a well-articulated and politically endorsed outside the public sector were encouraged to engage macroeconomic and multisectoral policy. Also in sectoral activities. The audit report on the Philip- important are clearly defined responsibilities for the pines Second Population Project recommends greater various ministries and agencies and a high-level, reliance on NGOs and the private sector for under- politically stable and capable agency to coordinate, taking health sector activity. According to the promote, and monitor activity. The audit report for Sixteenth ARIS, the sucoful emergence of institu- the Philippines Second Population project recom- tional pluralism should be accompanied by a reduc- mends assigning principal responsibility for family tion in size and a redefinition of the role of the planning to the one agency that is the least political- public sector in PHN. Such a redefinition should ly vulnerable among reasonable candidates. This preserve and, where appropriate, promote preventive same recsamendation is made for the iutrition health activity. sector, based on lessons of experience6. The linisia Health and Population PCR noted that the institu- 3.13 Forming and Strengthewning of Local Organfza- tional rivalry that interfered with the smooth imple- dons. 7he evidence is overwhelming that the partic- mentation of that project might have been avoided pation of well-functioning local community -oups in had collaborative arrangements been better. The the design and implementation oi PHN sector report further recommends that the Bank needs to activity has a strong influence on project success and be ready to intervene and help resolve interagency sustainability. OED's two reports on project sustain- disputes. abilHey reveal that within the right institutional framework, beneficiaries can be mobilized to partic- 3.15 Decenralfiawon. The extent to which health pate in a wide range of activides: needs identifica- sector authority and responsibilities can and should tion; project design; adaptation of project acivities be decentralized is a matter of some debate; there is and technologies to local needs; information collec- no one correct solution to this issue, which would be tion, monitoring, and evaluation; management of applicable and equally appropriate in all countries. activities on a local level promotion of services; and The definition of roles and the distribution of maintenance of Infrastructure. These groups offer responsibilities across the various levels of govern- communities a way to make decisions that will ment should be done with a view to achieving the improve their lives, a power many of them would not appropriate and optimal contnbutions of each of otherwise have, especially those such as women and those levels together and separately. 14 PHN 1991 Sector Review 3.16 Many, if not most, developing countries view system based on a pyramid of services is well accept- the decentralization of sector activities as a viable ed in principle, but needs to be established in prac- means of achieving greater effectiveness and efficien- tice. Many developing countries continue to use cy in health sector activity and thus strive for greater expensive, higher-level facilities to provide primary decentralization. Realization of this objective, ealth care, whether because of a shortage of lower- however, has been elusive. The Indonesia Provincial level facilides or because such facilities are inade- Health PCR notes a failure to decentralize health quate or perceived to be so. And even when lower- services effectively despite the government's stated level facilities are consulted, they do not always refer objective and the project's Intention to support this patients up the health services pyramid when they effort At the end of the project, major decision- should because of inadequate training and guidelines, making, financial control, and other administrative lack of equipment, such as ambulances and radios, responsibilities remained overly centralized. and failure in the referral system itself--no coordina- tion, communication, support, or follow-up between 3.17 More rigorous efforts should be made at the the various levels. A strengthening of the referral country and regional levels by Sector Operations system improves resource use and makes health Divisions (SODs) and Tbchnical Divisions (TDs), services more available and responsive, especia;ly to respectively, and eventually at the global level by the needs of the poor and vulnerable groups. What PHRHN, to study and test both the means and the is needed, among other things, is a clear definition of end of decentralization of decision-maldng and man- the pyramid of services, the range and sophistication agement authority to the provincial, district, and of services to be provided at each level, and the roles lower levels of government. This task may provide a and responsibilities of staff at each level with respect good opportunity to implement the recommendation to referral and operational norms. Also important made in Chapter IV that PHN staff draw on the are staff training, mechanisms to facilitate commu- expertise of in-house management and institutional nication among various service levels, adequate development staff working on publc sector manage- equipment, and a strengthening of basic health ment issues across sectors. Experience gained thus services. Sometimes different price structures are far strongly indicates that success requires clear helpful in discouraging consultation at unnecessarily delineation of responsibilities at each leveL mecha- high levels of services. Any effort to strengthen or nisms for communication and coordination among expand the pyramid of services should cover an the various levels, sufficient management training to service providers, public and private. A study pre- enable ful assumption of decentralized responsi- pared by the Population, Health and Nutrition bilities, and a redefinition of the central govern- Division of the Africa Tbchnical Department ment's role that would limit it to policymaking and (AFTPN) on the Health Center in Sub-Saharan coordination, regulation, flnancing (in part), and Africa, provides practical guidelines and insight on supel sion of sector activity. Useful insight on how how to address these issues.9 to accomplish this is provided in the proceedings of an Economic Development Institute (EDI) policy 3.19 Srengthening of Key Components of the Insii- seminar on Strengthening of Local Governments in donal Framework. All institutions and actors that Sub-Saharan Africa7 A recent paper produced by the influence the PHN sector need to be well organized Poverty and Social Policy Division of the Africa and effectively managed, with adequate legal frame- lbchnical Department (AF1SP) on the poverty works, in order to maximize their contribution to orientation of public expenditure6 argues that effi- sector activity. Any weak links in this institutional ciency gains in resource allocation can be realized framework must be identified and strengthened from the decentralization of financial decision- through internal organization and management making responsibilities to allow local and community changes or a change in legal status. These efforts groups a greater role in choosing, designing, and should focus on skills, functions, systems, and struc- providing core services. ture. PCRs on the Indonesia Provincial Health, Pakistan Population, and linisia Health and Popula- 3.18 OrgankationofServiceDeivery.Thedesirabili- tion projects all conclude that early and rigorous ty of providing PHN services through a referral assessments of the institutiuns involved in project PHN 1991 Sector Review 15 implementation would have had a positive impact on of information and countries' capacity to use it. the success and sustainability of those projects. A Countries need to have at their disposal both quanti- review of institutional development in World Bank tative and qualitative information on the population operations entitled, Institutional Development in (PHN status, needs--both perceived and real- World Bank Projects: A Cross-Sectoral ReviewVl, socioeconomic status, traditions, cultures) and on provides a useful matrix of analytical frameworks for PHN services (coverage, performance, quantity, institutional analysis, along with a critique of Bank's quality, efficiency, mix). Such information should be performance to date in undertaking such work, sufficiently disaggregated (e.g., by geographic region, socioeconomic group, gender, age group) to permit the development of differentiated information, b. Management Capacilyfor Policy Analysis and education and communication (IEC) activities and Implementation strategies for their delivery. Information should be gathered by various agencies and through several 3.20 We have already noted the importance of a channels, e.g., research, surveys, beneficiary assess- macroeconomic and multisectoral policy framework ments, and monitoring and evaluation. and transparency in the policymaking process to the capacity of countries to develop and refine their 3.23 Management information systems are often PHN policy and ensure its effective implementation. too complex and camberseme, in many cases because As imnportant are the quality and availability of they were designed to meet the needs of various information; skills in planning and programming and donor programs rather than to monitor and evaluate budgeting to ensure the translation of appropriate, PHN policies and services countrywide. Operational well-articulated policy into implementable projects research and evaluation activities are frequently and programs; the availability, distribution, and man- underdeveloped and underutilized. Efforts to im- agement of sector resources; and sound project and prove information collection and analysis must focus program management. on the development of a streamlined MIS, designed to meet the carefully defined information needs of 3.21 Infonmation. Almost every PHN PCR pro- the country rather than those of donors. The capacity duced this year highlights the need for improving to undertake needs assessment, operational research, information, both for evaluating Bank-supported survey work, data processing, and monitoring and operations and for enabling governments to assess evdluation (including the encouragement and orches- the needs of the PHN sector and to monitor and tration of local input)--al of which have been ne- evaluate performance with a view to refining policy. glected--must be developed. The Indonesia Provincial Health PCR states that a simple monitoring system is more effective than a 3.24 Plannng, Programming and Budgetig. Capac- complex one collecting large amounts of data. The ities must also be developed for using information monitoring and evaluation system, envisaged under appropriately to ensure that PHN seetors articulate the Malawi Health project, was never put into place and effectively re-pond to issues and needs. Skills because it was accorded low priority by both the need to be developed and methodologies identified Bank and the government. The PCR on the Yemen for targeting, priority setting, policy formulation, First Health project, notes that lack of an evaluation testing and experimentation, implementation and plan and of any evaluation activities may have evaluation. Policy statements need to be translated compromised the success of project activities. The into implementable activities through the formula- Tunisian Government, as documented in the PCR on tion of an operational strategy with medium-term the Health and Population project, judged the MIS targets and specific plans for priority programs, as to be overambitious and problematic. The PCRs on well as an action plan with key indicators for success- 'Inisia and Indonesia both noted that research ful and monitorable implementation. Skills in plan- activities had been neglected. ning, programming and budgeting need to be devel- oped, with a bottom-up emphasis on nlanning so that 3.22 The above and other experience reveals a need local government and community groups can become for increased attention to the quality and availability sufficiently involved in the process. 16 PHN 1991 Sector Review 3.25 Management and Dswibutdon of Resoures. management skills, including planning, budgeting, Proper management of physical, human, and financial accounting, and cost containment. 'Me "Poverty resources will improie the effecwvenus and efflclen- Handbook1"m provides useful guidance on the use of cy of P-N sector activities and ensure that resources Public Expenditure Reviews (PERs), Public Invest- are used in compliance with stated policy and strate- ment Reviews (PIRs), and other instruments to gy. PJysical resource management can be improved strengthen the fnacial sustainabllity of projects. by establishing or strengthening appropriately decen- tralized maintenance programs for buildings, equip- 3.28 Project Development and Management. How ment, and vehicles; by improving the planning of new policies and strategies are translated into implement- infrastructure; and by setting up better systems for able programs and projects also affects how well replenishing drugs and other essential supplies. The poverty alleviation objectives are achieved. As donor Tbnisia PCR highlights the importance of building support to the PHN sector continues to move away and equipment maintenance to project sustainability. from specific investiment projects toward broader support of sector policy, national governments, 3.26 Management of human resourcte requires a rather than the Bank or other donors, become clearly articulated strategy and capacity in manpower increasingly responsible for the management and planning, recruitment, deployment. It also calls for oversight of project development and implemen- weli defined pre-service and n-servie training tation. Acvities financed through sector funds (para programs focused on the provision of basic services, 24) and sector adjustment operations (see Sections and skills for interacting with the community. The C_2.a and c of this chapter), which transfer signifi- quality of staff performance and their motivation can cantly increased responsibility for project analysis be improved through a well-managed program of and management to national governments, in particu- re ar supervision, the definition of professional lar, require a strong national capacity in project at as and performance criteria, and the estabUsh- identification, proposwd writing. outreach, appraisal, meAt of incentives and career development paths. and supervision of subprojefts involving community iTe India ¶lmil Naac PCR provides useful guidance and NOO initiatives. Other needed project manage- on a system of management of local health workers ment skills include procurement, disbursement, that has met with great success. Key features suggest- accounting, financial management, aid coordination, ed for replication include carefully defining recruit- monitoring, evaluation, and reporting AFISP has ment criteria, limiting tasks to those that are man- recently issued guidelines for the design and imple- ageable and high in priority, and specifying work rou- mentation of socioeconomic development funds, tines. Furthermore, tus project has demonstrated which provides insight on these issues based on that health worker skills can be effectively upgraded project experience.n and sufficiently maintained by decentralizing training activities to an appropriate level, estabUlshing super- 2 Lessons of Deg and Mcess an4 Some Useil vision ratios that facilitate on-the-job training, using Tooh MIS to track performance closely, and reporting of performance to clients and workers. 3.29 Several of the lessons learned from Bank experience concern design features and processes, 3.27 FInall, the management of fnancial resoures that seem to have a significant impact on the success has a substantial impact on the realization of poverty and sustainability of Bank interventions. Many of alleviation objectives in the PHN sectors. Resource them apply to the achievement of poverty alleviation mobilization, including aid coordination and cost objecives and are worth presenting here, however rewvery schemes, is important for protecting the briefly. Some of these lessons apply to nonproject poor and promoting optimal use of essential preven- assistance (sector work and dialogue), some to tive and curative services. Resource allocation within project development and implementation, and some and across sectors should favor basic seAvices for the to both categories of assistance. TMe recommenda- poor and vulnerable in order to be most cost effec- tions, while derived primarily from OED's two tive and have the most impact on poverty. Also reviews of project sustainabilityu are corroborated important is the development of strong financial by the findings of all seven PCRs produced this year. PHN 1991 Sector Review 17 Attention to the following process factors should d. Project managment angemnu, that ensure increase the effectiveness and efficency of efforts in smooth implementation and encourage institution the PHN sector to improve the promotiont and building and sustainability-from the use of existing delivery of basic services to poor and vulnerable organizational structures to a gradual and better- groups and to develop institutional and management planned transfer of responsibility from temporary to capacity in support of that objective. permanent structures. Also helpful are clear commu- nication of all procedures and regulations governing a. Sufficient analysis preceding project preparation implementation of World Bank projets (useful to permit a thorough understanding and appreciation guidelines on action planning workshops are of the soclocuitural environment and the institutional available14), organizational arrangements that facili- and organizational culture. Especally useful is tate effective coordination among multipls imple- analsis of policy, institutions, and the needs and menting agencies, and better planning for Bank perceptions of beneficiaries. The latter process dLsengagement from projects nearing completion should involve the ful participation of local govern- through the use of "graduation missions,. ments, NGOs, and community groups. Several tools and guidelines to facilitate such work are available in e. Improvements in the quay of supeision work, the Bank, they include the beneficiary assessment including greater attention to institsitional capacities, tool (described in the "Poverty Handbook1"), the social and cultural issues, and sustainabilty, more participatory rural appraisal tool'3, and a series of time in the field, particularly to visit project sites; a fmeworks for institutional assessments.10 larger, more clearly defined role for field offices in oversi3ht of implementation; and more intensive b. Fetibilky in project desig and implemeuioan, supervision at early and middle stages of imple- to permit the detecion of changes In the composi- mentation. A Policy, Research and External Affairs tion of target groups and of shifts In beneficiary (PRE) working paper-" has pulled together field needs to ensure the continued relevance of the experience into a useful and insightful manual on project Tlhs would require the development of PHN supervision of field sites. national institutional capacity and a properly de- signed MIS. Also required are mechanisms and f Increased use Qf quaiidlocal erise in a capacities for adapting project objectives, justifying aspects of the Bank's work, e.g. NGOs, local and and communicating revised objectives to the parties community organizations, and universities and other concerned, and assessing future activities against local and regional institutions providing training, revised objectives. Useful in this regard are carefully consulting, and research services. designed and monitored pilot studies, supporting a research and extension approach. Such activities g. Greater commnuniiypanipon, which results provide considerable scope for learning, and would in more apptopriate project desig and use of effectively respond to the need for flexbility in technology thereby increasing the chances of success projec design and implementation. and sustainability of Bank interventions. A learning group on popular participation, managed by the c. Deliberate ateton to polihica4 nstutional International Economic Relations Division (EXTlE), and financial sustajiwbility at al stages of a project. was recently formed and will seek to determine more One way to do this is through a long-run, program- precisely when participation is worth the effort and natic approach th,at encompasses a series of projects, how the Bank and borrowing governments can each with its own modest, strategic objectives. Other effectively enoourage particpatory Bank projects. ways are to use PER/PIRs as a stratcgic planing Among the twexty projes this group will study is tool (see Poverty Handbook"11 for useful guidelines) the Guinea Population and Health project (FY88), and to give more attention to post-completion a project in which community involvement bas had sustainability in project design and supervision high returns to date. missions. 18 PHN 1991 Sector Review L Improved pknWng and management of technical and reformed through dialogue conducted in the asslstance, with the full participation of the govern- course of sector and lending worL Many, If not ment right from the planning stage. A recently most, of the FY91 projects support and are support- completed report by a Bankwlde task force on ed by structural adjustment operations (El Salvador, technical assistance presents recommendations that Egypt, Madagascar, Zaire, to name a few), which em- have great relevance to work in PHN.16 phasize growth and poverty alleviation. PHN pro- jects leveraged by these adjustment operations have been particulary successful in encouraging govern- C Evaluation of FY91-Apprioved PHN Operations meats to reallocate resources in favor of basic Against Lessons Larmed services, which would benefit the poor and vulnera- ble groups in particular. In this regard, many PHN projecs are using PERs/PlRs to encourage and 1. Ovenriw monitor appropriate resource allocation and to ensure the financial sustainability of social sector policy. 3.30 hs sectiop loks at the twenty-eight PHN operations approved in FY91 from the perspectve of 3.32 Virtually all FY91 operations support instiu- management and institutional development and tional development and improvements in management poverty alleviation. (Summary descriptions of the full capacity. A predominant feature of such assistance set of objectives and components of each of these is support of decentralization policy in the PHN operations are presented in Annex 2.) sector by strengthening lower-level planning, deci- sion-making, and financial management; encouraging 3.31 The FY91-approved portfolio of PHN opera- community participatlon; and redefining and limiting tions has a strong poveny focus: twenty-six of the the role of central govermmenL Significant efforts twenty-eight projects support the provision of basic have been made to involve NOOs and communities services to targeted poor and vulnerable segments of in the design and implementation of operations, national populations. The two remaining projects, although less so at the design stage than during which support the hospital sector In oDuntries where implementation. Some operations also made a access to basic services is universal emphasize modest effort to explore the role of the private effidency and equity issues. The Ibnisia Hospital sector in the PHN sectors. The Korea Health Restructuring Support project is intended to improve lbchnology project is unique in this regard as the equity in the financing of health services by changing first IBRD operation in which 100 percent of the the balance of financial burden sharing among the loan proceeds will be on-lent to the private sector state, Insurers, and patients. This project is com- (hospitals). There were noteworthy efforts to devel- plenmented by another FY91 operation in Ibnisia to op national capacity in infolknation collection and streagthen basic health services, especialy maternal analysis, including research and monitoring and and child health and family planning services. The evaluation activity, which have been somewhat Korea Health lbchnology project aims to increase neglected in the past (El Salvador, India, Indonesia, equity by improving the geographical distribution of Mali, Pakistan, Zaire, and Zambia, to name a few). biomedical equipment, thereby making it more Also, improvements are evident in the Bank's PHN accessible to the population at large. The project has support to human resources management: many excluded high-cost equipment, in part because the components aimed at improving staff performance cost of using such equipment is not reimbursed by are more comprehensive than they have been in the the national insurance, and consequently, the equip- past, including not only training (pre-service and in- ment is not accessible to the poor. With the excep- service) and supervision, but also assistance to tion of the Yemen Socal Emergency project, pro- establish or improve operational guidelines, job cessed in rapid response to the crisis in the Gulf, all descriptions, 'operational norms, re-deployment projects support the implementation of government schemes, manpower planning, recruitment practices, policies, that embrace the primary health care philos- and greater and more thoughtful attention to incen- ophy. And most of these operations were refined tives. PHN 1991 Sector Review 19 2. InovadveCa2dM et f gOadojt 3.36 Not all seven projes are allke. Only two of them (Nigeria ! icalth Fund and Nigeria Population) focus solely on the PHN sectors, and are imple- a. Sector Fuds mented by line ministries. The remaining Eve are multisectoral and coordinated through oental 3.33 One-quarter of PHN operations approved this (primarily finance) ministries. Five projects finance year were designed as social funds (see lTxt Table 2), subprojects on a grant basis; one (Nigeria Health which finance subprojects prepared and implemented fund) onlends funds to states with the involvement of by decentralized institutions and agencies represent- financial intermediaries for the purpose of whole- ing local populations and sometimes by the local saling Bank health asslstance; and the Sri Lanka fund populations themselves. Of the seven projects, three provides for both onlending for small credit opcra- are in Africa, two in LAC, and one each in Asia and tions and grants for the financing of subprojects. By EMENA. The design of these projects draws heavily combining immediate and direct assistance to the on the successful experience of the Bolivia Emer- poor with efforts to build information and capacity gency Social Fund, one of the first funds of this type for policy analyis, these projects are able to focus on to be designed and implemented as a Bank opera- both discrete short-term needs and equally important tion, and on guidelines prepared by AFMSP'2, derived longer-term needL from Bank xperience with this relatively new ap- proach to socal sector lending. 3.37 Most of these projects support an agency -- usually also created under the project - to manage 3.34 Sector hfnds were found to be quite respon- and administer activities. lhese agencies are usually sive to the lessons presented in Section B of this semi-autonomous and report to central ministries; chapter. These funds are intended to support grass- their coordination with line ministries varies 'y roots activities for social seor developmen4 particu- project. With the exption of the Honduras project, larly those benefiting poor and vulnerable groups. whose fund agency has an explicitly defined three- These projects foster institutional pluralism, decen- year life, it is not clear whether or when other fund taliztion, and community participation by giving agencies might be disbanded and, if so, how activities local- level entities--local govermnents, private sector would be sustained institutionally. Tb attract high- groups, NGOs, community organizations-responsi- quality staff, many of these agencies are exempted bility for assessing and articulating the social sector from civil service rules and regulations, and their needs of poor local populations and for designing salaries are competitive That means that an eventual and implementing projects and ensuring their transfer of their responsibilities to the government sustainability. would pose a dilemma that would be difficult to re- solve. 3.35 Sector funds increase the probability that subprojects are socally and culturally appropriate, b. Social Sector Operatons provide opportunities for experimentation and learn- ing (with a view to extending successful initiatives 3.38 The ten social sector projects, which comprise nationally), promote community participation, one-third of this year's portfolio of operations (see support intersectoral coordination, and favor sim- text Mbble 2) and which, incidentally, include a few plicity in subproject design. All but one of these sector fund operations, descrbed above, are more projects include significant support for improving comprehensive in their approach to poverty alievia- national capacity in the collection, analysis, and use tion and institution building than projects focusing of information for sector policy analysis, including exclusively on thi PHN sector. These projects operational research, surveys, beneficiary assessment, support the refinement and implementation of targeting methodologies, and monitoring and evalua- integrated social sector policy. Because the; are tion. Furthermore, subproject proposals are likely to multisectoral, they are coordinated through a central provide government with rich information and ministry (usually finance, or planning) that is insight on the social sector needs of various groups, strengthened to enable it to collect, use and analyze which may influence social sector strategy. integrated and appropriate social sector information; 20 PEN 1991 Sector Review formulate policy, and coordinate activities among health care and education, rationalizing the roles of sectors. government and nongovernmental institutions in social services financing and delivery, and providing 3.39 As opposed to 'pure' PHN operations, the an adequate framework and data base for larger majority of which are managed by one line ministry, investments in the social sectors. It will also fill social sector operations take a more holistic ap- some of the basic PHN needs of disadvantaged proach to poverty alleviation, which facilitates population groups. coordination and collaboration among the line ministries responsible for various aspects of social c. Sector Adjustment Operation sector activity. Such operations also encourage greater economy and coherence in social sector 3.41 The lbgo Population and Health Sector investment by consolidating and rationalizing activi- Adjustment operation is ihe first and only one of its ties in information collection and analysis, and in the kind in the PHN sector. It will support a compre- development and implementation of policies, pro- hensive package of sector policy reforms that empha- grams and institutional reforms, such as redefining size basic health and family planning services, panic- the roles of government (central and local), NGOs, ularly for poor and vulnerable groups (underserved the private sector, and communities in social sector rural areas and women and children). Through activity. Because these operations are coordinated by balance of payments support that will be released in a central ministry, they generally have high visibility three tranches upon satisfactory completion of a and strong political support -- conditions that can be series of reform measures, this project will support difficult to achieve and that make a large contribu- improvements in sector planning and management of tion to project success and sustainability. Strong sector resources; institutional reform, including political support is also likely to facilitate a realloca- beneficiary participation in the management of tion of public resources to the social sectors and, services; and increased resource mobilization through within social sectors, to basic services serving the cost recovery. poor and vulnerable groups. Management arrange- ments for these projects are designed to foster good d Emergency Recovery Operation intersectoral coordination and oversight, with an emphasis on using existing units to implement them: 3.42 The Yemen Emergency Recovery project, the while the projects are coordinated by central minis- only one of its kind this year, was put together tries, activities are implemented by line ministries. rapidly to address the social services needs of migrants returning to Yemen because of the recent 3.40 The Venezuela and Zaire projects provide Gulf crisis. While the Bank has an ongoing dialogue good examples of well designed social sector opera- with Yemen on medium-term economic planning and tions. The Venezuela project will assist the govern- policy formulation, this operation is an emergency ment to implement its Social Sectors Action Pro- one only and does not address long-term social gram, which shows a strong commitment to poverty sector issues. alleviation. The program seeks to expand the nation- al capacity to design, plan, implement, and monitor 3. Issues social programs and to develop a social sector strate- gy that will redirect social expenditures into well 3.43 As the focus of PHN operations has rapidly targeted and efficient programs. A presidential com- evolved away from the well defined investment mittee for poverty alleviation, with representatives of project towards the broader support of national the ministries and institutions involved in social policies and programs, the importance and complexi- sector plaaning and a Fund for Social Investment, ty of institutional and organizational issues which modeled after the sector funds described above, need to be addressed have increased. Consequently, provide for intersectoral coordination and institu- PHN operations require increasingly greater atten- tional pluralism. The Zaire Social Sector project will tion to sector- or subsector-level institutions and support social sector reform by increasing and their structures and functions, as opposed to the carefully monitoring budgetary allocations to primary project implementation unit (PIU) only. While PHN 1991 Sector Review 21 attention to these issues in most PHN operations has c. Lack of Thme broadened in sope sufficiently, the quality and depth of institutional development work in the sector could 3.46 Detailed attention to institutional and man- benefit from further improvement. A review of the agement issues takes time and competes with other sector analyses contained in the SARs for each of the rigorous input requirements for lending, supervision 28 operations approved during FY91 reveals that, in and sector work, all of which have very tight coeffi- some cases, institutional assessments were not cients and which are closely monitored by manage- undertaken fully adequately as a part of upstream ment. sector or project identification work. In some SARs, the treatment of institutions and organizations is 3.47 Chapter IV includes some suggestions on how more descriptive than analytical. Sustainability and these constraints might be alleviated. long term strengthening of sector-wide institutions are not always sufficiently addressed. Sometimes overlooked are: institutional alternatives for service delivery and for IEC activities, the incentive frame- work for long-term organizational performance and interorganizational collaboration and issues of leadership and stakeholder support, aU of which are essential for sustainability. Yet all 28 projects in their "benefits and risks" sections note that weak institutional and managerial capacity constitutes the greatest risk to project success and sustainabUity. The constraints to improving PHN treatment of management and institutional issues are as follows: a. Number and Skills Mix of PHII Staff 3.44 The growth in PHN staff over the last five years has not kept pace with the dramatic growth in PHN operations, documented in Chapter II of this report. Furthermore, as the scope and complexity of institutional/managerial issues continue to grow, so will the need for management specialists working on the PHN sector. A review of the composition of preapprai-al and appraisal missions for the FY91- approved operations reveals a deficiency in manage- ment and institutional development expertise. b. Absence of Standards and Guidelrnes 3.45 There are currently no official standards or guidelines in the Bank for analyzing and addressing institutional/organizational and management issues in the PHN sector, which could guide task managers in undertaking such work and Bank management in monitoring and evaluating it. CHAPTER IV. PROSPECTUS A. Future Work Portfolio a more rigorous review of institutional development work; (3) expanding the role of Country Operations 4.1 The future lending program looks sttong. The Divisions (CODs) in developing a macroeconomic very dramatic increase in the program size achieved and multi-sectoral policy framework and a strategy in FY91 will be followed by a decline in FY92 in the for poverty alleviation and institution-building, number of projects and the volume of lending; these within which PLIN policies and strategies would be levels, however, still exceed those achieved in FY90, refined and implemented; and (4) making more both in terms of the number of operations and the creative use of Bank instruments and leverage. volume of lending. Furthermore, continued growth is projected for FY93 and FY94. The largest num- 1. Exangin Bank Epetise in Institutional ber of projects in FY92 is planned for Africa, though Development well over half of the financial commitments will be made to Asia. a. Improving Capacity of Existing Sector Staff 4.2 The sector work program is expected to 4.4 For several reasons, lessons learned during continue at the same level over the next two years, project implementation are not applied as effectively with work on just over thirty studies planned annual- as they could be in new operations and sector work ly. The Africa region is the most heavily engaged in This occurs most notably because of Bank incentive sector studies. systems, which favor lending work and so limit somewhat the time and attention given to supervi- B. Conclusions and Recommendations sion work and PCRs, and because of inadequate assessment and dissemination of best practices. PHN 4.3 While the FY91 portfolo of PHN projects staff need more access to guidelines, tools, methodol- pays great attention to poverty and institutional ogies, and training, drawn from experience and from issues-many with ingenuity and creativity--it stil state-of-the-art technology inside and outside of the reveals some variance in the depth, breadth, and Bank, for further improving the quality of their work. quality of PHN analysis and interventions aimed at While the Bank has produced materials and guide- strengthening institutions and management capacity. lines documenting useful lessons and offering tools The notably increased policy orientation of PHN and guidelines - many of which were referred to in operations is not always accompanied by fully ade- this report - such efforts need to increase. The quate capacity building efforts to permit national demand in Operations for such material needs to be institutions to assume responsibilities and implement better articulated, while the collection, adaptation, activities generated by such operations. Chapter III creation, and dissemination of such material is a has distilled a wide array of documented experience responsibility of both the technical departments and and wisdoLl in the Bank into a matrix of lessons or PHRHN. principles, which give direction in this regard. The quality and effectiveness of Bank efforts to strength- 4.5 Documented experience clearly highlights the en institutions, particularly with a view to facilitating important contnbution to project success and the achievement of poverty-alleviation objectives, can sustainability of Bank staff posted in the field. and should be further improved. Ways to achieve Management should therefore seriously consider this include (i) expanding the Bank's expertise in allocation of additional PHN staff to field posts. management and institutional development in divi- sions responsible for the PHN sector, (2) b. Increasing Use of In-House Management and strengthening the commitment to institutional Institutional Development E&pertise development work by Bank senior management, as manifested in a reallocation of resources and a 4.6 Task managers should be encouraged to draw reorientation of incentives, which would support on expert resources elsewhere within the Bank to high-quality institutional development work, and in advise on or undertake the required institutional 24 PHN 1991 Sector Review analysis and the design of institutional development a. OED has clearly demonstrated the key role of strategies and components. The Africa and LAC supervision for successful institutional devel- regions have divisions in their technical departments opment and project sustainability. Discus- fer Institutional development and management, and sions with Bank staff reveal agrowing concem for public sector management, respectively, that pro- that a casualty of the tightening of supervision vide such support, although resources devoted to coefficients may be poor performance of sector operating division are limited. institutions. Sector operations divisions could make more economical use of scarce resources c. Increasing Use of Consultants devoted to supervision, by focusing more on key issues affecting institutions and manage- 4.7 A review of the composition of preparation, ment and by using the most appropriate and preappraisal, and appraisal missions for FY91- ap- qualified expertise. In addition, the low level proved operations revealed that, in some projects, of supervision coefficients in the PHN sector expertise in management and institutional develop- needs to be addressed by senior management: ment was under-represented relative to their promi- this Issue wil surely be raised again in the nence in the projects. Sector operations divisions ARIS. With the changing nature of PHN may wish to consider supplementing missions with projects, which are increasingly more policy experts in the management field, which would not and institution oriented and which pass on only benefit the project, but would also provide on- more responsibility to government, and the the-job training for Bank staff working with that even stronger emphasis on reaching the poor, expert. PHRHN and technical departments could whose administrative and implementation facilitate this process by compiling and disseminating capabilities are generally weak, the nature and rosters of qualified consultants. extent of supervision requirements need to be redefined and given due priority and resourc- d. Increasing Instditional Development Epertise es. in Divisions Responsible for PHN Sector b. The importance of upstream diagnostic work 4.8 There are relatively few management and has been repeatedly emphasized in numerous institutional development specialists among aU PHN review documents, including some PHN PCRs staff in the Bank PHN's increasing focus on policy produced this year. Yet some of the Baks anci institutional issues caUs for reexamination of the sector work and project preparation does not skills mix of PHN staff with a view to increasing the include sufficiently in-depth institutional proportion of institutional development specialists analysis. Even with a no-growth budget, more working in the sector. The shortage of such exper- resources must be allocated to such upstream tise in all SOD divisions (and not just PHN, in work, which, if wel done, will lead to greater particular) was identified as a constraint in the efficiency in lending and supervision work. Bank's capacity to support its overall development objectives, at a recent Bank symposium on public c. The discipline of systematic institutional sector management, held in early September of 1991 analysis wiUl become Bank practice only when and attended by staff from a large cross-section of senior managers seek evidence of such analysis divisions (TDs, SODs, CODs, PRE). Diversifying whenever institutional development designs or the skills mix in those divisions by recruiting institu- reforms are proposed in projects. Bank tional development specialists was strongly recom- management should evaluate more rigorously mended. 2. Chanl= hfores and Pracdces in the Bank ' The essence of these recommendations is drawn from Working Paper Series No. 392, 'Institutional 4.9 This report recommends several changes in Development in World Bank Projects: A Cross priorities and practices in the Bank, which would Sectoral Review', by Samuel Paul and has been support high-quality institutional development work: greatly substantiated by the findings of this review. PHN 1991 Sector Review 25 lending and sector work with respect to: the national policy. Resident mission staff, as an exten- objectives and scope of the analysis, elements of sion of country operations divisions, could also make the institutional development issues investigated, a valuable contribution in this area and their roles the extent of borrower involvement in the diag- and responsibilities should be reviewed with a view nosis, the analysis of interest groups (including toward increasing time spent on institutional issues. beneficiaries) and 'weir likely impact, and the quality and commitment of the local leadership. 4. Making Creative Use of Bank Instruments and Resources 3. Expanding the Role of Country Operations Divi- 4.12 With the rapidly changing nature of PHN sions operations over the recent past - more policy based, more integration of social sectors, more flexible 4.10 The full potential of PHN policies and inter- financing mechanisms, delegation of more design and ventions to contribute to institution building and implementation responsibilities to countries, greater poverty alleviation can be realized only when policies community involvement -- the way lending instru- are grounded in a macroeconomic and multisectoral ments are used might usefully change as well. Thus policy framework oriented towards growth with it may be useful to review the nature and features of poverty reduction, accompanied by a sound strategy the various lending instruments available, focusing on for building institutions and the capacity to manage their strengths and weaknesses in addressing various and implement policy. That means that country PHN sector interventions in different political and operations divisions have a critical role in assisting economic settings. key national decision-makers to understand and internalize poverty alleviation and institution-build- 4.13 Significant effort has been made to increase ing objectives and to plan and prioritize sector the use of qualified local consultants in all aspects of interventions and allocate resources accordingly. the Bank's work on the PHN sector. Their knowl- Currently, however, macroeconomic and edge of the socioeconomic and cultural dimensions multisectoral policy dialogue is not always fully of the sector is particularly valuable when applied to coordinated to facilitate the development of an managementand institutional issues and to commu- efficient and comprehensive strategy for poverty nity involvement in PHN activity. But more informa- alleviation or for institution building. tion is needed about the availability of local expertise at the regional and national levels. Tbchnical depart- 4.11 Thanks to the impact of the 1990 WDR on ments should develop reliable rosters of regional and poverty followed by the "Poverty Handbook," atten- national experts, perhaps through occasional missions tion to the poverty issue continues to grow. The to identify and assess such individuals and institu- "Poverty Handbook" is rich in information and guid- tions. They should also set up closer ties with the ance on how to analyze and measure poverty, and various capacity-building efforts being undertaken how to design country assistance strategies. It is within and outside the Bank, and the PHN sectors. likely to have strong, positive impact on those Thist funds should be further exploited to finance aspects of a poverty strategy. Over and above all of such assistance, when appropriate. Even though this, however, remains the need for greater country some of these local resources may be fully quaUfied, operations divisions'attention to institutional issues. Bank staff may hesitate to spend scarce budget Cnuntry operations divisions, in partnership with resources on people with no Bank experience, given public sector management divisions where they exist, the enormous pressures they are under. A special could play a major role in analyzing institutional fund using administrative budget or other resources, issues in depth. They could also provide valuable could be created to cover the costs of well-designed assistance in developing strategies for strengthening and clearly defined short- or medium-term "intern- institutions and management capacity as an integral ships" for lhird World experts, who have never part of macroeconomic and multisectoral policy worked with the Bank and who need a chance to analysis and dialogue, in order to identify and ad- become familiar with Bank procedures and to dem- dress constraints to sustainable implementation of onstrate their expertise. 26 PHN 1991 Sector Review 4.14 Finally, with the exception of the notable efforts of EDI, the country-based orientation of Bantk assistance tends to constrain opportunities for the exchange of experience and idea among developing countries, a significant potential stimulus to learning and development. The Populadon and Human Resorrces Operations Division of the East Africa Department (AF2PH) has initiated such activities during FY91 through specilly designed sector work, which permits a number of countries in the region to analyze, compare, and improve their capacities In policy analysis, management and implementation. 'he Safe Motherhood initiative in francophone Africa has recently establisied a network of experts from the region to promote needed improvements in the region at the policy and program leve. These initiatives should be monitored, and the successful ones should eventually be replicated in other depart- ments and regions. Other ways of supporting com- munication, learning, and collaboration among developing countries should also be explored. 5. t0e Recmme_daqMns 4.15 The subsector classification of PHR projects needs to be revisited to accommodate the changing composition of the PHN project portfolio - especial- ly its marked increase in social sector projects that encompass PHN, educadon and employment and often other sectors as well. 4.16 Last years Annual Sector Review recommend- ed that PHRHN intensify its effort to improve processes and systems for the collection and analysis of information on the Bank's PHN work portfolio. During FY91, a PHR sectoral information feature was set up on All-in-One that provides basic infor- mation on PHN and education lending and super- vision portfolios, drawn from the MIS. PHRHN is now embarldng on an information needs assessment, including a review of existing Information systems with a view to improving the availability and quality of essential information. PHN 1991 Sector Review 27 FOOTNOTES 1. World Bank. "Sustainabfluty of Projects: First Review of Experiene Report No. 571& (Operations Evaluation Department, Washington, D.C, June 14, 1985) 2. World Bank. Annual Review of Evaluation Results.- (Operarations Evaluation Department, Wbshington, D.C, October 30,1989) 3. World Bank 'IBRD and Bangladesh's Population Program." (Operations Evaluation Department, WVashington, D.C. 4. World Bank. 'IBRD and Indonesas Population Program.' (Operations Evaluation Department, VMshington, D.C.) 5. World Bank. 'Population and the World Bank: A Review of Actives and Impacts from Eight Case Studles.' (Operations Evaluation Department, Vbshington, D.C, June 1991) 6 Berg, Alan. ManuMlion J7a Can Be Done? Lessons fhm World Bank Eqiencwa (Baltimore, Maryland: Johns Hopkins University Press, 1987) 7. Economic Development Institute. SwnheningLocalGovnment Sub.SaharanAfta Policy Seminr Report No. 21. (Wshington, D.C.: World Bank, December 1989) 8. Schacter, Mark 'Improving the Poverty Orientation of Public Expenditure: An Operational Approach.' (World Bank, Washington, D.C, June 1991) 9. Lmboray, J.L, and R. Nimi. 'he Health Center in Africa.' (AFIPN, World Bank, June 1991) 10. Paul, SamueL 'Institutional Development in World Bank Projects: A Cross-Sectoral Review.' World Bank Worldng Paper No. 392. (Washington, D.C, April 1990) 11. World Bank. 'Poverty Handbook. Working DrafL (August 4, 1991) 12. World Bank 'Socloeconomic Development FNads: A Guideline for Design and Implementation.! Social Dimensions of Adjustment Status Report and FY91 Work Plan. (Wshington, D.CC) 13. Heaver, Richard. 'Participatory Rural Appraisal: Potential Applicatons in Famlly Planning, Health and Nutrition Programs! (World Bank, Washington, D.C) 14. Slverman, Jerry M., and others. 'Action-Planning Workshops for Development Management Guidelines.' World Bank 'ibchnical Paper No. 56. (Washington, D.C, World Bank, December 1986) 15. Heaver, Richard. Using Field Visits to Improve Pamly Panning, Health and Nutrition Program Quality: A Supervisor's ManuaL' (World Bank, Washington, D.C, 1991) 16. World Bank 'Managing lbchnical Assistance in the 1990s.^ (rechnll Assistance Reviews lbsk Force, Wbshington, D.C, November 11, 1991) ANNEX 1. Statistical Annex PHN 1991 Sector Review 31 Table 1: FY91 Population, Health and Nutrition Portfolio by Sectoral CoMposition (US$ mitlions) ..... ...... ......... .............. .... ..... ..................................................................... ................................................................................................................. PHN Education Water Income Gen. Infrastructure Agriculture ,..... ............... .......... .......... .... .......... ................ .............. ............... ......... Country Project IBRD IDA S X S X S X S X S X S X .... ..... ....................................................................................................... ..................................................................... AFRICA Ghana Health & Population II 27.0 27.0 100.0 Madagascar Nat. Health Sector 31.0 31.0 100.0 Nalawi PHN Sector Credit 55.5 55.5 100.0 Met Health/Poputation/Rural 26.6 20.3 76.4 6.3 23.7 Nigeria Health Fund 70.0 70.0 100.0 Nigeria Population 78.5 78.5 100.0 Rwanda Poputation 19.6 19.6 100.0 Senegat Human Res I (Pop./Hea.) 35.0 35.0 100.0 Togo Population/Health Ad. 14.2 14.2 100.0 *Zaire Social Sector Proj. 30.4 30.4 100.0 Za bia Social Recovery Proj. 20.0 11.7 58.5 4.6 23.0 3.7 18.5 Zimbabwe Family Health II 25.0 25.0 100.0 ASIA Bangladesh Pop. & Health IV 180.0 180.0 100.0 India ICDS I (ORIS & ANOHR) 10.0 96.0 106.0 100.0 Indonesia Population V 104.0 104.0 100.0 Korea Health Tech 1 60.0 60.0 100.0 Sri Lanka Poverty Alleviation 57.5 10.5 18.3 32.3 56.2 14.7 25.6 EMNENA Aigeria Pilot PIllic HeaLth 16.0 16.0 100.0 EgM t Emergency Social Fund 140.0 9.7 6.9 3.3 2.4 57.0 40.7 70.0 50.0 Pakistan Family Health 45.0 45.0 100.0 Tunisia Hospital Ngt. & Fin. 30.0 30.0 100.0 Tunisia Population & Family 26.0 26.0 100.0 Yemen Emergency Recovery Credit 33.0 0.0 0.0 9.4 28.5 20.7 62.7 2.9 8.8 LAC El Salvador Social Sec. RHB 26.0 10.8 41.5 15.2 58.5 Haiti Economic and Social Fund 11.3 7.7 67.9 2.5 22.1 1.1 10.0 Honduras Social Fund 20.0 13.5 67.5 6.5 i2.5 Mexico Basic Health 180.0 180.0 100.0 Venezuela Social Devt. 100.0 82.8 82.8 17.2 17.2 Total 647.0 920.6 1300.2 82.9 58.7 3.7 6.3 0.4 89.3 5.7 110.2 7.0 2.9 0.2 Total Lending for PHN Sector 1567.6 * This multisectoral project encompesses education, poticy, and plaming. 32 PHN 1991 Sector Review table 2t Prim"r Heath Care (PlC) Cffxnt of PUI Landino FY91 (USS ttIlIons) 1 2 Official Total Total *Pure Of Wlicht Baelace cCIWTRY PRWECT PHII Lading PHNI Mn-PNC PNC Coorpnts * S S X De eription s S AFRICA - - - aha He"ath & Populatlon If 27.0 2r.0 0.0 0.01 27.0 100.0% Nadagesar Nat. Health Sector 31.0 31.0 0.0 0.0X 31.0 100.0% alatwi PHI S etor Credit 55.5 55.5 3.6 6.9S 3 51.7 93.1% mali Health/PopuolaetiVurat 26.6 20.3 0.9 4.2X * 19.5 °5.8X Nligaria Nealth Pisi 70.0 r0.0 0.0 0.0% r0.0 100.0% Migeria Poputetion r8.: 78.5 15.6 19.9% 4 62.9 80.1% Rande Population 19.6 19.6 1.0 5.13 4 18.6 94.9% Sanet Hmum Rae I (Pop./mees. 35.0 35.0 4.5 12.9% 3. 4 30.5 87.13 Togo PopulatoinjNoa1th Ad. 14.2 14.2 0.0 0. ax 16.2 100.0% Zaire Soolet Sector Project 30.4 30.4 4.6 15.0x 3. 6 25.8 85.0% Zmbia Soclt Recovery ProJect 20.0 11.7 0.0 0.0% 11.) 100.0% Zimb_bw I mlty Heatth It 2z.0 25.0 0.0 0.0% 25.0 100.0o Totat for APRICA 432.8 418.2 30.4 7.3% 387.9 92.7% ASIA engtednh Pop. & Heaoth IV 180.0 180.0 1.6 0.9% 3 178.4 99.1% Irdia IC0S I (OIlS & AHDHlt) 106.0 106.0 2.5 2.4X 3 103.5 97.6s IndloeSi POpulation V 104.0 104.0 0.0 0.0% 104.0 100.0% Korea Heatth Tech 1 60.0 60.0 30.0 50.0% 5 30.0 4 0% Sri Lanka Poverty Alleviation 5s.5 10.5 0.0 0.0% 10.5 100.0O ............... ......... . ......... . ................ ............. Totat for ASIA so5.5 460.5 34.1 7.4, 426.4 92.6X Algeria Pltot Pubtie H"alth 16.0 16.0 0.0 O.O% 16.0 1f4.0S EgYt Ewrgecy Social Ftmd 140.0 9.7 0.0 0.0% 9.7 100.0% Pakistan Ftlly Health 45.0 45.0 0.0 0.0% 45.0 100.0% Tulnsfe Nospitat 1st. 1 fin. 30.0 30.0 15.0 50.0X 5 15.0 50.0% Tunaisi Population & FPmty 26.0 26.0 0.0 0.0% 26.0 100.0% YeOM rgwncy RecovRry Credit 31.0 0.0 0.0 n.o 0.0 n.e. ............... ......... . ......... . ................ ............. Total for ENEMA 250.0 126.7 15.0 11.8S 111.7 88.2% LAC El Salvador Socit Se. ORB 26.0 10.8 0.0 0.0% 10.8 100.0% Haiti Economic d Social Fwud 11.3 r.7 0.0 0.0% 7.7 100.0% Hondures Socalt Ftad 20.0 13.5 0.0 0.0% 13.5 100.0% NeIxco aiec Health 180.0 180.0 0.0 0.0% 160.0 100.0% Vanuteual Soclet et. 100.0 82.8 0.0 0.0% 82.8 100.02 ............... ......... . ....... ........... ...... ............. 33S.3 294.8 0.0 0.0% 294.8 100.fO Totat 1567.6 1300.2 79.5 6.1% 1220.Z 93.9% Total PlC 1220.7 Total Bank Landin for FT9 22685.5 PHC &a S of Total ank LewdIng 5.4% 1 Net of non-PHI caoneto (e.g. In eCation, infrartructure, agriculturetrural devviopfnt...) 2 entc support to the PNC cenaIt is broadly defined a ny eupport to faclitate the ipltemntation of nationt PNC polfcleo. Thia would Inctud institution an coaity bultding; support of nutrition activities; support of fily plamfnn earvice delivery end IEC; oed stranthening of referral hospitals in suport of PNC. 3 Iorn-health related MID 4 Non-4P related Population 5 Aseistance to Hospital Sector not difretty auortiv of PlC strategy. 6 Other PHN 1991 Sector Review 33 TabLe 3: Poputation, Health and Nutrition Lendfig Volumn, FY80-91 Amount and Percent of Total PHN Sector Lending by Region (Commitment in USS millions) I ~~~. .......... ..................... ............. ............................ ......................... .................................... ............................. Percentage change Three year averages ...................................... |................................................................- FY80-82 to FY83-85 to FY86-88 to FY80-82 FY83-85 FY86-88 FY89-91 FY83-85 FY86-88 FY89-91 AFRICA 7.7 39.3 78.0 248.8 413.0 98.3 219.0 ASIA 47.7 89.0 105.3 330.C 86.7 18.4 713.3 EMENA 4.3 26.7 4.3 163.0 515.4 (83.8) 3,661.5 LAC 4.3 30.7 71.7 275.2 607.7 133.7 284.0 ......... -----..-- ... ....... ......... ....... . ..... ------- ................... TOTAL $64.0 $185.7 $259.3 $1,017.0 190.1X 39.7% 292.2X FY80 FY81 FY82 FY83 No. of No. of No. of No. of S X ProJ. $ % Proj. $ X Proj. S X Proj. AFRICA 0.0 0.0 (0) 0.0 0.0 (0) 23.0 63.9 (1) 22.0 18.3 (2) ASIA 143.0 100.0 (.J 0.0 0.0 (0) 0.0 0.0 (0) 27.0 22.5 (", EMENA 0.0 0.0 (0) 13.0 100.0 (1) 0.0 0.3 (0) 37.0 30.8 (3) LAC 0.0 0.0 (0) 0.0 0.0 (0) 13.0 36.1 (1) 34.0 28.3 (1) TOTAL 143.0 100.0 (4) 13.0 100.0 (1) 36.0 100.0 (2) 120.0 100.0 (7) FY84 FY85 FY86 FY87 No. of No. of No. of No. of S X Proj. S X Proj. S X ProJ. $ X Proj. AFRICA 31.0 12.7 (3) 65.0 33.7 (3) 82.0 19.5 (5) 31.0 57.4 (4) ASIA 155.0 63.5 (2) 85.0 44.0 (2) 242.0 57.6 (4) 0.0 0.0 (0) EMENA 0.0 0.0 (0) 43.0 22.3 (2) 0.0 0.0 (0) 13.0 24.1 (1) LAC 58.0 23.8 (1) 0.0 0.0 (0) 96.0 22.9 (2) 10.0 18.5 (1) TOTAL 244.0 100.0 ~6) 193.0 100.0 (7) 420.0 100.0 (11) 54.0 100.0 (6) FY88 FY89 FY90 FY91 No. of No. of No. of No. of S K Proj. S K Proj. S K Proj. S K Proj. AFRICA 121.0 39.8 (5) 81.0 14.7 (4) 232.7 24.9 (8) 432.8 27.6 (12) ASIA 74.0 24.3 (2) 290.0 52.7 (4) 192.5 20.6 (2) 507.5 32.4 (5) ENENA 0.0 0.0 (0) 80.0 14.5 (2) 119.0 12.7 (2) 290.0 18.5 C6) LAC 109.0 35.9 (1) 99.0 18.0 (1) 389.2 41.7 (6) 337.3 21.5 (5) TOTAL 304.0 100.0 (8) 550.0 100.0 (11) 933.4 100.0 (18) 1567.6 100.0 (28) .............................................................................................. 34 PHN 1991 Sector Review Table 4: FY91-Approved PHN Projects: Funds Components (USS millions) Regional as Region/ Total Percent of X Total Country Project Fund Amount proj. costs proj. costs fund amount AFRICA Ghana Health & Pop. II Prizes 1.0 34.4 3.0 Malawi PHN Sector Credit Social Programs Support 4.9 74.3 6.6 Mali Health/Pop/Rural Population 4.9 61.4 8.0 Nigeria Health Fund Health System 94.5 94.5 100.0 Nigeria Population Pop. Activities/Research 85.6 93.6 91.5 Zaire Soc. Sec. Project Pilot 1.0 37.0 2.6 Zambia Social Recovery Project Cofmmunity Initiatives 41.7 45.8 91.1 Total 233.7 25.5 ASIA Bangladesh Pop. & Health IV Developing Innovative Proj. 4.9 601.4 0.8 India ICOS I (ORIS & ANDHR) Cofmunity Mobilization 11.0 157.5 7.0 Sri Lanka Poverty Alleviation Nutrition Fund 14.2 85.0 16.7 Rural Works Fund 16.3 85.0 19.2 Human Resource Dev. Fund 14.5 85.0 17.1 Credit Activities 35.0 85.0 41.2 Subtotal 80.0 85.0 94.1 Total 95.9 10.5 EMENA Egypt Emergency Social Fund Municipal Services 217.6 572.3 38.0 Community Development 36.9 572.3 6.4 Enterprise Development 109.5 572.3 19.1 Labor Mobility 82.0 572.3 14.3 Subtotal 446.0 572.3 77.9 Yemen Emergency Recovery CredIt Expanding Social Infrastructure 32.2 59.5 54.1 Strengthening Social Services 17.0 59.5 28.6 Supporting Agricultural Activities 9.7 59.5 I6.3 Subtotal 58.9 59.5 99.0 Total 504.9 55.1 LAC Haiti Economic and Social Fund Health & Nutrition 10.4 23.6 44.1 / Education 4.9 23.6 20.8 Infrastructure 5.7 23.6 24.2 Technical Asst. to Particiating Org. 0.2 23.6 0.8 Subtotal 21.2 23.6 89.8 Honduras Social Fund Social Investment 61.3 68.0 90.1 Total 82.5 9.0 917.0 2008.3 45.7 PHN 1991 Sector Reiew 35 Table 5: Population, Health & Nutrition Sector Reports Completed by Region, FY82-91 Number of Reports …-----------------------------------------------------------------__- Region FY82 FY83 FY84 FY85 FY86 FY87 FY88 FY89 FY90 FY91 …---------------------------------------- --------------------------__ AFRICA 5 6 8 8 6 4 7 9 15 12 ASIA 1 4 4 3 2 0 1 9 8 7 EMENA 0 0 5 1 1 1 2 5 5 6 LAC 0 3 3 2 4 2 6 6 4 8 …___________________ .______________________________________ Total 6 13 20 14 13 7 16 29 32 33 …-------------------------------------------------------------------- 36 PHN 1991 Sector Revew Table 6: Population Health & Nutrition Sector Reports Completed in FY91 Region/ Report Report Country Project Date Color Final MFRICA Cameroon *Women in Development. 11/90 Green Yes Kenya *Human Resources: Improving 6/91 Grey Yes the Quality and Access. Kenya *Food and Nutrition. 3/91 Grey Yes Malawi Population Sector Study. 6/91 Green No Nigeria Implementing the National 12/90 Yellow Policy on Population. Nigeria Strategy for Food & Nutrition 6/91 Grey Yes Security. Sao Tome & Pr. Human Resource Dev. Strategy. 6/91 White No Senegal Women in Development. 6/91 White No Sudan *Toward an Action Plan for 9/90 Grey Yes Food Security. Tanzania Women and Development. 10/90 Yellow No Zimbabwe Strategy for Women in Dev. 3/91 Green Regional Gestion du Secteur de la Sante 6/91 Green outils de Gestion des Programmes Sectoriels. ASIA Indonesia *The World Bank and Indonesia's 2/91 Grey Yes Pop. Program. Indonesia *Health Planning and Budgeting. 1/91 Red Yes Lao PDR Population, Health & Nutrition. 11/90 White Papua N.Guinea Health & Pop. Roview. 2/91 Grey Yes Papua N.Guinea Management, Manpower, Money. 2/91 Grey Yes Papua N.Guinea*Structural Adj., Growth & Human 5/91 Grey Resource Development Philippines New Direction in Family Planning. 6/91 Green B4ENA Egypt Poverty Alleviation and Adj. 6/90 Green Maghreb Demographic Challenge to 8/90 Green Sustainable Econ. Development. Poland Health System Reform. 3/91 Green Romania Accelerating the Transition: 7/91 Green No Human Resource Strategies for the 1990s. Saudi Arabia *Review of Roles, Functions and 4/91 Yellow Operations of the Ministry of Health. Turkey Issues and Options in Health 9/90 Grey Yes Financing. PHN 1991 Sector Review 37 Table 6: (continued) Region/ Report Report Country Projoet Date Color Final TAC Brazil Addressing Nutritional Problems. 11/90 Green Brazil New Challenge of Adult Health. 8/90 Red Yes Costa Rica Public Sector Social Spending. 10/90 Grey Ecuador *Social Sector Strategy for 11/90 Grey Yes the Nineties. Honduras Social Sector Programs. Grey Mexico Nutrition Sector Memorandum. 2/90 White No Uruguay Population, Health & Nutrition. 8/90 White No Regional Food & Nutrition Programs. 4/91 Yellow * PHN reports completed outside of PHR divisions. 38 PHN 1991 Setr Review Table 71 Operations 3valuation Departaent RePorts OR PIE Sector, fY91 Region/ country Project Date proisat omnletion LRenot. Malawi Health Project. 12/28/90 Pakistan Population Project. 12/28/90 India Tamil Nadu Integrated Nutrition Project. 12/28/90 Indonesia Provincial Health Project. 11/16/90 Tunisia Health & Population Project. 10/11/90 Yemen First Health Project. 12/28/90 Audit Renorts Philippines Second Population Project. 3/11/91 country 2alaific Seotoral Reviev Bangladesh IBRD & Bangladesh's Population Program 2/13/91 Indonesia IBRD & Indonesia's Population Program 6/28/91 cast 4ta{1fit Multi-Country Population and the World Bank: A Review of 6/11/91 Activities and Impacts from Eight Case Studies. PHN 1991 Sector Review 39 Table 8: Lending for Population Projects and Components by Region, FY 86-91 No. of No. with Total PHN Population Population Fiscal PHN population lending lending lending year Region Projects component/a ($ million) ($ million) % of PHN 1986 AFRICA 5 5 81.1 9.7 12 ASIA 4 2 242.4 129.0 53 EMENA 0 - - LAC 2 1 96.0 0.3 - Subtotal 11 8 419.5 139.0 65 1987 AFRICA 4 4 30.8 7.9 26 ASIA 0 - - - - EMENA 1 0 - - - LAC 1 1 10.0 6.8 68 Subtotal 6 5 40.8 14.7 36 ---------------------------------------------------------------------__------__ 1988 AFRICA 5 3 121.4 19.9 16 ASIA 2 2 74.5 62.3 84 EMENA 0 - - - - LAC 1 0 109.0 - - Subtotal 8 5 304.9 82.8 27 ---------------------------------------------------------------------__------__ 1989 AFRICA 4 2 81.3 0.4 .5 ASIA 4 1 290.0 24.6 9 EMENA 2 1 79.5 0.4 .5 LAC 1 - 99.0 - - Subtotal 11 4 549.8 25.4 23 1990 AFRICA 4 3 232.7 45.7 20 ASIA 2 1 192.5 96.7 50 EMENA 2 2 119.0 11.9 10 LAC 4 2 389.2 15.0 4 Subtotal 12 8 933.4 169.3 18 1991 AFRICA 12 9 432.3 135.3 31 ASIA 5 2 507.5 163.5 33 EMENA 6 2 290.0 39.5 14 LAC 5 5 337.3 10.7 3 Subtotal 28 18 1567.6 351.0 22 a. "Free-standing" population projects and PHN projects with population components. 40 PHN 1991 Sector Review Table 9: PHN Projects with Population Components, FY91 ($US millions) Region/ Total Loan Amount for Country Project Title or Credit Population AFRICA Ghana Health & Population II $27.0 $4.9 Mali Health, Pop & Rural Water 11 26.6 3.0 Madagascar National Health Sector 31.0 4.4 Malawi Population, Health & Nutrition 55.5 5.8 Nigeria National Population 78.5 78.5 Rwanda First Population 19.6 19.6 Senegal Human Resources Development 35.0 14.8 Togo Pop & Health Sector Adjustment 14.2 4.3a Zimbabwe Family Health II 25.0 0 Ob Total 135.3 ASIA Bangladesh Fourth Population & Health 180.0 61.5 Indonesia Population V 104.0 104.0 Total 165.5 EMENA Pakistan Family Health 45.0 13.5a Tunisia Population & Family Health 26.0 26.0 Total 39.5 LAC El Salvador Social Sector 26.0 1.5 Haiti Economic & Social Fund 11.3 0.5 Honduras Social Investment Fund 21.0 0.2 Mexico Basic Health 181.0 3.5 Venezuela Social Fund 100.0 50 Total 10.7 Total Lending for Population 351.0 a. These projects so thoroughly integrated population and health that it was impossible to derive a specific figure for population lending. Therefore, an arbitrary proportion of 30% for population was applied to each of these total loans or credits. b. No IBRD money went directly toward family planning in this project. However, co-financiers contributed $17.7 million toward family planning service delivery out of a total project cost of $116.9 million. YHN 1991 Sector Review 41 lTble 10: Nutrition In Structural and Agricultural Adjustment Operations, FY91 RegionlCountry Operations Nutrition Actions AFRICA Burkina Faso SAL I - Collect nutrition data to assist in formulation of nutrition policy. Kenya Agriculture SECAL - Prepare food security and nutrition strategy. - *Adopt a nutrition action plan and implement nutrition actions. Rwanda SAL I - Establish a Social Action Fund and prepare FY92 Social Action Project, including nutrition components. Tbnzania Agriculture SECAL - Reduce price of food grains as a poverty alleviation measure. Togo SAL IV - *Develop a nutrition action plan. r - Change agriculture policy to encourage food crop production for local consumption. Zambia Recovery Credit - Companion Social Recovery Fund to compensate for adjustment's negative impact on nutrition. ASIA Sri Lanka Economic Restruct - *Restructure major poverty alleviation programs: The Mid-day meal, Food Stamp and Jana Saviya (poverty reduction -- includes nutrition components) programs. - Implement a food stamp program for school children of poor families instead of providing meals to all children. - Introduce operational selection criteria to more effectively target the Food Stamp program to the poor and increase the benefits to those households. 42 PHN 1991 Sector Review lTble 10: (continued) Region/Country Operations Nutrition Act EMENA Egypt SAL Companion Social Fund to compensate for adjustment's negative impact on nutrition. Poland SAL I - Define health policy through Implementation of studies of food consumption and school feeding programs. LAC El Salvador SAL I - Provide infant foods through health posts; introduce a pilot food coupon program and implement a fortified biscuit program for primary schools. - Establish a Social Investment Fund. Honduras SAL II - Implement a food coupon program. - *Agree on parameters for measuring the effect of the food program. Mexico Agriculture SECAL - Continue reform of food and nutrition programs begun under AGSAL L Implement a pilot nutrition and health project to evaluate procedures, operational viability and cost-effectiveness of current nutrition and health programs. Use the results of the pilot program to implement an expanded national nutrition and health program. Continue to reduce untargeted subsidies to urban consumers and replace them with targeted distnbution of maize. Present to the Bank an evaluation of food and nutrition programs and agree with the Bank on general and agency-specific action plans for nutrition for 1993 to 1994. *Condition for tranche release. PHN 1991 Sector Review 43 Figure 1: PHN Projects under Supervision ASIA 35% 1547.1 ~~~~~LAO 18% AFRICA 46% 17 EMENA 15% 683.7 EMENA 14% AFRICA 25% 14 L/ AC" 21092.7 LAO 25% 1120.2 ASIA 22% 21 Lending in Number of US$ Millions Projects . 44 PHN 1991 Sector Review Figure 2: Tot-l Project Resources for Nutrition in Bank-Asisted Operations, FYS1-91 US$ millions 500 450 400 350 300 250 200 150 100 50 _ 81 82 83 84 85 86 87 88 89 90 91 Fiscal Year Figure 3: The Bank's Nutrition Lending, FYS1-91 US$ millions 300 250 200 150, 100. 50 8 1 8 2 8 3 8 4 8 5 8 6 8 7 8 8 8 9 9 0 9 1 Fiscal Year Tese figues ar lasedo an sm_ent of the total moure allocated to nutrition In nutdtin prject and nutrition ouponentm of proects desipated as PHN, bealth, or populatin prc$eca, and education, food security and WID projectL They do not, bemuse of dffcties of quantlfication, Iclude structurl adjusment or agricultue sector autment pojL (For lstng the latter, see lbbl 12.) 7btal prect m o allocated to nuaition were estimated from cost tables in Staff Appmbial Reports or, In case whee thse wre not suficekntly detaied, they we upplied by the pec' task mamg. Bank nutrition klndig amounts are baed an a pmrated share of Bank fnancing of eU prject se. If tbe nkloan comprbi SO pecent of the to poect and 15 percent o the prect b nutrtion, then l5 percent at the 50 peent b attributed to nutrition PHN 1991 Sector Pv&w 45 Figure 4: World Bank Lending for Population, FY80-91 Millions of US$ 400 300- 200- 100 80 81 82 83 84 85 86 87 88 89 90 91 Fiscal Year I I i I I i I I I ANNEX2 i i Uan and Credit Summaries of EY-91 - A-Dpmtd i PHN Opf ns ,ratio - r i i i I Loan and Credit Summaries of FY91-Approved PHN Operations' Africa Region Ghana - Second Health and Populaton Project The project will support the qualitative improvement, reform, and extension of coverage of the family planning and health services of the Mlnistry of Health and leading NGOs. Tle program in population will focus on institution building and on strengthening and expansion of family planning programs to Implement Ghana's long-standing populat.on policy-, In health it focuses on strengthening and expansion of primavy health care, procurement/supply, institutional development, manpower development and public expenditures. Project components are for: (a) drug and vaccine supply and drug infrastructure rehabilitation, (b) MOH institution-building, (c) supply, repair and maintenance of district hospital equipment, (d) population and family planning, (e) district-level primary health care, and (f) a prizes fund to provide incentives for better performar -e by health workers and health-promoting behavior by communities. Madagascar - Health Sector Improvement Project The project would support the implementation of the government's Health Sector Program (HSP) over the period 1992-96, with objectives of: (a) reducing mortality and morbidity, (b) moderating fertility levels; and (c) improving the efficiency and sustainablity of public expenditures for health, the sector policy framework and institutional coordination mechanisms. By accelerating the integration of family planning services into the basic activities of the public health system, it would also contribute significantly to implementation of the National Population Law adopted in 1991. The project would help finance: (a) delivery of comprehensive communicable disease programs to control malaria, tuberculosis, leprosy, sexually transmitted diseases (including AIDS), and the plague, and the establishment of a communicable disease monitoring system; (b) introduction/upgrading of family planning services as an integral component of maternal and child health care offered in at least 500 of MOH's clinics; (c) improved delivery of primaty health care services, iicluding reasonable access to essential drugs in all MIOH outpatient facilities; and (d) the first phase of a long term institutional development program to: (i) progressively restructure and strengthen the MOH's health delivery system to increase its efficiency and invite greater population/community participatihn; (ii) strengthen MOH's policy formulation and programming, monitoring and evaluation capacitr, and (iki) broaden the financing base and improve the sustainability of public health expenditures. Malawi - Population, Health and Nutition Project The project's objectives are to improve quality, access, efficiency, and effectiveness in the sector through: (a) st.,ngthening of basic programs, focussing on primary health care, maternal and child health care, child spacing (family planning), malaria control, AIDS program, nutrition interventions, and women in development activities; (b) strengthening of support services, focussing on staffing issues, pharmaceuticals, and IEC5 (c) efficiency improvements, focussing on management strengthening, hospital decongestion, cost sharing, and budget reform; and (d) support to the Government's social dimensions of ,4justment initiative. In line with these objectives, the project's component on strengthening of basic programs will include: (a) for primary health care and maternal and child health care, development and expansion of the These summaries are taken directly from the Staff Appraisal Reports. 50 PHN 1991 Sector Review Health Surveillance Assistants into outreach-oriented and village-based PHN promoters and service providers; rehabilitation and/or construction of rural health centers; provision of rural housing where needed to attract essential personnel; and provision of some vehicles to improve the effectiveness of district level services.; (b) for malaria, improvements in logistical support, in the supply of anti-malarial drugs, and in support for drug resistance monitoring, (c) for AIDS, acceleration of efforts in education and prevention campaigns and in acquisition of blood screening equipment; (d) for child spacing, launching of a Family Welfare Council to promote family planning and expansion of the MOH's program; (e) for women in development, institutional strengthening, upgrading of training activities, and testing of small scale demonstration projects on appropriate technology dissemination and credit provision; and (f) for nutrition, extension of a community-level food security approach developed and tested by UNICEF, and a micronutrient deficiency program. The component on strengthening of support services will include: (a) for staffing issues, upgrading of training programs and facilities for health cadres currently in critically short supply, and enhancement of personnel management information and planning capabilities; (b) for the IEC program, expanded activities for training health workers, and provision of resources for conveying population, health, and nutrition messages to communities; and (c) for pharmaceuticals, technical assistance and training on drug procurement, distribution and production, and improvement of facilities and equipment. The component on efficiency improvements will include: (a) rehabilitation of three urban health centers and construction of two others to shift more outpatient care away From the more costly and overcrowded hospitals, (b) rehabilitation of one district hospital, construction of another, and replacement of worn-out equipment in selected other hospitals; (c) introduction of reforms in patient fees; and (d) budget reforms involving increases in the MOH budget and the share of it devoted to outreach and peripheral health services. The component on the social dimensions of adjustment initiative will include support for a "social support program fund" to assist small z"ale pilot interventions derived from felt needs of communities and expressed through Government or NGO channels. Mali - Second Health, Population and Rural Water Supply Project Through an integrated program of policy/institutional reforms and investments, the project will support the Government's efforts to improve the health status and well-being of the Malian population, notably women and children, implement its emerging population policy, and broaden access of deprived rural communities to health services and safe water. lb attain these objectives, the project comprises three components. The health component will increav: the coverage and quality of health care: (a) directly in four Regions and the capital area of Mali throue,h the development of a decentralized, District-based health development program involving the construction/rehabilitation of primary and referral care centers, as well as active community, NGO and private sector participation; and (b) indirectly by improving the planning and management of the sector's personnel, physical asud financial resources as well as the provision of essential drugs. The population component will: (a) strengthen the institutions in charge of disseminatingrlimplementing the national population policy and of planning, managing and evaluating family planning (FP) programs; and (b) Increase the demand for, availability and quality of FP services nationwide. The rural water supply component will: (a) increase the supply of safe drinking water for the rural populztion in the project area; (b) support the Government's policy of community participatio& in the financial and technical management of rural water supply; and (c) implement an iodination program in areas where iodine deficiency is prevalent. Ngia - Health System FRnd Project The primary project objectives are to finance Improvements in State health systems by the establishment of a wholesaling mecWanism utilizing PFIs to appraise, supervise and co-finance State health PHN 1991 Sector Review 51 subprojects; and to assist the States in improving health system investment planning. The project comprises: (a) a line of credit, called the Health System Fund (HSF), for health subprojects in the various States to include one or more of the following components: (i) institutional development; (ii) strengthening of health services, including facility upgrading and new facilities; (iii) essential drug programs; (iv) strengthening of MCH/FP service delivery, (v) disease sufvelllance; (vi) information, education and communication programs; (vil) nutrition; (viii) promotion of non-governmental organizations (NGOs); and (ix) preparation work for future projects; (b) assistance to FMOH, for the strengthening of its Department of Planning, Research and Statistics, and the establishment of a management information system in FMOH; and (c) support to the State Ministries of Health by providing technical assistance and training. Niria - National Population Project The overall objectives of the project are to strengthen the institutional framework and expand the experiential basis for undertaking a large-scale, intersectoral National Population Programme (NPP) over the coming uecades. Based on Nigeria's recently approved comprehensive National Population Policy, NPP is being developed under the leadership of the Department of Population Activities (DPA), which was established in FMOH in 1988. The project will assist Government in gradually evolving an effective strategy for the program by developing a mechanism for funding and evaluating subprojects that are designed and implemeated by a number of CAs in the public and private sectors. The project will consist of three basic elements. 7he first is the Population Activities Fund (PAF), which will provide grants to qualified CAs for subprojects they have prepared. Subprojects will fit within a rolling three-year work plan for NPP; detailed guidelines for subproject content are under preparation. Many of the subprojects will focus on increasing family plmnning (FP) practice through provision of services and intensive information/education/communication (IEC). Other subprojects will develop leadership commitment to NPP to help prepare CAs to provide support functions for NPP in planning, coordination, training, monitoring, evaluation, or research. It is anticipated that PAF will attract funds from other donors. Seven subprojects (Phase I Suibprojects), utilizing about 51% of the initial allocation for PAF, have already been jointly appraised by IDA and DPA. Second, the project will help develop a small PAF Agency (PAFA) that will manage PAF in cooperation with DPA. Jointly, PAPA and DPA will develop the capacity to assist CAs with preparation of additional subprojects (Phase II Subprojects) and to appraise and supervise thern. The third element of the project is designed to stimulate intensive analysis of socio-cultural constraints to fertility reduction, review relevant experiences from other countries, and design innovative interventions kir adoption by implementing CAs. It wIll take the form of support for the establishment and Implementation of the first stage of the Population Research Fund (PRF). PRF would be managed by NISER with guidance from several relevant groups including DPA and the National Population Commissifn (NPC), which is responsible for the census and demographic surveys. Rwanda - FYrt Population Project The project will support the implementation of the National Population PolHcy and will contribute to: (a) reducing the total fertility rate (TFR); (b) improving maternal and child health (MCH); (c) integrating the demographic dimension in cross-sectoral development activities. These objectives will be reached by: (a) improving the quality and efficiency of Family Planning (FP) service delivery, (b) increasing demand for and access to FP services; (L) carrying out a set of population demand for and access to EP services; (c) carrying out a set of population studies and strengthening the FP information system; and (d) supporting multsectoral activities within the framework of the national population policy. Selected demographic targets for 1997 (last year of project implementation) include (figures for 1990 are in 52 PHN 1991 Sector Review parenthesis): TFR at 7.2 (85); modern contraceptive prevalence rate (CPR) at 20.0 (9.0); and 276,000 FP users (100,000). Senel - Population and Health The objectives of the proposed project are to support Government's efforts to: (i) control fertility and reduce the rate of population growth, through the implementation of a National Population Program; and (ii) restructure the health sector to enable It to provide basic health services of improved quality and wider accessibility, through the Implementation of its National Health Policy. lb achieve these objectives, the project would finance investments for (a) population to: (i) strengthen the National Rimily Planning Program; (ii) promote the status of women; (iii) sensitize youth on family welfare issues; and (iv) strengthen institutional capacity to promote the national population program; and (b) health to: (i) develop the district health system, including the promotion of community healt rganizations; (ii) promote the use and availability of essential drugs; and (iii) strengthen institutio.1il capacity in the health sector, with emphasis on manpower development, and budgeting and financial planning. While the project is a specific investment operation, it will involve the adoption and implumentation of key policy measures in both the population and health sectors including: (i) liberalization of regulations on contraceptive distribution and use; (ii) adoption of organizational norms for the district health system, ensuring sufficient budgetary allocations, personnel re-deployment, and adoption of organizational and procedural guidelines for community health associations; and (iii) promotion of essential drugs. Tbgo - Population and Health Sector Adjusm Operation The credit would support the implementation of a comprehensive package of sector policy reforms ia the area of population and health aimed at assuring a satisfactory level of primary health care and family planning services to the population, especially in rural areas. It would address in the short to medium term, pervasive morbidity and mortality resulting from inadequate treatment and prevention of tropical communicable and parasitic diseases and would increase current use of family planning services among couples. The Credit weald help the Government achieve these results by providing balance of payment support; the resulting counterpart funds will be used over four years for: (a) instituting better sector planning; (b) reforming institutional deficiencies within MSP and at regional levels; (c) improving personnel and financial management in the sector, and (d) instituting cost recovery and improving beneficiary participation in management of services. Specifically, reforms incorporated in the operation would effect a transformation of the Health Sector and the Government's population activities through policy measures geared to address prevailing key sector systemic constraints. It would: (i) launch the Government's new population policy by expanding family planning services, supporting NGO activities in family planning and creating greater awareness of availability and use of services; and (ii) reverse the deterioration in the quality of basic health care services and gradually increase their accessibility to the general population particularly in rural areas and for the most deprived groups. Specifically, the Program would: (a) integrate family planning into expanded primary health care activities; (b) strengthen institutional capabilities in: (,) planning and programming. (ii) budgeting, financial management and cost recovery, and (iii) sector coordination; (c) rehabilitate, re- equip and provide adequate operating expenses for operating existing facilities, and (d) redeploy, train, and improve the productivity and efficiency of technical and management staff. PHN 1991 Secor Review 53 Z& - Social Sector Project (a) to protect vulnerable populaton groups from the adverse social effects of a deteriorating economic situation; (b) to maintain, in coUaboration with other donors, essential public health, nutrition and fmily planning programs; and (c) to prepare future projects and programs in the sodal sectors by developing new policies on women-in-development, population and environment, and by establishing a national capability for collecting and anabling soial indicators Zambia - Social Recovey PNect lb fund community initiatives to help mitigate the negative effecs on the poor of the eownomic crisis. lb this end, the project will support the rehabilitation and improvement of eisting infrastructure and service delivery through the Micro-projects Unit in the Ministry of Finance. The project will strengthen communities' ability to improve their situation through self-help. Fnrther, the project wiU improve the information base and provide analyses to enhance the Government's planning and policy makdng in the social sectors. Zimbabwe - Second Family Health Project The project will provide the required financial and human resources for most of the Covernment's five-year investment program (1992.96) for health/population/nutrition (H/P/N), and wil promote policy and institutional reforms, in order to: (a) improve maternal and chfld health and nutrition status; (b) reduce the rate of population growth; and (c) ensure that households in the 16 worst-served districts (40% of the population) have access to basic H/P/N services. lb achieve these objectives, the project will increase the output and effective utilization of trained Zimbabwean health, family planning, and nutrition workers; enhance MOH capacity to plan and manage H/P/N activities; and increase efficiency and mobilize additional resources. 'he project will support the following six components: (a) Famlly Planning; training, community outreach and static facility services, special youth services, EEC campaigns, evaluation and research, and better management; (b) Maternal and Child Health; midwifery training, maternity equipment, school health program, and operations research; (c) Nutrition; supplement^ary food production, growth monitoring, micro-nutrient supplementation, IEC, and training; (d) Rural Health Delivery: upgrading of 16 district hospitals and about 80 RHO, prvision of staff housing, ambulances and supervisory transport, medical equipment, and radio communication; (e) Health Manpower Development: institutional strengthening, curriculum reform, systems development and studies, and selective upgrading of training facilities; and (f) Health Management Strengthening: training and systems development in financial management, materials/equipment management, district-level informaton systems, and sector planning. Asia RegIon Bw,#ad - Fouth Populadon and Health Project The project, which covers a flve-year time slice of GOB's development program in populadon and health (1991-96), has four main components: (a) strengthening FP service deliveiy, (b) strengthening health services deliery, and (c) improving supportive acivities to the deliery of FP and health services; and (d) women's and nutrition progmams. It will strengthen FP service delivery by improving access to FP services, strengthening MCH services, enhancing clinical servic- delivery and FP/MCH quality assurance, imparting in-service training of upazila and district staff in FP/MCH, construction and renovation of 54 PHN 1991 Sector Review FP/MCH facilities, and marketing of contraceptives through the private sector. The project will strengthen health service delivery through increasing the range of maternal and neonatal health care, strengthening nursing and medical education, introducing medical quality assurance, supporting medical research, strengthening disease prevention and control, developing urban primary health care, continuing and expanding school health programs, improving district and upazila health facilities, and improving the utilization of Upazila Health Centers. In support of the first two components, the project will assist In strengthening information systems, improving FP and health management, expanding communications programs, supporting NGO activities, and developing innovative projects. Finally, the project will assist continuation of the three women's programs financed under the previous three projects and will strengthen and develop the national Nutrition Council, in anticipation of a substantial program of nutrition interventions. India - Integrated Child Development Services Project The project would support the objective of the Central and Andhra Pradesh and Orissa state govermnents of improving the nutrition and health statuLs of children under 6 years of age, with special emphasis on those -3 years old, and pregnant and nursing women. Its specific objectives in project areas would be: (a) to reduce severe malnutrition in those children by 50% in both states; (b) in Andhra Pradesh to reduce moderate malnutrition and increase the proportion of those children in normal or only mild (Grade I) malnutrition status by 35% and help reduce the infant mortality rate (IMR) to 60 per 1,000 ihve births and the incidence of low birth weight (LBW) by 30%, and (c) in Orissa to reduce moderate malnutrition and increase the proportion of those children in normal or Grade I status by 25% and help reduce the IMR to 100 per 1,000 live births and LBW by 20%. The project would comprise the following components: (a) service delivery, to increase the range, coverage and quality of nutrition and health services to target groups through improvements in the design and implementation of software systems, training for health and nutrition workers, provision of nutrition and health education and health referral services, increasing the availability of drugs and equipment for maternal and child health and the supply o therapeutic supplementary food to malnourished beneficiaries, and construction of village nutrition centers, offices and residences for key field staff-, (b) communications to stimulate demand for project services and improve child feeding practices and care through production and dissemination of media messages, provision of equipment and materials and training, (c) community mobilization to increase local participation in and support for project services and activities through testing of innovative women's development activities including activation of village women's groups, development of income-generating activities, non-formal study courses for women and development of training programs for adolescent girls; and (d) project management and evaluation to manage, monitor and evaluate the project and conduct operations research to anabze and improve aspects of project design. Indansia - Ffh Populaton Project (Family Planning and Safe Motherhood) The main objective of the project is to help the government intensify its efforts to lower fertility and maternal mortality during the 1990's. This would be achieved through two major parts: Part A to further strengthen the family planning program under the National Family Planning Coordinating Board (BKKBN) and Part B to assist the Ministry of Health (DEPKES) strengthening its policy and capacity to train and improve the availability and skills of midwives, designed to become a primary source of family planning and maternal and child health services at the village level. Through Part A, BKKBN would continue. to provide leadership to coordinating high quality family planning services using the public sector, non-governmental organizations (NGOs) and private providers, and it would extend the family planning program among hard-to-reach populations. lb accomplish these goals, Part A would have the following specific components: (a) lhrgeted Family Planning and Safe Motherhood promotion, intended to improve PHN 1991 Sector Review 55 the accessibility and utilization of services among the urban poor and populations in coastal and transmigration areas, promote family planning services in the organized sector and promote nationwide availabilitv of long lasting contraceptive methods including intra-uterine devices (IUDs), implant and sterilization services; (b) an IEC and Community Outreach would support improvements in BKKBN's IEC strategy and system capacity, promote participation of youth in family planning and activate new community groups in selected vilages; (c) Institutional Development would provide for staff development training activities and personnel policy changes to support BKKBN's family planning strategy, support reform and streisgthening of BKKBN's program monitoring, evaluation and research capacity and strengthen field operations through the provision of vehicles, equipment, contraceptives and other materials and remodeling of selected buildings. Part B would consist of three major components: (a) strengthening of a policy framework on the objectives and related training and planning principles that would govern the deployment of community midwives; (b) strengthening training capacity through training of trainers and improving teaching materials and equipment; and (c) supporting training and improvement of the effectiveness of about 16,000 community midwives, requiring improved certification and examination procedures for these workers and accreditation standards for nurse midwifery training schools. The project would also provide support to both BKKBN and DEPKES for costs related to Project Management including support for additional professional and administrative contract staff for the project duration in both agencies. Korea - Health Technology Project Tne project would: (i) expand the diagnostic and treatment capabilities of NCD specialty units in large referral hospitals; (ii) replace and add biomedical equipment in hospitals located in large and medium-size cities and distribute it more equitably; and (iii) provide equipment to medium-size city hospitals designated as emergency centers in the national Emergency Medical Services network Agreed criteria would be strictly applied to the selection of participating hospitals and of equipment. The selection criteria for hospitals would consider the hospital's financial status, its location, its size, and the need for and potential efficient utilization of the requested equipment. The selection of the biomedical equipment would take into consideration the regional distribution among the eight medical regions, the relevance of equipment to medical needs, training of equipment users, availability of a recurrent cost budget for operating the equipment, and sharing of equipment by several facilities. The financing of high cost equipment would be excluded from the project, partly because there is an active leasing market for this type of equipment, and partly because some procedures are not reimbursable by the national insuranos and would therefore not be accessible to the poor. Project implementation would be the responsibility of the Bureau of Medical Affairs in MOHSA. Independent review panels would be set ! ~ to select hospitals and equipment. MOHSA staff would receive training to manage the on-lending process and the sub-loans with the selected hospitals. Sn Lanka - Poverty Alleviation Project The project will assist the newly created Janasaviya ihist Fund (the Thust), with a governing board having representatives from the Government, Non-Government Organizations (NGOs), private sector and the academia, in financing credit operations, human resource and infrastructure development, and nutrition intervention activities of NGOs and government agencies. The 'Blust will manage four funds: (a) a Credit Fund to lend to partner organizations (POs) which will on-lend to the poor in a manner prescribed by the Blust at interest rates which will make the credit fund operations self-supporting; (b) a Human Resources Development Fund for promoting the productive use of credit and for developing the lending capacity of POs; (c) a Rural Works Fund for building economically viable infrastructure and 56 PHN 1991 Sector Review creasing wage employment; and (d) a Nutrition Fund for reducing the proportion of wasting and stunting in children and reducing the incidence of low birth weight and the prevalence of maternal malnutrition. In addition, the project will support an Employment and Poverty Policy Unit in the Ministry of Policy Planning and Implementation. EMENA Region Algeria - Pilot Public Health Management Project The proposed project would help improve productivity and efficiency in the Algerian health care delivery system. It would introduce, on a pilot basis and in a limited area, management tools that will allow the Govemment to implement changes in the management and operations of the health system at central and local levels. These management tools would subsequently be extended nationwide. The pilot area would include the teaching hospital (CHU) and adjacent urban health district of Bab el Oued in Algiers, and the rural wilaya of Medea. The project would: (a) improve resource management through the introduction of health managemeri and information systems for: (i) financial reporting and cost accounting, (ii) patient administraton, (iii) service and personnel performance evaluation, and (iv) building, medical and non- medical maintenance; complemented by pre- and in-service training programs for managers and support staff; (b) improve quality of services by: (i) raising professional skills of public health sector personnel through stronger pre- and in-service training, and (ii) strengthening professional communication between health personnel at different levels; (c) improve the utilization of project area facilities through upgrading of their diagnostic and emergency handling capabilities and rehabilitation of basic systems such as electricity and water supply; and through the development of a masterplan for the teaching hospital of Bab el Oued; and (d) strengthen strategic planning and management in MOPH, including its capabilities to closely monitor and evaluate project results for eventual replication at national levels. Egjpt - Social Fund Project As part of a continuing effort to ensure a social safety net associated with economic reform in Egypt, and in response to the adverse effects of the recent Gulf crisis, the proposed project will be the first phase of an overall program aimed at addressing the immediate and pressing needs of those most vulnerable to the reform process, in addition to facilitating the reintegration of Egyptian workers returning from Kuwait and Iraq. The proposed investments will focus on income and employment generation activities, and the provision of essential physical infrastructure and public services. The project will also include efforts to strengthen the Government's capacity to design and monitor future poverty alleviation policies and programs, and will establish mechanisms to protect selected target population groups (e.g., households that are dependent on unemployed workers, or that are headed by women) from the likely longer-term adverse social effects of adjustment. Jordan - Emergency Recovery Project The project would support the Government's strategy for: (a) alleviation of some of the adverse effects of Jordan's economic adjustment program and the Gulf crisis on the poor in the short run, and (b) establishment of an institutional basis for targeted poverty reduction programs over the medium term. To this end, the project would help finance a new entity, the Development and Employment Fund (DEF), which is mandated to work with existing governmental and non-governmental organizations to create new productive employment opportunities targeted at households at or below the poverty line. DEF is PHN 1991 Sector Review 57 administratively constituted as a unit within the Industrial Development Bank, but operates in accordance with its own project eligibility and appraisal criteria, and is subject to the oversight of an 3utonomous DEF Management Committee comprised of representatives of relevant Government departments/agencies and non-governmental organizations. Bank and concessionary bilateral financing would be provided under the project to support DEFs first three years of operation. Paksan - Family Health Project The project has three main objectives: (a) to improve the health status of the population of the two provinces; (b) to increase the effectiveness of the existing health care network; and (c) to build the institutional capacity to realize these objectives. The project has three main components: (a) strengthening health services from the village to the district level, focusing on improved maternal health services including family planning and integrating and expanding communicable disease control activities; (b) staff development focusing on improved staff capabilities and performance and increasing the number of female paramedical staff; and (c) management and organizational development focusing on improved management capabilities. The project will finance: construction or expansion of training facilities and limited health facility upgrading, furniture, equipment and transport; training costs; technical assistance; and incremental recurrent costs including medicines. It will be implemented by the provincial governments with technical support from local NGOs and universities. Tunisia - Population and Family Health Project TMe Population and Family Health project aims to assist the Government of linisia (GOT) to lower both fertility and mortality, by targeting basic health care services to underprivileged groups with a strong focus on mothers and children. The quantitative target of the project are to recruit about 30,000 new family planning acceptors per year in the public sector while continuing to serve over half a million women with such services through the project period. Further reductions in mortality and morbidity would be addressed through: (i) reducing regional disparities in access to basic health care (including the first referral level of care) and in the availability of resources; and (ii) improving the quality of Basic Health Care (BHC) of which Family PlanningrMaternal and Child Health services (FP/MCH) is a critical component. The project would provide: (a) works and equipment to BHC facilities to accommodate the strengthening of FP/MCH services and upgrade the technical quality of the services; (b) mobile clinics and vehicles to deliver family planning and other basic health services with a strong focus on underserved areas; (c) ambulances and equipment for the district hospitals; (d) works and equipment for five peri-urban diagnostic centers; (e) educational materials and expert services for a comprehensive pre- and in-service training program for staff who are to deliver the services; (f) expert services to improve strategic planning and monitoring capacities; and (g) spare parts and expert services for the development of a maintenance program for vehicles, equipment and buildings. nia - Hospital Restructuring Support Project The objectives of the project are to support the Government policy in its effort to: (i) address major hospital internal efficiency issues to contain costs while improving quality of services; and, (ii) provide the information that would permit adjustments in financial burden-sharing by better linking actual utilization of hospital services to financial contributions. 'lb this end, the project would include the following components: (a) development of management capabilities and policy adjustments. The project would finance technical assistance, training and office technology (hardware and software) to develop and implement: (i) financial management and performance evaluation procedures; (ii) a Management Information System; (iii) the reorganization of the administration and patient registration units; and (iv) 58 PHN 1991 Sector Review sectoral strategies and reform program management: a framework and action plan for new burden-sharing arrangements, a medium-term strategic plan for hospital development, hospital architectural masterplans and reform program management. (b) Improvement of service quality. The project would support: (i) the replacement of priority medical equipment; (ii) the strengthening of hospital maintenance units; and (iii) improvements in patient accommodations, hospital hygiene, and handling of medical wastes. Yemen - Emergency Recovery Project The objective of the project is to support a set of core components from the ERP that will help meet immediate retarnee-induced needs for essential social services, maintain basic nutritional levels, and expand housing facilities and social infrastructure. Actions will be focused on the geographic centers of concentration of returnees and will help to create employment opportunities associated with project expenditures. In addition, the project is expected to provide the framework for mobilizing bilateral and other multi-lateral support for the ERP Within the above objectives, components for the ERC have been selected on the basis of: (i) maximum potential assistance to returnees, (ii) capacity for emergency implementation, and (iii) Government's preferences and other sources of aid available for expanding social services. The project will provide financing for the following: (a) Expanding social infrastructure through: procurement of key equipment, materials, and training, for: (i) the labor intensive construction and maintenance of 410 km of priority and economically viable secondary and feeder roads related to centers of concentration of returnees (US$22.8 million); and (ii) the provision of 2,500 serviced sites for housing construction by returnees (US$9.4 million). (b) Strengthening essential social services through: expansion of existing education facilities (construction of 420 classrooms), equipment, materials and teacher training construction of, to incremental meet part of the increased demands from returnees and to partially compensate for shortages of expatriate teachers (US$17.0 million). (c) Supporting agricultural activities through: provision of gabion baskets (to help in land and water conservation), as well as supplies of seeds, chemicals, fertilizers and spare parts for farm machinery, and feedstuff and veterinary products, to help maintain crop and livestock production, thereby reducing the need for incremental food imports and helping to ensure basic nutritional standards for returnees, a majority of whom have returned to rural areas (US$9.7 million,. (d) Strengthening program management through: equipment, vehicles, training and operating expenses and technical assistance (12 staff months) for planning and procurement (US$0.6 million). The project would be fully implemented within three years, with components being specifically designed to create temporary employment for returnees. All construction would be restricted to small, simple structures, for which plans or models already exist, and with emphasis on quick implementation and wide distribution of benefits to centers of concentration. A map of ROY (IBRD 22921R) is attached to the report. LAC Region Vl Salvador - Social Sector Rehabilitation Project The objectives of the proposed project would be to: (a) improve the delivery of basic social services targeted to some 80 of the most disadvantaged municipalities. Selected priority areas are based on the severity of malnutrition among children, according to the National Nutrition Survey conducted by the Institute for Nutrition for Central America and Panama (INCAP), and low supply of health and education services; and (b) strengthen the institutional capabilities of MIPLAN, MOH and MOE to efficiently plan and manage the delivery of social programs. PHN 1991 Sector Review 59 Haiti - Economic and Social FAnd Project The objectives of the project would be to: (i) establish an effective mechanism, the Economic and Social Fund (ESF), as a means of responding flexibly and efficiently to the basic needs of the poor through NGOs, cooperatives, community associations and other grass roots organizations; (ii) assist the GOH to improve health, nutrition and education services and provide physical infrastructure, and employment opportunities to the poor; (iii) provide an effective channel for critically required donor financing and coordinate domestic efforts that are currently fragmented; and, (iv) strengthen the capacity of community groups, cooperatives and other grass roots organizations in preparing and implementing projects. The proposed operation would consist of a project component and an institutional development component. The project component (US$10 million, IDA contribution) would address the needs of the poor in health and nutrition, education and physical infrastructure. Financing would be provided for. (i) health and nutrition projects primarily for children, pregnant and lactating mothers, rehabilitation and construction of primary health care facilities, essential drugs, immunization, construction of small water supply systems, small-scale sewerage systems and latrines (US$6.4 million); (ii) rehabilitation and construction of pre- school centers and primary schools, provision of school furniture and pedagogic material, literacy and vocational training programs (US$2.5 million); and (iii) rural market and social service access roads and related drainage works (US$1.0 million); and advisory services to participating organizations (US$0.1 million). The institutional development component (US$1.3 million) would finance administrative and technical assistance to the ESF, including salaries for selected ESF staff, equipment (vehicles and computers), consultant services and operating costs. Honduras - Social Investment Fund Project The objectives of the proposed project are to: (i) mitigate the social costs of adjustment and allow economic reform measures to be put into place rapidly with the necessary support of the population, (ii) lay the basis for a decentralized program of direct support for the poor and malnourished to buy food, and (iii) support the improvement of service delivery In the social ministries. The project would have four components: (i) the financing of the FHIS (more than 95% of total project cost), (i) sutpport to a pilot targeted nutrition assistance program (the executing agency would be the Family Assistance Program), (iii) technical assistance to help design a program to improve the efficiency and equity of the services of MOH nd MOE, and (iv) the setting up of a monitoring and evaluation system of the government's social policy interventions through the use of a Living Standards Measurement Study (the coordinator of this program would be the Ministry of Planning). Mexico - Basic Health Care Project The project would: (a) strengthen and extend basic health care services and targeted nutrition assistance to about 13 million uninsured poor in 47 health jurisdictions in Oaxaca, Chiapas, Hidalgo, and Guerrero and in the Federal District (Project States); (b) support institutional improvements to strengthen management capability to enhance the efficiency and effectiveness of the health care system; and (c) strengthen the implementation of sectoral reforms to decentralize budgetary, management, and operational responsibilities from the federal level to the states. Attainment of these objectives would support a broader government policy for poverty alleviation and contribute to improved health and nutritional status of low-income residents in Mexico's poorest states. The project consists of two major components: (a) Health Services Component (89 percent of total project cost including contingencies), which would focus on improving and extending delivery of basic health care and nutrition assistance (PASSPA program) for 13 million uninsured people. Specific actions 60 PHN 1991 Sector Review include: (i) rehabilitating, upgrading, and expanding the health network and developing a maintenance program for facilities and biomedical equipment; (ii) providing equipment, furniture, vehicles, and basic medical supplies; (iii) hiring, reassigning, and regarding personnel to flt the PASSPA program; (iv) improving the supervision system and technical training for professional and auxiliary health staff; and (v) producing and distributing operational manuals and materials; and (b) Institutional Development Component (11 percent of total project cost). At the federal level, it would: (i) provide assistance to facilitate the decentralization process; (ii) conduct operational research to improve services delivery, to set policies and priorities, to mobilize additional resources for basic health care, and to carry out operational research and impact evaluation; and (iii) strengthen management information systems to improve planning, analysis, and management capacities. At the state level, this component would assist in improving: (i) the management, administration, and planning capacities of the State Health Authorities; (ii) personnel policies and management; and (iii) training opportunities in management and administration for managers and administrative staff. Venuel - Social Development Project The objective of the proposed project is to assist the Government of Venezuela (GOV) in developing a social sector strategy to redirect its social expenditures into well-targeted and efficient programs, by financing high priority activities, within the framework of its Social Sectors Action Program. It aims to: (a) improve living conditions of a large and poor segment of the population, especially pregnant and lactating women, and children under six years of age, while mitigating the potential adverse impact of the adjustment program; (b) replace indirect subsidies with targeted social programs, while improving their efficiency and rationalizing their distribution; and (c) promote institutional development by improving the planning and management capacity in the Ministries of Health and Education, as well as the capacity to target, develop and monitor social programs in the Ministry of the Family. The GOV has drawn up a set of policies and actions to be undertaken (Social Sectors Action Program), which, together with the project components to be financed, will effectively implement its basic objectives and strategy for the social sectors. The project would support: (a) rehabilitation and development of the primary health care network, including provision of basic health and nutrition services for pregnant and nursing women and children under six years of age; (b) development and expansion of pre-school education, focused on the lower-income urban and rural areas; (c) information, education and communications services for health, nutrition, and education promotion; and (d) improvement of the GOVs capacity to design, plan and implement social programs and to monitor the effect of such programs. A technical coordinating office attached to the MINFAM would liaise with implementing agencies on project planning, budgeting, and implementation. Autonomous agencies attached to the MOE and MOH would be in charge of day to day administration of the project; technical supervision would be carried out by regular ministry staff. Special attention wouid be given to strengthening implementation and coordination capacity in the various institutions involved. ANNEX 3. Bibliography BIBLIOGRAPHY OF ANNUAL SECTOR REPORT GenenwlI Miwelan* Economic Development Institute. EDI Activities Report. FY1990. (Washington, D.C.: World Bank, December 1990). Griffin, Charles C 'The Need to Change Health Care Priorities in LDCs.' Finance & Development, vol. 28, no. 1 (March 1991): 45-7. Paul, Samuel. 'Community Participation in Development Projects: The World Bank's Experience." World Bank Discussion Paper No. 6. (Washington, D.C., Februaly 1987). United Nations Development Programme, Human Development Reporn 1991. (Oxford: Oxford University Press, 1991). World Bank "FY92 Priorities and Budget Policy Directions." Board Report SecM90-1391. (Washington, D.C, November 1990). World Bank a16th Annual Report on Implementation and Supervision - FY90." (Washington, D.C, December 1990). World Bank 'FY92 Priorities and Budget Policy Directions.' (Washington, D.C., November 20, 1990). World Bank. Medium-Term Planning Framework (FY92-94).' (Washington, D.C., February 14, 1991). Managent Institutional Development Adamolekun, Ladipo. Issues in Development Management in Sub-Saharan Aftica. Economic Development Institute, Policy Seminar Report No. 19. (Washington, D.C: World Bank, October 1989). Agarwala, Ramgopal. 'Planning in Developing Countries: Lessons of Experience." Worli Bank Staff Working Paper No. 576. (Washington, D.C., December 1983). Cochrane, Glynn. "Policies for Strengthening Local Govermment in Developing Countries.' World Bank Staff Working Paper No. 582. (Washington, D.C., July 1983). DaVanzo, Julie, and John Haaga. "Women in Development: Issues for the Latin American and Caribbean Region." World Bank Technical Paper No. 2. (Washington, D.C., April 1991). Economic Development Institute. Strengthening Local Govemments in Sub-Saharan Africa. Policy Seminar Report No. 21. (Washington, D.C.: World Bank, December 1989). Hegstad, Sven 0. and Ian Newport. 'Management Contracts, Main Features and Design Issues.' World Bank Technical Paper No. 65. (Washington, D.C., July 1987). Kubr, Milan and John Wallace. 'Successes and Failures in Meeting the Management Challenge: Strategies and Their Implementation.' World Bank Staff Working Paper No. 585. (Washington, D.C., July 1983). 64 PHN 1991 Sector Review Lacey, Robert M. "Managing Dublic Expenditure: An Evolving World Bank Perspective." World Bank Discusslion Paper No. 56. (Washington, D.C., June 1989). Paul Samuel. 'Institutional Development in World Bank Projects: A Cross-Sectoral Review." World Bank Working Paper No. 392. (Washington, D.C., April 1990). '- "nstitutional Reforms in Sector Adjustment Operation: The World Bank's Experience." World Bank Discussion Paper No. 92. (Washington, D.C., June 1990). '1raining for Public Administration and Management in Developing Countries." World Bank Staff Working Paper No. 584. (Washington, D.C., July 1983). , and others. "Educating Managers for Business and Government: A Review of International Experierce." World Bank Discussion Paper No. 54. (Washington, D.C., June 1989). Silverman, Jerry M. and others. "Action-Planning Workshops for Development Management Guidelines." World Bank Technical Paper No. 56. (Washington, D.C., December 1986). World Bank 7he Afnican Capacity Building Initiative: Toward Improved Policy Analysis and Development Management. (Washington, D.C., January 1991). World Bank 'Managing Technical Assistance in the 1990s.' Report of the Technical Assistance Task Force. (Washington, D.C., August 1991). PopulaHon Swamy, Gurushri and Catherine Patillo. 'Population in World Bank Economic and Sector Work - A Review of Some Best Practices and Methodologies." World Bank Intemal Discussion Paper, Africa Regional Series. (Washington, D.C., March 1991). World Bank. Population and The World Bank: A Review of Activities and Impacts from Eight Case Studies." Operations Evaluation Departrent (Washington, D.C., June 1991). Demery, Lionel, and Tony Addison. The Alleviation of Povety under Smutural Adjustment. (Washington, D.C.: World Bank, November 1987). Ferroni, Mike, and Ravi Kanbur. Poverty-Conscious Restructuring of Public Expenditure: Social Dimensions of Adjustment in Sub-Saharan Africa." World Bank Staff Working Paper No. 9. (Washington, D.C.: World Bank, December 1990). Holt, Sharon, and Helena Ribe. "Developing Financial Institutions for the Poor and Reducing Barriers to Access for Women." World Bank Discussion Paper No. 117. (Washington, D.C., February 1991). Jorgensen, Steen, Margaret Grosh, and Mark Schacter. 'Easing the Poor through Economic Crisis and Adjustment: The Story of Bolivia's Emergency Social Fund." World Bank Technical Paper No.3. (Washington, D.C., May 1991). PIIN 1991 Sector Review 65 LAvy, Santiago. 'Poverty Alleviation in Mexico." World Bank Working Paper No. 679. (Washington, D.C, May 1991). Ribe, Helena, and Soniya Carvalho. rargeted Poverty Projects Supported by the World Bank: An Overview of Operations Approved During FY85-89." Draft repor. (Washington, D.C.: World Bank, April 1991). Ribe, Helena, and others. "Towards a Social Action Program for Pakistan: Impediments to Progress and Options for Reform." Draft interim report. (Washington, D.C: World Bank, April 1991). Ribe, Helena, and others. *How Adjustment Programs Can Hep the Poor: The World Bank's Experience." World Bank Discussion Paper No. 71. (Washingt nn, D.C., January 1990). World Bank. "Assistance Strategies to Reduce Poverty." Board Report R90-243. (Washington, D.C., December 1990). World Bank. Povert and HNuman Development. (New York: Oxford University Press, 1980). World Bank. Poverty and Hunger, Issues and Options for Food Security u6 Developing Countries. Policy Study. (Washington, D.C., February 1986). World Bank. Taigeted Programs for the Poor During Stmuctural Adjustnent: A Summaiy of a Symposiun on Poverty and Adjustment April 1988. (Washington, D.C., September 1988). World Bank The Social Densions of Adjustment in Afica: A Policy Agenda. (Washington, D.C, March 199). World Bank. he World Bank's Support for the Alleviation of Poverty. (Washington, D.C, June 1988). World Bank. Social Dimensions of Adjustment Status Report and FY91 Work Plan. 'Socio-economic Development Funds: A Guideline for Design and Implementation. (Washington, D.C, March, 1990) Policy Research Working Paper Series Contact Title Author Date for paper WPS871 The D:stribution of the Benefits from Dominique van de Walle March 1992 A. Bhalla Social Services in Indonesia, 1978-87 37699 WPS872 Romania's Evolving Legal Framework Cheryl W. Gray March 1992 CECSE for Private Sector Development Rebecca J. Hanson 37188 Peter G. lanachkov WPS873 Measure and Interpretation of Francois M. Ettori March 1992 F. Ettori Effective Protection in the Presence 32340 of High Capital Costs: Evidence from India WPS874 The Trade Restrictiveness Index: An James E. Anderson March 1992 G. Ilogon Application to Mexican Agriculture Geoffrey Bannister 33732 WPS875 Rural Finance in Developing Jacob Yaron March 1992 C. Spooner Countries 30464 WPS876 Old Debts and New Beginnings: Ross Levine March 1992 W. Pitayatonakarn A Policy Choice in Transitional David Scott 37664 Socialist Economies WPS877 Assessing Gains in Efficient Gary H. Jefferson March 1992 CECSF Production Among China's Industrial Wenyi Xu 37188 Enterprises WPS878 Adjustment and Private Investment Kazi M. Matin March 1992 D. Ballantyne in Kenya Bernard Wasow 37947 WPS879 Comprehensive Water Pesources Peter Rogers March 1992 D. Ranger Management; A Concept Paper 31296 WPS880 Exchange Rate Policy, the Real Miguel A. Kiguel April 1992 R. Luz Exchange Rate, and Inflation: Lessons 34303 from Latin America WPS881 Dual and Multiple Exchange Rate NitaGhei April 1992 R. Luz Systems in Developing Countries: Miguel A. Kiguel 34303 Some Emp,rical Evidence WPS882 'ksues in Reforming Financial Alfredo Thorne April 1992 L. Ly Systems in Eastern Europe: The Case 37352 of Bulgaria Policy Research Working Paper Series Contact Title Author Date for ,paper WPS883 Malaria: The Impact of Treated Bed- Pedro L. Alonso April 1992 0. Nadora Nets on Childhood Mortality in the Allan G. Hill 31091 Gambia Patricia H. David Greg Fegan Joanna R. M. Armstrong Andreas Francisco K. Cham Btian M. Greenwood WPS884 Intercommodity Price Transmittal: Harold Alderman April 1992 C. Spooner Analysis of Food Markets in Ghana 30464 WPS885 The Impact of EC-92 on Developing A. J. Hughes Hallett April 1992 A. Kitson-Walters Countries' frade: A Dissenting View 33712 WPS886 Factors That Affect Short-Term Sudarshan Gooptu April 1992 L. Dionne Commercial Bank Lending to- Maria Soledad Martinez Peria 31426 Developing Countries WPS887 Power Sharing and Pollution Control: William Jack April 1992 P. Pender Coordinating Policies Among Levels 37851 of Government WPS888 Transformation of Agriculture in Csaba Csaki April 1992 C. Spooner Certral Eastern Europe and the Former 30464 USSR: Major Policy Issues and Perspectives WPS889 On-th-Job Improvements in Teacher Stephen W. Raudenbush April 1992 C. Cristobal Cornpetence: Policy Options and Suwanna Eamsukkawat 33640 Their Effects on Teaching and Ikechuku Di-lbor Learning in Thailand Mohamed Kamali Wimol Taoklam WPS89O Population, Health, and Nutrition: Denise Vaillancourt April 1992 0. Nadora Fiscal 1991 Sector Review Janet Nassim 31091 Stacye Brown