AFR I CA REG IO N HUMAN DEVE LO PM ENT U WORKIN G PAPERS SERI ES TRE WORLD BANK Enhdncing Humdn Development in the HIPC PRSP Context Progress in the Africd Region during zooo 22606 May 2001 't.~~~~~~~~~~~~~~~~~. 1 a '.' # ,...~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~4 Other Titles in This Series Dynamic Risk Management and the Poor-Developing a Social Protection Strategy for Africa Engaging with Adults-The Case for Increased Support to Adult Basic Education in Sub-Saharan Africa Inclure les adults-Pour un appui a 1'6ducation de base des adultes en Afrique subsaharienne Africa Region Human Development Working Paper Series Enhancing Human Development in the HIPC/PRSP Context Progress in the Africa Region during 2000 Jee-Peng Tan Agnes Soucat Alain Mingat ii AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES ©) May 2001 Human Development Sector Africa Region The Work Bank Cover design by Tomoko Hirata Cover photo by Curt Carnemark ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT Foreword P overty reduction is the central focus of the the current size of social sector spending in the eigh- World Bank's development assistance strategy. teen countries, the content of HD policy measures in- In recent years the institution has, together cluded in the debt relief agreement, and countries' with its partners, evolved new concepts, processes, and progress in preparing PRSPs. Readers will also learn operational instruments in an effort to enhance the about the World Bank's efforts to engage country effectiveness of its support to governments in the fight counterparts in the HD sectors in a more effective dia- against poverty. The most notable of these new ap- logue on sector development, particularly in the health proaches include (a) debt relief through the Highly and education sectors. A key aspect of these efforts Indebted Poor Countries (HIPC) Initiative, (b) coun- involve collaborative work between the World Bank try leadership in articulating poverty reduction strat- and national teams in sector analysis that consolidate egies through Poverty Reduction Strategy Papers and deepen sector knowledge, the aim being to (PRSPs), and (c) World Bank financial support through strengthen the basis for preparing sector inputs into Poverty Reduction Support Credits (PRSC) to imple- PRSPs. ment these strategies. Because human development A stock-taking exercise of a still evolving process (HD) is central to any poverty reduction effort, these inevitably runs the risk of telling at best an incomplete new approaches typically place heavy emphasis on im- story. It is thus my hope that, as we make progress in proving performance in the social sectors. implementing the new concepts, processes, and instru- Given the newness of these developments, it is still ments associated with debt relief and poverty reduc- too early to evaluate their impact on human develop- tion strategies, subsequent updates to this report will ment and poverty reduction. Yet, they have proceeded document the emerging lessons that can help to en- far enough in a large number of African countries to hance the effectiveness of the World Bank's support make an initial stock-taking exercise worthwhile. This for poverty reduction. paper is intended to serve that modest purpose. It of- fers readers an account of the progress during 2000 in the eighteen African countries that passed their Deci- sion Points in the debt relief process during that year. The report includes basic facts on the countries in- Birger Fredriksen volved, the pipeline of possible newcomers in coming Sector Director years, the amounts of debt relief offered in relation to Human Development Department Africa Region iV AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES This paper reports on the current status of an evolving process, and is circulated mainly to inform readers about what has happened so far. The authors wish to thank Fay Chetnakarnkul for help in consolidating the information, Tony Gaeta for sharing valuable information on debt relief, Birger Fredriksen for providing feedback on an earlier draft, and Lawrence Mastri for editorial assistance. While these colleagues have helped to improve the report, the authors alone are responsible for any errors that remain. The views expressed in the report are those of the authors and do not necessarily reflect the opinions or policies of the World Bank or any of its affiliated organizations. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT V Contents Part I The HIPC/PRSP Process and HD Engagement in It I The countries involved and amount of debt relief 1 The debt relief process and policy levers 3 Advancing Human Development in the context of HIPC/PRSPs 5 Enhancing HD inputs for the design of completion point triggers and PRSP follow-up 6 Progress to date 8 Part 2 Strengthening the Content of HD Inputs to the HIPC/PRSP Process 16 Policy-relevant analytical work in health 16 Policy-relevant analytical work in education 21 Part 3 Emerging Lessons 27 Bibliography 41 Figures Figure 1 Grouping of the Heavily Indebted Poor Countries 2 Figure 2 Relation between public spending on health and education and sectoral outcomes 5 Figure 3 Infant and under-five mortality by income group, Cameroon 1998 17 Figure 4 Health indicators by income group, Burkina Faso 1996 17 Figure 5 Prevalence of diarrhea and acute respiratory infection by wealth group, Mali 1995-96 18 Figure 6 Reasons for non-utilization of basic health services in Burkina Faso 1998 20 Figure 7 Population per medically trained personnel by region, Niger 1997 20 Figure 8 Comparing service provision gaps for IMCI, Mauritania 2000 21 Figure 9 Disparities in student flow profiles in Mauritania 1998 22 Figure 10 Functional allocation of staff and public spending on education in Madagascar 1998 24 Figure 11 Relation between number of pupils and teachers at the school-level, Mozambique 1998 24 Figure 12 Relation between spending and student learning among fifth graders, Burkina Faso 1996 25 Vi AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Tables Table 1 Debt relief relative to social sector spending in eighteen African countries 3 Table 2 Topics addressed in health and education Country Status Reports 6 Table 3 Phases in preparing and discussing Country Status Reports on health and education 7 Table 4 Health sector measures to reach the floating completion point under the HIPC Initiative 9 Table 5 Education sector measures to reach the floating completion point under the HIPC Initiative 10 Table 6 Completed and planned interim and full PRSPs for African countries 12 Table 7 Preparation of health and education Country Status Reports in the Africa Region 13 Table 8 Household health care practices, Guinea 1999 19 Table 9 Out-of-pocket health spending in Burkina Faso 1998 19 Table 10 Gross enrollment ratios in villages with and without schools in three regions, Niger 1998 23 Appendix Tables and Figures Table Al The role of health and education in Uganda's Poverty Eradication Action Plan (PEAP) 2000 30 Table A2 Uganda's 2000 PRSP: Health and education sector measures & monitoring indicators 30 Table A3 Uganda's PEAP/PRSP First Year Progress Report 2001 31 Table A4 The role of health and education in Burkina Faso's 2000 Poverty Reduction Strategy (PRSP) 32 Table A5 Health sector strategy/objectives and monitoring indicators in Burkina Faso's 2000 PRSP 32 Table A6 Education sector strategy/objectives and monitoring indicators in Burkina Faso's 2000 PRSP 33 Table A7 The role of health and education in Mauritania's 2000 PRSP 34 Table A8 Health and nutrition strategy/measures and monitoring indicators in Mauritania's 2000 PRSP 34 Table A9 Education sector strategy/measures and monitoring indicators in Mauritania's 2000 PRSP 35 Table AIO Role of health and education in Tanzania's 2000 PRS 36 Table All Health sector strategy/measures and monitoring indicators in Tanzania's 2000 PRSP 36 Table A12 Education sector strategy/measures and monitoring indicators in Tanzania's 2000 PRSP 37 Table A13 Examples of health indicators for cross-country comparisons 38 Table A14 Selected best buys in health 39 Figure Al Grouping of the Heavily Indebted Poor Countries 42 ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT Vii Introduction In 1996 the World Bank and the IMF - supported by governments around the world - proposed the Highly Indebted Poor Countries (HIPC) Debt Ini- tiative as a coordinated approach among official creditors to bring down debtor countries' external debt to sustainable levels. An enhanced version of the initiative was put in place in September 1999 to simplify and accelerate the process, as well as deepen the amount of debt relief and tighten the link to poverty reduction. The expectation was that, in return for debt relief, benefi- ciary countries would commit themselves to policies that advanced sound eco- nomic management and poverty reduction. The initiative emphasized struc- tural and social policy reforms, particularly in delivering basic health care and education services, facilitated where needed by additional financing under the HIPC Initiative. In addition, governments benefiting from the debt relief would be expected to articulate their plans for poverty reduction in a Poverty Reduc- tion Strategy Paper (PRSP). Given the focus on health and education within the context of debt relief, the Africa Region formed a HD HIPC/PRSP Team in November 1999 to help task team leaders in the Human Development (HD) family provide sectoral inputs for the various HIPC/PRSP documents.* This report is intended to update World Bank colleagues and others on the team's work. It has three parts: the first summarizes key aspects of HIPC/PRSP processing and how the team has orga- nized itself to provide sectoral inputs into the process; the second part uses examples to elaborate on the analytical work that the team is developing to strengthen capacity - both within the Bank's HD family and in counterpart national teams -to work with macroeconomists and ministries of finance of- ficials in designing sector policy measures included in the HIPC/PRSP docu- ments; the third part of the report concludes with some thoughts on lessons learned thus far. 'The team is led by Jee-Peng Tan (Lead Economist, AFTHD); its members include Alain Mingat (Principal Economist, AFTH2), Agnes Soucat (Senior Health Economist, AFTH2), Shiyan Chao (Senior Health Economist, AFTHI, on a part-time basis), and Dandan Chen (Economist, AFTH1, on temporary assignment as a young professional). Three of the team members are part of the task forces that prepared the health and education sections of the PRSP Sourcebook. Mr. Mingat was already on board when the team was formally organized, while Ms. Soucat joined in Janu- ary 2000. The team gratefully acknowledges the Norwegian Government's financial support for a significant portion of its activities. Viii AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES 1 The HIPC/PRSP Process and HD Engagement in It This section identifies thze HIPCs and their cuirrent status vis-t-vis debt relief, and highlights selected aspects of the processing of the initiative, including the windows of opportunityfor policy intervention to tighten the link between debt relief and poverty reduction. It reports on thle progress to date in leveraging the process to advance social sector development, and elaborates on the team's efforts at capacity building. The countries involved and amount of debt relief after traditional debt relief, to $24 billion after HIPC debt relief, a reduction of 45 percent.3 Second, these A s of February 2001, there were forty-one highly countries' debt service obligations also shrink. For the indebted poor countries, thirty-three of them eighteen African countries in the sample, the reduc- -Aot in Africa (Figure 1). Of these, thirty-seven tion relative to the actualdebtpayments made in 1998- countries (thirty-one in Africa) have unsustain- 1999 will amount to a total of $0.6 billion a year aver- able external debts (defined in most cases as a situa- aged over 2000-03; and the reduction relative to the tion where the net present value of the country's debt debt service payment due will amount to a total of $1.8 relative to exports exceeds 150 percent), even after the billion a year averaged over 2000-03. The financial full use of traditional mechanisms of debt reschedul- impact of the initiative can also be appreciated in terms ing and debt reduction (e.g., under Naples terms, of other indicators: the debt service obligations of the where low-income countries can receive a reduction eighteen African countries relative to their exports is of eligible external debt of 67 percent in net present projected to fall from the 1998-99 average of 17.0 per- value terms).' As of February 2001, twenty-two of cent to an average of 8.1 percent during 2001-03; cor- these countries (eighteen in Africa) have passed the respondingly, debt servicing relative to the GDP is decision point under the Enhanced HIPC Initiative, expected to drop from 3.3 percent to 1.8 percent, while having been formally approved for debt relief by the debt servicing relative to government revenue is ex- Executive Boards of the IMF and the World Bank. Two pected to decline from 26.0 to 11.8 percent. countries, Ghana and Laos, have opted not to seek debt Taking the calculations over a longer time span, Table relief under the HIPC Initiative. Decision points could 1 shows the average annual difference in debt service be envisaged in the future for thirteen countries, obligations with and without the HIPC Initiative dur- twelve of which are in Africa. ing 2000-09 for the eighteen African countries con- The financial impact of the HIPC Initiative can be cerned; for contextual purposes, the table also includes assessed in various ways.2 First, it unambiguously re- data on the current levels of public spending on edu- duces beneficiary countries' stock of external debt. For cation and health in these countries. For most coun- the twenty-two countries that have reached their de- tries, the reduction in debt service obligation is large cision points thus far, the stock of debt declines from relative to current public spending on education and an estimated US$44 billion in net present value terms health; leaving aside the outliers (i.e., Benin, Guinea- 2 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Figure 1 Grouping of the Heavily Indebted Poor Countries Status as of February 2001 Decision point countres through February 2001 22 approved, 18 African 37 unsustainable cases / 31 in Africa 41 HIPCs /t X Future decision Doint countries 13 countries, 33 in Africa ~ 4 sustainable cases Afia _ 2 in Africa A \At government request not seeking debt relief 2 countries, 1 African Source: World Bank website at http://wwwl .worldbank,org/prsp/PRSP_Related_Documents/hipc_groupings.pdf; for a detailed listing of countres see Appendix Figure Al. Bissau, and Zambia), the reduction ranges from nearly A good start has been made by having countries as much as total health and education spending in benefiting from the HIPC Initiative commit to increas- Guinea and Mozambique, to around a fifth of the to- ing their public spending on health, education, and tal in Uganda, Burkina Faso, and Senegal, with the other services targeted to disadvantaged populations. other countries positioned in between. Based on plans reported in the HIPC documents, pub- The sizable reduction in debt service obligations pro- lic spending on social services in the eighteen African vides an important context for the debate on social countries is expected to rise from an estimated $2.5 sector development and poverty reduction. Many poor billion in 1999, to an average of $3.4 billion annually countries have explicitly identified high debt service during 2001-02, corresponding to an increase in spend- as an obstacle to providing basic education and health ing from 4.4 percent of GDP to 5.1 percent, or an in- services, and have argued that debt relief would help crease in spending from 29.6 percent of government them expand and improve the provision of such ser- revenue to 32.4 percent (World Bank 2001 cited vices. Conversely, as debt relief is provided, many con- above).4 How much the increase in spending would stituencies in creditor countries would like to ensure produce tangible progress in social outcomes clearly that the money thus freed would actually advance depends on how effectively the countries use not just social development and reduce poverty. Thus, for both HIPC relief but all public resources. Policy reforms to sides of the transaction, it is important to take advan- remove constraints on service delivery are therefore tage of the specific opportunities presented by the critical. In the sections below we elaborate on1 some HIPC Initiative to strengthen the link between debt key aspects of the debt relief process under the HIPC relief and improvements in social services and even- Initiative, and the instruments associated with it, in tually, progress in poverty reduction. order to clarify the opportunities for initiating and supporting the policy reforms needed to improve health and education outcomes. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 3 Table 1 Debt relief relative to social sector spending in eighteen African countries a, Annual reduction in debt Public spending, 1998 Country service obligations (millions of US$) Debt relief as % of social (2000-09) sector spending (millions of US$) Education Health Benin 2 68 30 2.0 ukina Faso 33 97 66 20.2 Cameroon 86 225 48 31.5 Gu"ies . 45 10 9Q.9 tunea-Sfsau - 34t 2 1 1133.3 Madagascar 52 77 30 47.7 Malawi 520/ 90 46 38.2 Mali 44 83 60 30.8 Mauritania 48 49 17 72.7 Mozambique 117 87 35 95.9 Niger 47bi 45 27 65.3 Rwanda 31 576 64.4' SD Tom & Princie pe 1.8 X_oegal 44 182 29 20.9 Talzanla 115 150 74 51.3 The Gambia 9b/ 9 6 60.0 Uganda 45 170 43 21.1 Zambia 176 54 36 195.6 Source: HIPC decision pointdocumentfor each country, fordata on the annual amountof debt relief. HIPC decision pointdocumentforMalawi, Niger, The Gambia, Madagascar, fordata on these countries'public spending on education and health; World BankAfrica Live Database for Guinea, Guinea Bissau, Zambia, Mozambique, Mauritania, Benin, Burkina Faso, for public spending on education and health; and World BankAfrica Live Databasefor Senegal for public spending on educaton and Mali for public spending on health. Vanous health and education sector studies for Cameroon and Tanzania's public spending on educabon and health; and Mali's public spending on education; and Senegal's public spending on health (forTanzania, thefigure foreducaton refers to the budgeted spending). a/ These are the eighteen countries that have already passed their decision points as of end-December 2000. b/ Annual reduction in debt services (2001-10). c/ The figure refers to overall social sector spending in 1998. d/ Debt relief as % of overall social sector spending in 1998. The debt relief process and policy levers decide on a country's eligibility for debt relief, and the international community commits to providing suffi- The process involves two key phases, the first cul- cient assistance by completion point for the country minating in the decision point, and the second in the to achieve debt sustainability as assessed at the deci- completion point. To reach the decision point a debtor sion point. country must have achieved a three-year period of After passing the decision point, a country enters satisfactory performance on the macroeconomic ad- the second phase and progresses toward the comple- justment and reform programs supported by the IMF tion point when the bulk of assistance under the En- and the World Bank. At the decision point, the Execu- hanced HIPC Initiative is delivered. During this phase, tive Boards of the IMF and the World Bank formally 4 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES the IMF and World Bank provide "interim relief" the government's plan for poverty reduction. Because while other creditors are generally expected to re- a full PRSP inevitably takes time to prepare, coun- schedule obligations coming due. The time it takes to tries often start with an interim PRSP, which sets out reach the completion point is not pre-specified (hence the government's commitment and plans for devel- it is called a "floating" completion point), but depends oping a full PRSP) at the time they reich the decision on the country being on track for macroeconomic per- point, and expands it into the full version in the sub- formance under IMF/World Bank-supported pro- sequent months. grams, and how soon it achieves various structural The HIPC decision point document and the PRSP policy reforms. At completion point creditors are free are two instruments with a potentially powerful in- to choose the modality for delivering their debt re- fluence on the poverty focus of health and education lief assistance, including up-front debt reduction or policies. In order to accelerate countries' progress to- debt-service reduction (e.g., Paris Club), debt-service ward debt relief, the completion point triggers speci- reduction (World Bank), or grants made available to fied in the HIPC decision point document typically service debt as it falls due (IMF). concern policy targets that can be achieved in a rela- For each country eligible for the HIPC Initiative, tively short time-frame, say betweeni twelve to eigh- two key documents formalize the process. The first is teen months. In contrast, the government's poverty the HIPC decision point document, a joint paper pre- reduction strategy is expected to stretch over a longer pared by the staffs of the World Bank and IMF for time frame and cover a broader reform agenda. The consideration by the Boards of the two institutions. difference in timing implies that the HIPC document It contains three types of information: (a) the is best used as an instrument for nudging forward country's record of macroeconomic adjustment and immediate short-term strategic reforms - reforms on structural and social reforms; (b) the medium-term which the government's poverty reduction strategy policy outlook; and (c) debt sustainability analysis and can then build. assistance.5 The specific conditions agreed upon with The promise of the HIPC/PRSP process lies in the the country for reaching the completion point are a fact that it brings together various perspectives that key feature, typically arranged under three headings, are essential to any poverty reduction strategy but "macroeconomic," "structural," and "social." Under which have not been sufficiently integrated in the past. the "social" heading is invariably the condition that In particular, the articulation of the policy priorities the country prepare a Poverty Reduction Strategy involves collaboration - on both the IMF/World Bank Paper (PRSP) and implement it for at least one year; side, as well as on the government side -among in addition, specific actions are often specified for macroeconomists and others working on broad struc- policies in health, education, and HIV/AIDS control. tural issues on one hand, and sectoral staff on the other. The PRSP is the second key document that formal- In addition, an explicit role is reserved for other part- izes the processing of the HIPC Initiative in each coun- ners in the fight against poverty, including represen- try. It describes the country's rolling three-year mac- tatives of civil society, non-governmental organiza- roeconomic, structural, and social policies and pro- tions, and the donor community. The interactions grams to promote growth and reduce poverty, as well should help enhance the link between sectoral reforms as associated external financing needs and major and broader actions on the macroeconomic front, as sources of financing. As such, it is expected to be up- well as create mutual accountability for results. dated regularly, with progress reports in the years be- These processes are still new and as such remain tween updates. The government is expected to take imperfectly structured for systematic and consistent responsibility for managing the document's prepara- contribution from sectoral staff, both at the World Bank tion (with technical inputs from Bank and IMF staff as and (even more so) in the health and education min- needed) as well as its dissemination to obtain feed- istries in the HIPCs. Acceleration in the debt relief pro- back through a participatory process involving civil cessing schedule adds to the difficulty because it in- society and other partners in the fight against poverty. evitably reduces opportunities for meaningful inter- Having the government take the lead is not only logi- action and consultation in the process. Within the HD cal but also essential to create national ownership for family, the implications of the HIPC/PRSP process for the Bank's country assistance strategy needs to be ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 5 more fully recognized and acted on, specifically in beyond simply looking at aggregate spending on edu- terms of the provision of timely and pertinent cation and health to examine how resources are in sectoral inputs to inform the process. A start has been fact used and managed. made with the creation of the HD HIPC/PRSP team, The challenge can be visualized in Figure 2, which with some progress so far for the work on health and shows the relation between indices of health and edu- education.' The integration of social protection issues cation outcomes relative to public spending. While the into the process has proved to be much more elusive, indices may not reflect all aspects of sector outcomes, however, reflecting the spread of such issues across the graphs nonetheless highlight the tenuous link be- many sectors within the Bank, and across government tween inputs of resources and outcomes, thus raising ministries. As the teething pains are overcome with questions about underlying differences in policies that experience in the health and education sectors, the have produced such widely different outcomes across hope is that the work would expand to embrace so- countries.7 The graphs in effect suggest that, in some cial protection issues much more systematically than countries, substantial risk exists that the extra resources has been possible to date. freed up under the HIPC Initiative would produce weak results at best if simply poured into the health Advancing Human Development in the context and education systems as they currently operate. To of HIPC/PRSPs improve outcomes would require significant efficiency improvements, so that the same resources can finance There are two specific avenues for action to advance services that reach more people, with better targeting the HD agenda in the context of HIPC/PRSPs: (a) spec- to the disadvantaged. In the inherently short process- f:ying appropriate short-term policy interventions as ing time frame of the HIPC Initiative, the completion conditions for a country to reach its completion under point triggers are best understood as a means for ori- the HIPC Initiative; and (b) providing technical inputs enting the health and education systems toward im- to support the design of the poverty reduction strat- proved delivery. As for the PRSPs, they are best un- egy paper by each country's government. To perform derstood as picking up where the HICP document both tasks effectively requires a reasonably solid un- leaves off, in that they articulate a more comprehen- derstanding of the health and education sectors - sive medium-term reform agenda and the correspond- their current performance, the sources of inefficien- ing expenditure framework, as well as specific progress cies and inequities in each sector, and potential op- and outcome indicators to guide implementation and tions for improvement. That understanding must also assess results. be one that is shared by the government, and must go Figure 2 Relation between public spending on health and education and sectoral outcomes, circa 1993 (a) Healti (b) Education 250 1 5 Ma on Maozasraq.. Ga bia S.uth -200 ROd 0a Gu.e.it.*rf,k. Jaacoa n Z-mcabwb Pth,.p ~~~~~~~~~~~~~~~~~~~~~ Mrd,~ ~ ~ ~~~~~~~a. is (, Ethipan aom a Equatcna Gui a10 Id--on o Syra Egypt ChiftragoayKea 150 ~~~offA" sdo M& bEcuador Caer Tog E 150 C4ngo DR Comas RConq 0-g Zamie Toga in Coi dfivra Lana Mn-cac tit~, Nbogoacor Togo 5) L hnenda Cete Ghan- TTenzana :) s Ghana L sotho Sierra ad g 5al a 100 S,=0 Ginna M.carbiqu 1i ya Q Burkina SOo 5To0 &Pnn-p. - iggt Ethiopia Cpa Vernt 50 _ 0 I_r -_ i 0 20 40 60 0 2 4 6 8 10 Per capita public spending on health (US$) Public spending on education as percentage of GDP 6 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Enhancing HD inputs for the design of completion HIPC/PRSP team continues to support task team lead- point triggers and PRSP follow-up ers in meeting the short-term needs of HIPC process- ing, it also directs its activities toward the long-term In light of the above challenge, the work of the HD task of guiding the preparation of CSRs as the oppor- HIPC/PRSP team is organized on two parallel tracks: tunity arises. The focus on long-term needs is ines- (a) helping task team leaders to mobilize readily avail- capable because the Bank has on-going relations with able data and information to provide immediate in- governments. As such the HIPC process is only an puts, as needed, for the preparation of HIPC docu- initial step, albeit an important one, in the broader ments; and (b) guiding the preparation of Country task of engaging countries in sector reform for pov- Status Reports on health and education to consoli- erty reduction, a task that includes follow-up on the date existing sector knowledge.' The goal of this work PRSP and preparation of possible lending programs is to lay the groundwork for engagement - both for public expenditure reform and poverty reduction. within the World Bank among macroeconomists and Table 2 Topics addressed in health and education Country Status Reports Health Education 1. Macroeconomic and socio-economic context 1. Macroeconomic and socio-economic context 2. Trends and equity in outcomes 2. Trends in enrollment and coverage of the education system 3. Household caring practices 3. Education finance 4. Health seeking behavior 4. Functioning the education system 5. Out-of-pocket expenditures 5. Education and labor market links 6. Health sector performance: efticiency and equity 6. Equity issues in education 7. Public financing of health 7. Management issues in education 8. Policy implications tor sector development 8. Policy implications for sector development sectoral staff, as well as between the Bank and coun- Content of Country Status Reports try counterparts - in the process of preparing and on health and education discussing the HIPC/PRSP documents. The ideal sequencing is first to prepare the status Given the policy-intensive nature of the HIPC/ report, discuss it with government counterparts, and PRSP process the most relevant contribution from collaborate with them on designing a broad agenda sectoral staff is to identify key policy measures to im- for policy reform and implementation -an agenda prove health and education services, especially for the from which the key measures could be extracted for poor Thus, the Country Status Reports are essentially inclusion as conditions for reaching the completion diagnostic documents to identify the sources of inef- point in the HIPC Initiative. In practice, the sequence ficiency and inequity in the way health and educa- typically unfolds in a less than ideal order because, tion services are financed, managed, and delivered. wiethe preparation and discussion of a Country Based on the materials developed for the PRSP while tepeaainaddsusoofaCury Sourcebook for health and education, the HD HIPC/ Status Report would inevitably take time, there are SPuream has henlth and one te HD by pressures to accelerate the debt relief process. None- PRSP team has taken the work one step further by theless, the preparation of a Country Status Report developing analytical templates as a practical ap- remains important, both to institutionalize sector proach to implementing the analysis. To illustrate the knowledge within the Bank as well as to provide an scope of the Country Status Reports, Table 2 lists the objective benchmark for tracking subsequent policy main topics they cover. development and dialogue. Thus, while the HD ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 7 Four key features characterize the CSRs: (a) they The preparation of the status reports follows an ad are structured around a standard core of issues re- hoc process adapted to country conditions, but typi- lated to equity and efficiency in the management of cally goes through three phases, with a changing com- public spending in health and education; (b) they rely position of the actors involved at each stage (Table 3). on existing sources of information and data; (c) they In the first phase, the focus is on getting as accurate are policy-oriented documents underpinned by solid and comprehensive a view of the sector as possible. analysis, rather than research papers; and (d) they are The work does not usually involve new data collec- intended as living documents, both in the sense that tion, but relies instead on the data already on hand, they will need regular updating to keep the informa- whether through recently completed surveys or ad- tion fresh, and in the sense that they are open to in- ministrative data collected by the Ministries of Health corporating new sector knowledge as it becomes and Education. Experience in many countries suggest available. The living-document approach is especially that these data are often available but are under-uti- appropriate in the context of tight budgets because it lized for lack of coordination and effort to pool to- allows the task of sector-wide analytical work to be gether the various data sets. Given the nature of the separated into smaller, more feasible pieces of work. work during this phase, the main actors will be World Table 3 Phases in preparing and discussing Country Status Reports on health and education Phase Activities and focus of the work Main actors involved a) World Bank team (HD HIPC/PRSP team + task Phase 1 a) Data collection, cleaning and analysis team leaders for health and education) b) Drafting of the country status report (CSR) b) National team (mostly technical ministry staff) c) Technical consultants a) Validation & dissemination of technical aspecs of a) World Bank team (including ro co the CSRa)WrdBkta ndd mocag) Phase 2 bo of poicJy optons and drafting of policy b) National team (mainly senor Minstry stall) b)Dscso of polyofosa daf fOc c) tMF, donor and other partner chapter of theP } ' p a) Broad discussion among government and civil a) World Bank team (including macro colleagues) society on policy directions for the sector b) National team (senior ministry staff + political Phase 3 b) Government commitment to specific policies, along leadership) with plan for implementation and monitoring of c) IMF, donors + other partners agreed actions. Organizing the work to build capacity Bank staff and technical personnel from the relevant The approach is to engage appropriate counter- government ministries. In the second phase, the focus shifts toward the pars- incldn Ban nd M aff, goen en policy dialogue and development, based on the diag- offiial, doors andothr patnes - t al stges nostic results. At this juncture, the composition of the of the work, and to collaborate in ways that help to n build local capacity and ownership for the final prod- actors on the country team shifts from technical per- uct. The process is labor-intensive, and works best sonnel to policy staff, with some overlap between the when managed to include relatively frequent field two groups. The time will also be ripe at this point to visits to interact with national counterparts involved bring donors and other partners into the picture, so in the work, as well as close coordination within the as to agree on the accuracy of the diagnostic results Bank and between the Bretton Woods Institutions, as well as to brainstorm about possible policy options. Although complex, this web of interactions is perhaps Finally, in the third phase, the dialogue shifts into the only way to create a shared vision of sector devel- even higher gear to involve the political leadership. opment, to ensure continuity in the dialogue on policy In weighing the likely options, the government reform, and, most importantly, to implement the con- focusses on those with three key characteristics: (a) cept of "putting governments in the driver's seat." 8 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES potential for large positive impact on sector develop- (both financial and human) and strong government ment; (b) feasibility of implementation; and (c) po- commitment, and they target "best buys" in public litical acceptability. During this phase, the dialogue health interventions -i.e., interventions that are both will widen even further to involve civil society in gen- cost effective and especially responsive to the needs eral. The idea is to develop broad ownership for the of the poor. These include increased immunization government's policy choices as well as to identify spe- coverage and utilization of bed nets, expanded aware- cific goals for implementation and benchmarks for ness of HIV, greater use of condoms in vulnerable monitoring progress. groups, and better essential health coverage, such as increased utilization of antenatal care and primary Progress to date health care (Senegal) and reduction of iodine and iron deficiency related illnesses (Mauritania). For some bet- Eighteen African countries have passed their deci- ter performing countries, the reduction in inequality sion points as of February 2001. How has the process of outputs between regions was also introduced as a been leveraged to reduce poverty and advance sector trigger (e.g., Benin and Mozambique). Most included development, especially in health and education? HIV/AIDS-related triggers with the notable exception What progress is being made to prepare health and of Zambia, despite the fact that the HIV prevalence is education Country Status Reports to facilitate the 20 percent among adults in this country. In other coun- Bank's engagement in the PRSP process? tries, such as Burkina Faso, similar triggers were pro- posed but not retained in the final document to limit the number of triggers imposed. HIV/AIDS triggers were often worded in general terms and often did not A standard trigger is the completion of the PRSP include specific targets in terms of outputs with the and a one-year period of satisfactory implementation exception of Malawi, whlich included an indicator on of the strategy. In addition, a few specific social sector availability of condoms and test kits to the users, triggers are typically included. These triggers vary Cameroon and Guinea Bissau, which included popu- lation base behavior change indicators, and across countries, with some focus on child immuniza- Matania, whior c ha keepin preva- tion for health (Table 4), and teacher recruitment and Mauritania, which committed to keeping HIw preva- pay policy for education (Table 5). Uganda had a pov- The secnt of level erty reduction strategy in place before the PRSP pro- The second type of triggers relates to health sector cess was formalized, and reached its completion point reforms needed to overcome obstacles that hamper the in April 2000 based on satisfactory implementation of performance of the health sector in most Sub-Saharan the strategy (as well as satisfaction of two other condi- African countries such as, inadequate staffing of ru- tions pertaining to macroeconomic performance and ral health centers and district hospitals; poor incen- assurances of other donors' participation in debt re- tives for health personnel to accept posting to remote lief. Burkina Faso had a full PRSP by the time the coun- areas (Burkina Faso, Cameroon, Mali, Niger, Uganda); try reached its decision point under the Enhanced and dysfunctional arrangements for drug procure- HIPC Initiative in June 2000. ment and supply (Mauritania, Cameroon, Burkina- Completion point triggers can be thought of as struc- Faso, Madagascar, Niger). Some of the triggers also encourage greater communitv involvement in co-man- tural reforms that need to be put in place in the short u i term to advance long-term sector development. Ac- aging and co-finanicing health service delivery cepting this view raises an obvious question: how well (Mauritania, Cameroon, Burkina Faso, Tanzania); does the choice of triggers shown in Tables 4 and 5 stronger partnership with the private sector in ser- fulfill this role? vice delivery (Cameroon); and progressive implemen- For the health sector, the triggers typically fall into tation of performance-based budgeting (Cameroon three categories: (a) increase coverage of public health and Burkina Faso). programs; (b) health sector reforms; and (c) health fi- With regard to the third category of triggers, it is nancing measures. The triggers in the first category important to note that in all the countries that have focus on areas where considerable progress can be been processed for debt relief so far, except perhaps achieved in a short time with additional resources Uganda, public spending on health is modest; and ENHANCING HUMAN DEVELOPMENT IN THE H1PC/PRSP CONTEXT 9 Table 4 Health sector measures to reach the floating completion point under the HIPC Initiative a, (Countries approved for the decision point as of February 2000) Increase coverage with essential Reform health systems Increase financing interventions 75 c 0) 0 0) 0 2~~~~~C a CD 0) = 0~~~~~~~~~~~~~~~~~~~~~ (a - -F : 2 ° E < < o5 -' a} 3 t OE c i 8 0 CL0 ' 0.2 E ( 2 c X2 o ~ ~ ~ ~ ~ o2" < a)~~~~~ Uganda"! Mauritania X X X X Mozambique X X X X X X Develop health sector strategic plan Tanzania X X Benin x x x x x Adopt monitoring & evaluation system o Burkina Faso X X X X Prepare decentralizaton action plan Senegal x X Increase primary heafth care Senegal X ~~~~~~~~~~~~~~~~~~~~~~~~~~~~utlization Cameroon X X X Mali X X The Gambia X X Guinea X X Guinea-Bissau X X X Madagascar x Prepare bi-annual report on budget aRocation and execution Malawi X X X X X Niger X X x x Improve infrastructures; adopt and Rwanda x x x impement national health plans; and establish pubk, private, and NGO health providers cooperation. Sao Tomr' and x Construct health care centers Principe Zambia x x x Improve quality of health expeniture Source: Summary based on the decision point documents foreach country. al At the floating completion point the bulk of assistance for debt relief under the enhanced HIPC Initiative is delivered. b/ For Uganda (which reached its completion point in April 2000) no sector-specific conditions were specified for reaching its completion point. donors, households and communities make signifi- the adverse effects are exacerbated by inefficiencies cant contributions to health financing. Despite these in disbursement mechanisms. Indeed, many health extra budgetary sources of funding, the health sys- systems appear to be over-funded in terms of exter- tems of these countries suffer from inadequate fund- nal investment while being under-funded in terms ing for salaries and non-salary recurrent costs, and of recurrent costs financing. Increasing the health 10 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Table 5 Education sector measures to reach the floating completion point under the HIPC Initiative (Countries approved for the decision point as of February 2000) Improve education finance Address teacher issues Enhance coverage & student flow E Z) 0 0 : Si; f ; D , 07:; i; J 0 i eo:) c . , $i) e= e 2E >W .t 0 CC 0O)C , 2 2 -u a- :: 75~ ~~~~n *> ci)o C 0 Mauritania i 0 0 X X 0 0 0: ;; 0 t 0: 0 00Mozambique X E 0 0 0 X X : 0 :; 0 0 0 0 0 0 E C Tanzania:Cmlt scoo ¢ n mappng n 0% k~~~~~~~~a - -F S = >;:; N ):E+; SA;i : Bein X X X F- : 0 -- :6 cm ::co : f:: ':o 0 BurRina Faso 0 X ; :: X ;Prepare decentralizatEon ation Ul~~~~~~~~~~~~~~~~~~pa Senegad X Xb tCamnercon :X ; X Cosrc datl ssroofnas 0i Malu it: impleentation of PROEC, :; V ; 0 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~govt.'s 10 year de:. progam ;: 0 TGamnbia X n X50 Guinea X X 00Guinea-Bissau; X tf:00:X 00;;;; g;t ;5000 t Prepare bmitannual reportion BMadgascar X X b & execution tiMalawi; Imrv X grp handling of textbook Seriegal x x~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~itrbto Cgeron X construct classro ms;cp school mdappig Etblish f3ramwr for GRwanda X : pd*eia0 a;buidkb pongra S&o TPnhe and X :Constructaoosc-onipiet : | 0000:; 0 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Prepare actionplan fo raise ;000 Zabia X X survival ates in ging f i ; 0 ~~~~~~~~~~~~~~~~~~~~~~~~~~~provinces i;gt d:0 ::0f 0C:0 Source: Based on the decision point documents for each country. a/ At the floating completion point in the bulk of assistance for debt relief under the enhanced HIPC Initiative is delivered. b/No sector specific triggers were specified for reaching the completion point. c/ Gross enrollment ratios, share of girls' in total enrollments, transition rate from primary to secondary school, and so on. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 1 1 sector's share of the government's budget has there- schools. In Guinea, where enrollments are projected fore been included as a completion point trigger for to expand rapidly, the trigger aims mainly to ensure some HIPCs. Increasing the share of funding going an adequate pace of teacher recruitment. Although to services that serve the poor has also been included teacher availability in rural areas is a problem in most in some countries. In the Gambia, the trigger included of the countries, the completion point triggers specify increased financing for primary and secondary care the provision of incentives for rural postings in only services, and in Zambia increased cash release for two countries, Madagascar and Zambia. Finally, under health activities to the districts In Benin, the triggers the broad rubric of addressing teacher issues, a trigger specify budget allocation targets for HIV/AIDS and is included in four countries - Cameroon, Gambia, reproductive health activities. Such specificity was not Malawi and Rwanda -on the volume of teacher train- possible in other countries, however, because the avail- ing activities. able information was insufficient to identify areas where The third set of triggers relates to coverage of the edu- increased funding would be a clear priority. cation system and student flow indicators. In For the education sector, the triggers tend to focus on Francophone Africa especially, many of the education three areas across countries: education finance, teacher systems suffer from inordinately high rates of repeti- issues and coverage, and student flow. With regard to tion and dropping out. Where the background analy- education finance, the triggers concentrate on public sis is clear, such as in Mozambique, Benin, Burkina Faso spending and its allocation. In Mozambique, Mali, and Niger, the completion point trigger is tied to spe- Malawi, and Zambia, a trigger is included to increase cific action for improvement, often including the elimi- the share of current spending allocated to education, nation of grade repetition within sub-cycles of school- while in Senegal the trigger pertains specifically to ing accompanied by measures to equip teachers with increases in the allocation for primary education only. tools to improve the management of pupils' progres- In Malawi, a trigger is also included specifying a real- sion within the sub-cycle. Although low rates of stu- location of spending in secondary schools from board- dent survival affects most of the countries, in only ing services to pedagogical materials. Surprisingly, in Mauritania was a trigger included that focused spe- only two countries, Benin and Guinea-Bissau, do the cifically on this issue. In five countries, the triggers triggers seek to reduce or eliminate school fees or other relate to more aggregate indicators of coverage, such school-related spending borne by families, and in only as the gross enrollment ratio, girls' share of enroll- one country, the Gambia, is a trigger included to pro- ments, and the transition rate from primary to second- vide scholarships to target populations. ary education. With regard to triggers addressing teacher issues, To summarize, the quality of policy triggers is un- the most common ones relate to teacher recruitment even across countries, reflecting a corresponding un- and deployment. These triggers respond to the well evenness in sector knowledge at the time the HIPC known problems in many of the eighteen countries, decision point documents were prepared. In educa- especially in Francophone Africa, associated with the tion, for example, it is unclear that an increase in pub- high cost of teachers and their uneven availability lic spending on education in three of the countries in across schools, particularly in rural areas. New ar- the sample - Mozambique, Mali, and Malawi- rangements for teacher recruitment -such as con- would enhance outcomes, given that in all three coun- tracting with local communities outside the civil ser- tries, there is evidence that the education system func- vice - have been under experimentation with suc- tions with a high degree of inefficiency (see Figure 1), cessful results. Thus, in four countries -Benin, implying that any additional spending is likely, in the Burkina Faso, Senegal, and Mali - a trigger is in- absence of significant improvements in system man- cluded to facilitate the transition from experimenta- agement, to produce waste instead of the expected tion toward institutionalization of the new arrange- results. Tanzania is another example where the trig- ments. In Madagascar, where teacher shortages in ger for completion point - implementation of a primary education and their deployment across school mapping exercise in some districts of the coun- schools pose special difficulties, the completion point try - seems dubious as a way to advance sector devel- triggers focus on increases in numbers of teachers opment. Fortunately, as sector knowledge is built up in recruited and the criteria for their allocation across the meantime, possible shortcomings in policy design 12 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Table 6 Completed and planned interim and full PRSPs for African countries Interim PRSPs Full PRSPs Completed Planned in 2001 Completed Planned in 2001 (as of February 2001) Pandi201(as of February 2001) Benin Congo (Rep. Of) Burkina Faso Benin Cameroon C6te d'lvoire Mauritania Chad Central African Rep. Eritrea Tanzania The Gambia Chad Ethiopia Uganda Ghana The Gambia Lesotho Guinea Ghana Nigeria Guinea-Bissau Guinea Sierra Leone Kenya Guinea-Bissau Malawi Kenya Mali Madagascar Mauritania Malawi Mozambique Mali Rwanda Mauritania Senegal Mozambique Zambia Niger Rwanda Sao Tome and Principe Senegal Tanzania Uganda Zambia 21 7 4 14 Source: http://www.worldbank.org/prsp can be corrected as the PRSP process unfolds. Such tance strategies (CASs, which are the equivalent of busi- knowledge would also facilitate expansion of the re- ness plans) and are treated as such in the Region. Thus, forms that the government undertakes beyond those that even countries like Kenya and Ghana, which do not fit within the inherently narrow and short-term frame- currently expect to benefit from debt relief under the work of debt relief processing. HIPC Initiative, have prepared interim PRSPs. As of February 2001, a total of twenty-one African coun- tries have prepared an interim PRSPs, with seven more Preparation of Poverty Reduction Strategy Papers planning to prepare one in 2001 (Table 6). Four coun- tries-Burkina Faso, Mauritania, Tanzania, and These papers are a natural follow-up to the HIPC de- Uganda -have completed a full PRSP, while fourteen cision point document, but unlike the latter, the gov- plando s duin 2001. a is the fhe aon ernmens themelves withtechnial inpts, a plan to do so during 2001. Uganda is the furthest along ernments themsean/lvestaffand withotehnicals ipts, asv in the process, and has already prepared a first-year needed, from Bank!IM staff and whomever else the gov- progress report since its full PRSP was completed a eminment wishes to involve -prepare them. Recogniz- ing that the authorities may need time to prepare a full year ago. Given the typically compressed time frame for preparing the interim PRSPs, the content and coin- PRSP and to organize the process of participatory con- preteesno the documents var widely aco cou- sultation, the Bretton Woods Institutions have agreed to tries, wt the forsme curies fcusi mainl accept interim documents at the time of the decision on setting out specific plans and timetables for pre- point, in the expectation that the full PRSP would be completed and the strategy articulated in it would be paring the full PRSPs, using a participatory approach. In contrast, the full PRSPs are expected to be more com- implemented for at least one year before a country can re ecompletion point in the debt relief process. prehensive, typically including a documentation of the reach be completion point trief prSPss. profile of poverty, as well as the government's long-term Besides being a completion point trigger, PRSPs serve vision for poverty reduction, specific measures over the a broader purpose for Bank operations -namely, they next three years to implement it, and the corresponding are the logical basis on which to build country assis- budget provision and monitoring indicators. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 13 Table 7 Preparation of health and education Country Status Reports in the Africa Region (Status as of February 2001) Status of the work Health Education Benin, Burkina Faso, Madagascar, Mauritania, Completed Burkina Faso, Madagascar, Tanzania Mozambique, Niger Advanced stage Guinea, Mozambiue, Maurftania Cameromn Zaniba, Gunea-Bissau, Sao Tom6 & Principe Underway Benin, Cameroon, Chad, Guinea-Bissau, Gabon, Guinea, Gambia, Togo Malawi, Mali, Niger, Zambia, Uganda Ps st6 sts Wet d'lvoire, CAR, Ethiopia, Ganbia, Senegal Chad, Mali, Rwanda, Ethial, Seega While it is beyond the scope of this paper to delve PRSP noted that most of the outcome targets in health into the details of the four full PRSPs completed so far, and education were not met, explained why the targets a few key features are noteworthy (see appendix tables were not met, and identified specific areas for attention A1-A12). As expected, interventions in education and in the coming year. An interactive process informed by health typically figure in the overall framework for candid annual assessments of achievements and con- poverty reduction under such rubrics as improving straints on progress could indeed help countries to move human capacities, social well-being, quality of life, and toward realizing their long-term outcome targets. access to basic social services. But in some countries, investments in education also figure under other ru- brics of the governments' poverty reduction strategy. o i In Uganda, for example, interventions in higher edu- Since PRSPs are country-prepared documents, the cation appear under the economic growth rubric, while most effective way for the Bank to contribute is by pro- in both Uganda and Mauritania, interventions in vo- viding high value-added technical inputs that can help cational education and training appear under rubrics deepen the dialogue - between donors and the gov- having to do with enlarging poor people's capacity to ernment, as well as between the government and its in- raise their own income. In all four countries, HIV/AIDS country partners in development - on policy priori- is treated as a health issue rather than as a constraint ties for poverty reduction. HD Country Status Reports on economic growth. (CSRs) are a practical mechanism for providing such With regard to content, the PRSPs of the four coun- inputs. They essentially aim at creating, consolidating, tries invariably focus on outcomes. In health, common and organizing sector knowledge in a policy-oriented outcomes include the mortality of children and framework. As such, they serve not only as a basis for women, the burden of communicable diseases (espe- informing the design of completion triggers in the deci- cially HIV/AIDS and malaria), while in education they sion point document but, more importantly, also as a include various indicators of enrollments, and school- basis for assessing governments' poverty reduction strat- ing conditions (e.g., ratios of pupils to teachers, text- egies and for engaging in the subsequent policy dia- books, and classrooms). The strategies of Mauritania logue as it unfolds in the context of the annual progress and Burkina also include an explicit objective to pro- reports. tect the poor from overly burdensome health spend- As a mature international development agency, the ing. The focus on outcomes marks a salutary change Bank should in theory have the intellectual resources from past approaches to development efforts. Even needed to prepare HD CSRs on short notice. Yet, our though most of the PRSPs share an understandable knowledge base has been eroded because of inadequate tendency to set highly ambitious outcome targets, the past investment in analytical work. In addition, the in- iterative nature of the process implies that plans can be stitution is poorly positioned to take advantage of avail- adjusted as unforeseen constraints are discovered dur- able knowledge residing in country sector reports com- ing implementation. The experience of Uganda, the pleted by the countries themselves, or by other donor country with the most mature process so far, is instruc- agencies and academics. Part of the problem is that the tive in this regard. The first-year progress report on its information is typically fragmented or hard to access, 14 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES and sometimes dated, but the broader problem relates to Progress in capacity building issues of funding and incentives to get the work done. Building up the stock of CSRs was initially motivated The HIPC/PRSP process has created significant op- by the demand for sector inputs in HIPC processing; portuniities for building capacity through joint learn- but they also serve as a modest start in redressing the ing-by-doing. At the country level, the formation of Bank's pastneglect of sector workin health and educa- working groups on health and education is the first tion. step in the government's work of elaborating the PRSP Table 7 reports on the current status of CSR prepara- While their composition vary, these groups typically tion supported by the HD HIPC/PRSPS Team in various consist of senior managers of the line ministries as well African countries. The choice of countries is driven in as budget and policy analysts from the ministries of part by the debt relief processing schedule, but it is of- planning and finance. They sometimes include observ- ten also the result of several facilitating factors coming ers from donor agencies, and even representatives of together: timing, availability of funding, readiness of NGOs and other civil groups. In Cameroon, for ex- national counterparts to participate in the preparation ample, NGOs were consulted in the preparation of the of the report, as well as interest and commitment on the AIDS strategy, openinig the way for future collabora- part of the relevant Bank country team in having it pre- tioni between the governlment and NGOs, including pared. Because CSRs take time to prepare, they should the involvement of NGOs in specific activities under ideally be started well ahead of HIPC/PRSP processing. subcontracting arrangements. The Bank supports the But the realities of budget constraints and logistical ob- work of these working groups by sharing technical stacles are such that the reports are in fact being pre- resources (such as the PRSP Sourcebook, which is now pared as conditions permit. widely available via the internet, as are related tem- Table 7 indicates that some CSRs have already been plates for structuring the work in education and completed. It is important to note that completed docu- health), and by collaboratiing with members of the ments may not necessarily address all aspects of the group in preparing the CSRs where this has been cho topics for which documentation would be desirable; sen as the mechanism to consolidate sector knowledge. rather they represent the first round of work to amass Opportunities also exist for closer collaboration and structure the available information in a policy- among the BanKs development partners, including oriented framework. Where the information is plenti- bilateral donors and international organizations, such ful, and the work has had time to mature, the CSRs as WHO, UNICEF, UNAIDS, UNFPA, AfDB. This col- are more comprehensive, such as those for education laboration has meant increased support for the work- in Burkina Faso, Mauritania, Mozambique, and Mada- ing groups, as well as dialogue on (a) a common un- gascar. In contrast, most of the work on health started derstanding of the underlying analytical frameworks later, and the completed CSRs represent the results for assessing the link betweeni education and health of a first generation effort based on data that were and poverty reduction; (b) lessons from various ef- possible to gather in a brief period. As living docu- forts to improve service delivery (e.g., efforts to re- ments, CSRs are a repository for sector knowledge, form and reorganize the health sector in Sub-Saharan whose core content should ideally be updated peri- African following the Bamako Initiative, and to ac- odically to incorporate new country data or informa- celerate public health programs such as EPI, Family tion. In the time-sensitive context of the HIPC/PRSP Planning and Safe Motherhood, Polio Eradication, etc.); processes, the value of the CSR depends as much on and (c) the design of sound pro-poor strategies in the its availability on demand as on the comprehensiveness hiealth anid education sectors that take advantage of debt relief to reinfor-ce the donior comMiUn1itV'S efforts to) en- of its coverage. Thus, in this initial phase of creating a systematic knowledge base, the emphasis is on produc- sure increased fun dinig for the social sectors in Africa ing relatively simple CSRs that address basic issues of (through such initiatives as Roll Back Malaria, Stop TB, efficiency and equity in the management of public spend- GAVI, Massive Attack, Education for All). ing on health and education. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 15 Within the Bank, the HD HIPC/PRSP Team has also supply in Burkina Faso, poverty-related activities, such as de- mining and rural development in Guinea-Bissau, poverty reduc- initiated capacity building activities, beginning with a tion programs in Mauritania, promotion of women in Senegal, two-day training workshop in October 2000 on Health, water supply in both Tanzania and Uganda, and social safety Nutrition, and Population (HNP) issues in the HIPC/ nets, water and sanitation, and disaster relief in Zambia. These broader definitions explain the difference between the estimated PRSP context. Plans are underway to organize, in col- $2.5 billion indicated here, compared to the total of $2.0 billion laboration with the HD Network, similar training for for education and health shown in Table 1. educationsector*stff in theBank. Theidea of replicat- 5 A preliminary HIPC document is typically prepared before the education sector staff in the Bank. Thle ldea of repllcat decision point document, but for some countries this step has ing the training in regional workshops in Africa has been eliminated in order to expedite processing of the initiative. been explored but is being deferred at present because 6 To be emphasized is that the health and education task team lead- ers for each country are the primary sectoral contacts for matters of the prohibitive costs involved, especially in terms relating to HIPC/PRSP processing for the country. The HD of Bank staff time.9 HIPC/PRSP team was formed to support the task team leaders in this regard, as well as to enhance regional consistency in the quality of the HD inputs. 7 See Appendix Table A13 for examples of other health indicators that may be relevant for cross-country comparisons. 8 A Country Status Report of reasonable depth may take six months 1 The Executive Boards of the IMF and World Bank had al- or more of real time to prepare. ready formally considered nine (seven in Africa) of the 9 Following the HNP training session, the UNICEF and WHO rep- thirty-seven countries for debt relief before the Enhanced resentatives who attended the training expressed their in- HIPC Initiative was put in place. stitutions' interest in co-organizing similar training in regional 2 One perspective is the cost of debt relief to the creditor na- workshops for country teams (comprised of key policy ana- tions. The most recent estimates, made in September 2000 lysts and decision-makers from the ministries of health and for the thirty-two HIPCs for which the relevant data are finance/budget in various countries) from target countries. available, put the Initiative's total cost at US$28.6 billion (in Recognizing the potential of the workshops for sharing end-1999 dollars). knowledge and building the capacity of country teams to ana- 3 For more details, see World Bank 2001. "Financial Impact of lyze health and poverty issues using available data for their the HIPC Initiative. First 22 Country Cases." Mimeo, also country, UNICEF and WHO are prepared to help organize available at http://www.worldbank.org/hipc/ and finance the workshops, provided that the Bank is willing 4 While social services invariably include health and educa- to fund Bank staff to prepare the training materials and par- tion, the data's coverage beyond these sectors may differ ticipate in the workshops. across countries. Thus, social sector spending includes spending on new programs to be financed partly with HIPC assistance in Benin, rural development and water 2 Strengthening the Content of HD Inputs to the HIPC/PRSP Process In both the health and education sectors, a basic assumption is that the resources freed from debt rclief wouild bie utsed to enhance and improve the delivery of basic services, especially to the poor. What policy measures canl advance this agenda, and how can progress be tracked? Diagnosing the current statits of sector performanice anid souirces of poor outcomiies is a first step toward answering these questions. The work.forms the substance of the Country Status Reports discuissed above. This section provides examples of the kinds of analysis undertaken in this regard. Policy-relevant analytical work in health' as among the very rich. Health indicators also vary substantially across regions and across urban and ru- he examples relate to the following topics, all ral areas. In the context of preparing the health bud- T of which can be analyzed using data commonly get for 2000-01, the information is being used to jus- available in most African countries: (a) inter- tify the following decisions: (a) setting a reduction in actions between health and poverty; (b) house- regional inequities in under-five mortality rates as a hold behavior and the health of vulnerable popula- key policy objective; and (b) concentrating the bulk of tions; and (c) evaluating health system performance. additional spendinig on health to improve primary health care services and nutritioni activities in the poor- est rural areas. Assessing health outcomes among the poor In some countries, analysis of data from demo- The purpose here is simply to document the extenit graphic and health surveys can reveal the importance to which the health, nutrition, and family welfare ou t- of factors other than household wealth in affecting the comes among the poor differ from those among the health of the poor. In Burkina Faso, for example, health better-off. Data are increasingly available for this pur- indicators are not correlated with income inl an incre pose, disaggregated not only by socioeconomic char- mental way (Figure 4). The pattern shows a large gap acteristics, but also by relative income or wealth level, between the richest 20 percent and the remaining 80 In many African countries Demographic and Health percent of the population. Other determinants beyond Surveys (DHSs), for example, have been completed income, including environmental and household be- (with repeat surveys in some cases), which periilit lhaviors, probably also influence the health of the popu- documentation of the gaps in outcomes between the lationi. These factors will have to be further explored documentation of the gaps intakn outcomesn if he gverbetweensto the rich and the poor, thus giving policy makers informa- and taken into account if the government is to make a tion to evaluate the targeting of health resources to difference to child health outcomes. reach the poor.2 Data from Mali provides another example of the In Cameroon, this type of analysis shows that in- impact of environmental factors on the health of the fant and under-five mortality rates are highly corre- poor (Figure 5). The rate of diarrhea and respiratory lated with income (Figure 3), with under-five mortal- infections among children -ailments linked to the ity among the poorest groups more than twice as high qtuality of water supply, sanitation, and air -is com- ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 17 Figure 3 Infant and under-five mortality by income group, Cameroon 1998 2 5 0 5 2000 0 Source: Government of Mali, based on "Health and Poverty in Mali" (background document for the PRSP), draft 2000. mothers and urban residents have poorer health-seeking behavior-because of poverty or breastfeeding practices than those in lower socioeco- other factors - may constitute as much of an obstacle nomic groups; their care of children with diarrhea to better health as supply-side constraints in the also does not appear to be superior to that offered by health system. Evidence from household surveys are mothers in the latter groups (Table 7). In contrast, bet- increasingly making it possible to examine the role ter educated men and those who live in urban areas of self-selection, thereby permitting ministries of are much more likely to have used condoms than other health to take more systematic account of them in men. This kind of analysis can help to identify areas health planning and policy formulation. of health care practices that may need specific em- phasis in public health policy design. Evaluating the performancce of the health system IMPACT OF HEALTH SPENDING ON INCOMES OF THE POOR. One approach to assessing the extent to which Living on small incomes, poor people may decide to health services serve the poor is to evaluate the health accept the pain and discomfort of sickness rather than system's performance on a matrix of indicators - in- incur the out-of-pocket expenses of health care that cluding access to basic services, availability of human may bring economic ruin. Thus, even though poor resources, availability of drugs, vaccines and other es- households are generally less healthy than rich house- sential consumables, production of services, and con- holds, they may spend less on health services, in both tinuity of care and quality of services. The discussion absolute and relative terms. This is the pattern in below focuses on access to a core package of health Burkina Faso (Table 8) - a result that is consistent with services, the availability of human resources, and the observation in Sub-Saharan Africa that the poor evaluation of service delivery bottlenecks. often do not use modern health care services at all, whether public or private. The implication is that, in formulating health interventions to reach the poor, it ACCES t core PACiAG O He SERVICE BY THe needs to be recognized that adverse self-selection i ePOOR. Most countries define a core package of services based on the burden of diseases affecting the overall ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 19 Table 8 Household health care practices, Guinea 1999 Educational attainment of respondent Locality Health care behavior None Primary Secondary Rural Urban Average duration of breastfeeding with 6.4 3.7 0.6 6.4 3.8 water only (in months) % treating diarrhea by increased intake of 51.7 61.4 55.4 51.4 57.9 fluids % of men having ever used a condom 17.4 44.9 64.5 22.8 56 Source: Government of Guinea, based on "Health and Poverty in Guinea" (background document for the PRSP), draft 2000. population and the demand for health care. This pack- enough to justify a visit to a health center. This type age needs to be revisited in light of the specific bur- of analysis is important for understanding the key den of disease among the poor as well as evidence on factors that limit the demand for essential services the best buys in health care. The review can help iden- and, therefore, in formulating interventions that re- tify the need to add new interventions (e.g., micro- move the impediments to better health among the nutrient supplementation), while at the same raising poor. questions about interventions included previously (e.g., cardiologic services). In most low-income coun- AVAILABILITY OF HEALTH PERSONNEL. In many Sub-Sa- tries the best buys listed in appendix table A14 would haran African countries, essential health staff, such as have to be part of the core services targeted to the poor. multipurpose obstetric nurses and surgeons, are in Once there is clear agreement on the components critically short supply - a problem that particularly of the core package of services, it is important to ex- impedes delivering services to rural areas. The situa- amine the pattern of accessibility and use by the poor. tion in Niger is common: there is currently one medi- In Burkina Faso the utilization of essential services - cally trained staff for 400 people in Niamey, the capi- including vaccination, ANC, and assisted delivery - Table 9 Out-of-pocket health spending in Burkina Faso 1998 Rural areas Nationwide Urban areas Average North Other rural Per capita spending In Fcfa 4,900 9,490 3,000 1,300 2,250 to 3,700 In US$ 8 15.8 5 2 3.8 to 6.2 % of income spent on health 10 14 9 - Source: Government of Burkina Faso, based on 'Health and Poverty in Burkina Faso" (background document for the PRSP), draft 2000. varies widely across socioeconomic groups, a pattern tal city, compared with a ratio of more than 4,000 in that does not mirror the pattern of mortality but ap- the most deprived provinces of the country (Figure pears to reflect gaps in the supply of services to the 7). The poor distribution of staff reflects in part the poor. Closer examination of the problem reveals that effects of a civil service pay structure that pays health about a quarter of the nonusers had been discouraged personnel the same pay and benefits regardless of from using basic health services because prices were where the person serves. But the pay structure is not too high (Figure 6). Other reasons included distance the only problem; the difficulty of attracting staff to and a perception that the diseases were not serious rural areas has also been exacerbated by the recent 20 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Figure 6 The shortage of qualified staff is a prob- Reasons for non-utilization of basic health services in Burkina Faso 1998 lem that plagues almost all health sys- tems in Sub-Saharan Africa. While hardly any system has yet found a com- 9.3% Other 4.4 % Distance prehensive solution to address it, gov- ernments have experimented with inno- 24_4 i Price IIiIvative approaches, including using staff 24 4 % Hleb Price with different technical profiles (e.g., aux- iliary midwives), decentralizing recruit- 33.3 % Self Medication ment, offering financial incentives to staff who accept postings to remote and __ I l idifficult areas, remunerating staff ac- - - l / cording to performance, and even imple- menting civil service reform. Consolidat- 28 6% Not necessarv ing the lessons from these experiments and mainstreaming the promising ap- Source: Government of Burkina Faso, based on "Health and Poverty in Burkina Faso" proaches is critical to successful imple- (background document for the PRSP), draft 2000. proatis critic health ims, mentation of public health programs, explosion of private services, a development that has particularly in terms of their reach to tar- expanded the opportunities for public health staff to get populations. Without progress on this front, it is supplement their income in private clinics in the cit- hard to see how increased funding for health - fund- ies. As a result, it has become harder and harder to ing which is expected to become available in the HIPC/ attract staff to rural areas where this source of extra PRSP context -can be effectively absorbed to pro- income is nonexistent. In Benin, a study shows that duce genuine progress in health service delivery and the privatization of health services had led to a wid- ultimately in the health of the poor. ening urban-rural gap in staffing patterns, with health staff crowding into the capital city and into EVALUATING BOTTLENECKS IN SERVICE DELIVERY. The wealthy localities where the population is more able to health system can be evaluated for bottlenecks by track- pay for services. ing the delivery of specific pro-poor outputs -for ex- ample, immunization visits, vitamin A supplementation, Figure 7 Population per medically trained personnel by region, Niger 1997 4500 4000- 3500-'-um 3000- _. e2500- 2000- 1500- 1000- oj t)500 ,E 0-. r Source: Government of Niger, based on "Health and Poverty in Niger"(background document for the PRSP), draft 2000. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 21 visits for treatment of ARI, IMCI, full treatment of as the starting point for evaluating options to enhance TB, access to impregnated bed-nets, and treatment for the poverty-reducing impact of education policies. By malaria. Beyond aggregate patterns, it is also reveal- implication, this means documenting the grade-to- ing to examine the extent to which poor people ben- grade pattern of student flow. efit from continuity in health care (e.g., TB treatment To see the advantage of using grade-specific pro- courses finished, children fully immunized). For ex- files, compare two countries, Senegal and Chad, ample, simple indicators for immunization would be whose gross enrollment ratios in 1998 were 62 and 65 disparities by socioeconomic group in the dropout respectively. The similarity in the ratios hide wide dif- rate for immunization between DPT1 and DPT3. Es- ferences in the underlying pattern of student flow; pecially revealing are analyses to ex- amine the gaps across different as- Figure 8 pects of service delivery. In Maurita- Comparing service provision gaps for IMCI, Mauritania 2000 nia, this type of analysis for IMCI sug- gests that the largest bottleneck is lo- > 80 cated at the level of access (Figure 8), X 70 closely followed by constraints in the *u 60 availability of drugs and health per- , 50 sonnel. This kind of structural analy- 0 40 sis can be conducted across localities K 30. and socioeconomic groups to identify = 20 bottlenecks and possible options in 10 targeting actions for improving ser- 0 vice delivery. 0, Policy-relevant analytical work in v education Source: Government of Mauritania, based on "Health and Poverty in Mauritania" The examples below illustrate se- (background document for the PRSP), draft 2000. lected analytical approaches to docu- ment education sector outcomes, and evaluate poten- however, in Senegal 65 percent of each age cohort en- tial sources of inefficiencies in the management of ter grade one, and 40 percent of the entrants reach public spending on education, the end of the cycle, whereas in Chad the correspond- ing figures were 83 and 19 percent. These differences call for quite different approaches to expanding cov- erage: in Chad there is a clear need to improve sur- Gross or net enrollment ratios by level of educa- vival rates within primary schooling, while in Sene- tion are a common measure of coverage. The former gal, improving entry rates to grade one deserve as is defined as the ratio between total enrollments in a much emphasis as improving the survival rate. given cycle of schooling and the population in the of- Documenting student profiles across population ficial age range for that cycle; the latter ratio is com- groups within a single country can provide even more puted the same way, except that the numerator in- useful insights for policy development. In Mauritania, cludes only students in the official age range. Despite for example, the conditions for reaching completion their popularity as indicators of coverage, they tend point specified in the HIPC decision point document to obscure the nature of the problem, largely because refer to targets in the gross enrollment rate and share they refer to averages across all grades in a cycle of of girls in total enrollments. In aggregate terms, the schooling when what is needed is a more disaggre- gross enrollment ratio is relatively high at 86 percent, gated pattern of coverage. For this reason the World and girls already account for nearly half of total en- BanKs PRSP Sourcebook recommends focusing on the rollments. Subsequent analyses completed after HIPC enrollment rate in the final year of the primary cycle processing reveal that a high rate of repetition (aver- 22 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Figure 9 Disparities in student flow profiles in Mauritania 1998 100 00. 90 90_ 80 so 70 70 60 60 ----- ----------60Lr. girls c,s 60 > = 0 ' 0 0 00X00000X2\ -R~~~~~~~~~~~~~~~~~~~~~~~~Ur. boys 50 - __ _ _ 2 40 Ru. girls 30 30 20 _ Boys 20 10 - . Girls 10 0 o-~~~~~~~~~~~~~~~~~~ 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 Grade Grade Source: World Bank & Mauritania Education National Team, Le systeme 6ducatif mauritanien: Elements d'analyse pour instruire des politiques nouvelles (forthcoming). aging 16 percent) is partly responsible for the high Demand-side and supply-side constraints gross enrollment rate, and that much work remains on enrollments to be done to boost effective coverage. Raising the co- Student flow profiles alone are not sufficient to de- hort survival rate is indeed the most important policy term thrust needed to expand primary school coverage, andmeaporteievninsfrmrvmn. Additional analysis is needed to examine the relative efforts are especially needed to lift up the rate among roles of demand-side and supply-side constraints. Some rural boys and girls (see Figure 9). simple approaches can be applied to existing data to Computing the student flow profiles requires a shed light on the issue. In Mauritania, for example, blend of two types of data: (a) survey information on of the 45 percent of pupils who drop out before reach- enrollment status by single years of age for primary school age children, to fix the rate of entry to grade the enduof the yce,u two-is ar esimated one; and (b) the number of students and repeaters in to o solbecaus the atted schol in ic the each grade, to compute the grade-to-grade transition of schooling is toered.rA o n the rates. The former can typically be found in household posurvivalrsis therefor on temsuppl side Simulation analysis suggests that removing this im- surveys, many of which are now available -some- survys,manyof hicharenow vaiable- sme- pediment would raise the enrollment rate at the end times in repeated surveys - for African countries; the pe iment woule tro llment re atot en of the primary cycle from its current level of about 50 latter type of data is even more common, since most percent to 85 percent. education ministries collect and publish such data an- nually. In combination, the two items provide a com- Nie is otherconry wherelthe sur rateut plet docmenttionof suden flo thrughot . the end of the primary cycle is relatively poor (about plete documentafion of student flow throughout pri- 60preti198.Y,unkehesuaonn maryandsecnday shoo. Wilethereslt oespri 60 percent in 1998). Yet, unlike the situation in mary and secondary school. While the result does not Muiai,spl-ieitretosmyntb p reprsen a rul logitdina coortpatern ithas Mauritania, supply-side interventions may not be ap- te advantag ofubeingicurrnt. Givnth ratier ease propriate in most parts of the country. To illustrate, the sudrent. flow nproileslandtheeper consider the results in Table 10 showing the gross en- of documenting . . . rollment ratios in three regions of the country. In Diffa tinence of these profiles in policy dialogue and de- sign, they have now become a standard feature in all and Mirh about 70 percent of the children live in Status Reports. ~~villages with no school, while in Dosso 42 percent are education Country Status Reports. in such villages. Would building more schools in Mirriah, the region with the lowest gross enrollment ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 23 Table 10 Gross enrollment ratios in villages with and without schools in three regions, Niger 1998 Type of Popubtion group Region All three village Dosso Diffa Mirriah regions Overall 28 20 12 23 All villages Girls 21 18 9 17 Boys 34 22 15 28 Overall 47 65 40 47 Villages with Girls 35 59 30 36 a school Boys 59 71 48 58 % of school-age population in villages 42 70 70 52 without a school Source: Niger Country Status Report (forthcoming). ratio, help? The answer can be assessed by comparing sectors - for example, when sub-sectors such as pri- schooling only in villages with schools: the gross en- mary and lower and upper secondary education are rollment rate in such villages is 65 percent in Diffa, grouped within a single ministry. Moreover, budgeted whereas it is only 40 percent in Mirriah. In Dossa, where amounts may not correspond to actual spending, and the supply of schools is much more plentiful, the gross even if they do, the information can rarely be arranged enrollment rate in such villages rises to only 47 percent. to document the extent to which spending is allocated This suggests that even with a massive school building for administration and teaching activities at the school program in Mirriah, progress in extending coverage is level. likely to be limited unless demand-side impediments Yet these aspects of public expenditure management are also removed. are both desirable and feasible to document by com- bining two sources of information: budget data and information on personnel allocation and civil service Thedfunctional allocation of aggregate spending o pay. Consider the results for Madagascar shown in education Figure 10. The first panel shows the allocation of pub- In the debate on debt relief and poverty reduction, lic employees by level of education and function. Com- there is a tacit assumption that public spending on bining the data on staff allocation, and that of the dis- education should increase as extra resources from debt tribution of staff by salary grade, as well as informa- relief become available. In countries where public tion on the salary structure, it is possible to compute spending is modest, such an increase would seem quite the aggregate spending on salaries by level of educa- justified. Yet even in such countries, it is useful to ex- tion When the result is added to information on the amine the efficiency with which current resources are non-salary spending, we obtain a picture of the over- allocated across functions. all allocation of spending, both across levels of educa- The typical approach is to extract from budget docu- tion and by function within each level. The ap- ments the relevant information on the allocation of proach - building up the picture of spending from the composite components - serves two purposes: (a) the spenducationgbudg distribution byrs crenf anducapi- it offers an independent check on the correspondence taspending,distribution acrcategoriesofsspleve(souchat between aggregate budget amounts and actual spend- distribution by categories of spending (such as sala- ries, materials). While useful, the exercise is often frus- ing; and (b) it makes it possible to document the dis- trating because budget documents seldom contain tribution of spending between overheads, school-level sufficient detail to examine the allocation across sub- administration, and teaching services. 24 AFRICA REGION HUMAN DEVELOPMENT WORK1NG PAPER SERIES Figure 10 Functional allocation of staff and public spending on education in Madagascar 1998 (a) Allocation of staff Ibi Allocation of spending 0i8 0.6 06 024 0.4 0.0 (h Primarv Lower sec. Upper sec. Voc./tech. Higher Primary Lower.sc. Upper wc. Voc.itcch Higher U Svstem administration Local adniin. & support 3Teaching services Source: World Bank, "Education and Training in Madagascar: Towards a Policy Agenda for Growth and Poverty Reduction" (forthcoming). ing on overheads and institutional-level administra- For Madagascar, the approach suggests that bud- tion While the results may not be conclusive by them- geted amounts correspond to actual spending. In selves, the sul a pot proble in them- other countries, this approach sometimes uncovers selves, they signal a potential problem in the effi- discrepancies caused by staff attributed to the educa- ciency of public expenditure management that wa tion vote actually working elsewhere in government jobs unrelated to education. In addition, in Madagas- car the pattern of staff and expenditure allocation is School-level patterns in teacher deployment striking in highlighting the preponderance of spend- Beyond looking at patterns of allo- cation in the aggregate budget, it is Figure 11 also useful to examine the alloca- Relation between number of pupils and teachers at the school-level, o send ing sho as Mozambique 1998 tion of spending across schools as another possible source of ineffi- 60 cient expenditure management. Such analysis is possible with data 50i that are routinely collected through 40@ 1 annual school censuses in almost 40~ * * all countries. Figure 11 shows the 0 30 . " * 3: results for Mozambique; each z * * point in the graphs represents a 20 school with the indicated school size on the x-axis and the number to_ of teachers at the school indicated 0 on the y-axis. The relation between 0 250 500 750 1000 1250 1500 1750 2000 the two variables is relatively No. of pupils weak, with a R2 of 0.86, which im- plies that 14 percent of the varia- tion in teacher deployment is un- Source: World Bank, "Cost and Financing of Education. Opportunities and Obstacles related to school size. In contrast for expanding and improving education in Mozambique" (forthcoming). ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 25 Figure 12 Relation between spending and student learning among fifth graders, Burkina Faso 1996 135 I _ _ _ _ _ _ -_ _ _ _ _ _ *125 0~~ ~ . ...........- * 105 2s _________ O ..... ..... ...... -" ..* s5 .. _t . .._._ _ __- 75 - - -- ...... .: 4s .4 * * 654 10000 20000 30000 40000 50000 60000 70000 Spending per pupil (Fcfa) Adjusted for pupils' initial test scores and socio-economic backgrounds Source: World Bank, CoOts, f7nancement et fonctionnement du systeme 6ducatif du Burkina Faso; contraintes et espacespourla politique educative (forthcoming). a similar analysis for Guinea shows a much tighter because in the final analysis schools are accountable relation between the two variables, with a R2 of 0.92. for student learning. More data are becoming avail- Similar work in Benin, Burkina Faso, Madagascar, able to permit a good analysis of the issue. Consider and Zambia suggests that poor teacher deployment the results for Burkina Faso in Figure 12, which shows is often a significant issue in the sector, and the ef- on the x-axis public spending per pupil, and on the y- fects are particularly adverse in rural areas. Because axis fifth graders' year-end test scores adjusted for teacher salaries represent the bulk of spending by the differences across schools in pupils' initial test score state, the randomness in teacher deployment effec- and their socioeconomic characteristics. Three features tively implies a high degree of inequity in resource of the graph warrant comment: (a) schools vary sub- allocation, and by implication wide disparities in the stantially in resource endowment, ranging from a low conditions of schooling across schools. The outcome of only 12,000 Fcfa, to nearly 70,000 Fcfa; and (b) points either to the absence or lax application of ap- schools also vary in the effectiveness with which re- propriate criteria for teacher placement, or to inad- sources are transformed into student learning, with equate incentives for teachers to accept posting to rural the year-end test score ranging from around 65 to 135; areas. In some countries, it has therefore been appropri- and (c) the relation between resource endowment and ate to include measures to restructure teacher pay and test score is very weak, so that among schools with a incentives for rural postings as a completion point trig- spending level of 20,000 Fcfa per pupil, average year- ger under the HIPC Initiative. end test scores can range from 77 to 135. The results for Burkina Faso highlight a need for much better management of teaching and learning The link between resources and student learning processes within the classroom. This calls for inter- ventions, not only to equip teachers more effectively How efficiently are resources used to produce learn- fothitak(eg,hruhmeinnsvi-e- ing utcmes cros scool? Tis qeston i atthe for their tasks (e.g., through more intensive in-ser- ing outcomes across schools? This question is at the vctringbualoosrethnhenetvs heart of public expenditure management, not least pvice training) but also to strengthen the incentives ' ~~~for improvement, including tighter supervision of the 26 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES lagging schools. To see the importance of better man- student learning have been implemented. In coun- agement, note that the schools in the top bubble in tries where such data are unavailable, the approach the graph are on average twenty-five points ahead in can also be applied using examination results as a sec- test scores of the schools in the bottom bubble, even ond best measure of learning outcomes. In most set- though the two sets of schools have similar spending tings, the typical finding is that pedagogical processes per pupil. A difference of this magnitude is large be- could be much better managed. While the results do cause a decrease in the pupil-teacher ratio from 50 to not give guidance on what to do to improve outcomes, 30 (which implies a 67 percent rise in spending per they motivate greater attention to the problem, and pupil) would produce a gain of only 1.5 points in year- help to focus scarce management resources on the lag- end test scores in the same sample of pupils. ging performers. This type of analysis has been applied in an increas- ing number of African countries (e.g., Senegal, Cameroon, and Madagascar), where recent surveys on 1 The examples reported here rely on a paper prepared by Agnes Soucat and Abdo Yazbek on "Rapid Guidelines for Integrating Health, Nutrition, and Population Issues in Interim Poverty Re- duction Strategy Papers on Low-Income Countries," draft of Oc- tober 2000. 2 Based on data from demographic and health surveys, the HNP Department in the HD Network has prepared Poverty and Health Fact Sheets for more than forty countries. 3 Emerging Lessons In many ways the HIPC Initiative has created a new knowledge will obviously be needed as a long-term dynamic in international development. By reduc- strategy -but perhaps not so much in the lumpy ing the burden of external debt service, it amelio- model of standard economic sector work as in the rates what debtor countries have long contended model of initiating and maintaining a living knowl- is a significant impediment to better access to basic edge base around a core set of issues. Budget realities health and education services, especially among the may indeed make the latter approach more feasible, poor. At the same time, it opens the way for creditor since a living knowledge base can be built up in modu- countries to shift the focus toward increased account- lar increments around a core structure as budgets per- ability for results. The process has just been launched, mit. Taking the long view is important to minimize our and it is still too early to judge its effectiveness in bring- lack of readiness in future rounds of policy dialogue ing about progress in poverty reduction and human on the progress of poverty reduction and human de- development. velopment. The demand for current, off-the-shelf sec- Yet some lessons can be drawn regarding the pro- tor knowledge will intensify in a future where the cess itself. The building blocks for effective HD engage- Bank's business environment is increasingly charac- ment include the following: terized by the HIPC/PRSP process as a key feature. * on-demand availability of country-specific sector Changes in staff attitudes will also be important. In knowledge focused especially on issues relating to particular, HD sector development must be viewed as better management of public (and private) resources an integral part of broader efforts to reduce poverty, to deliver basic health and education services to the and our work needs to pay explicit attention to the poor; sector policy context for enhancing basic social services * collaboration on analytical work with counterpart for the poor - of which the delivery may sometimes country teams as a mechanism to build in-country be supported as part of the Bank's lending operations. capacity to prepare sectoral inputs to the PRSPs and Given that governments are expected to play the lead- subsequent monitoring of program implementation ing role in defining their own poverty reduction strat- and outcomes; and egies, the Bank's sectoral staff are perhaps most effec- * active partnership with key non-sectoral partners tive when making technical contributions to help ar- (such as macroeconomists within the Bank and min- ticulate these strategies in collaboration with the rel- istries of finance and planning) to address impedi- evant country counterparts and staff from other ex- ments to sector development and to increase ac- ternal partners, drawing on the BanKs intellectual re- countability for results. sources and comparative experience to inform the policy debates. While attitudes will no doubt take time With regard to the work at the Bank, the HIPC/PRSP to change and the change may not always be easy, the process calls for changes in business practices and staff shift in orientation is essential to making the Bank a behavior. Much greater investment in building sector more effective development partner for its clients. 28 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 29 Al Appendix tables and figures Table Al The role of health and education in Uganda's Poverty Eradication Action Plan (PEAP) 2000 Table A2 Uganda's 2000 PRSP: Health and education sector measures & monitoring indicators Table A3 Uganda's PEAP/PRSP First Year Progress Report 2001 Table A4 The role of health and education in Burkina Faso's 2000 Poverty Reduction Strategy (PRSP) Table A5 Health sector strategy/objectives and monitoring indicators in Burkina Faso's 2000 PRSP Table A6 Education sector strategy/objectives and monitoring indicators in Burkina Faso's 2000 PRSP Table A7 The role of health and education in Mauritania's 2000 PRSP Table A8 Health and nutrition strategy/measures and monitoring indicators in Mauritania's 2000 PRSP Table A9 Education sector strategy/measures and monitoring indicators in Mauritania's 2000 PRSP Table AIO Role of health and education in Tanzania's 2000 PRS Table All Health sector strategy/measures and monitoring indicators in Tanzania's 2000 PRSP Table A12 Education sector strategy/measures and monitoring indicators in Tanzania's 2000 PRSP Table A13 Examples of health indicators for cross-country comparisons Table A14 Selected best buys in health Figure Al Grouping of the Heavily Indebted Poor Countries 30 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Table Al The role of health and education in Uganda's Poverty Eradication Action Plan (PEAP) 2000 I Education Pillar of the PEAP Health Prim. Sec. Voc/tech Higher Adult Prim. Sec. Voc/tech Higher literacy Creating a framework for economic growth and transformation X Ensuring good governance and security Directly increasing the ability of the poor to raise their incomes X Directly increasing the quality of the life of the poor. X X X X Source: Government of Uganda 2000. "Poverty Reduction Strategy Paper. Uganda's Poverty Eradication Action Plan. Summary and Main Objectives," Ministry of Finance (Planning and Economic Development), Kampala. March 24. Table A2 Uganda's 2000 PRSP: Health and education sector measures & monitoring indicators Sub-sector Strategy/Targets Monitoring indicators By 2004 adhieve the following: • fwue chld motaliy fro 147to 10 perthousnd a Immunization rates * Reduce hlida mortality from 147 to 103per thousand %of health centers with trained staff Health * . materrl mortality from 506 to 39 . % of health centers without stockouts per 100,000 a Uiiaino elhsrie * Reduce HIV prevalence by 35% Petiiztionsofservices * Reduce total fertility rate to 5.4 . Perceptions of service delivery • Reduce stunting to 28% a Prevalence for HlV and malaria Net and gross primary enrolment Approach net enrolment close to 100% by 2003 . Pupil-textbook and teacher ratios Primary Reduce pupil-teacher ratio to 50 by 2000 and 41 . Public perceptions of quality P by 2009 . Estimates of quality from the Stabilize teacher-classroom ratio at 1.6: 1 by 2003/4. National Assessment of Progress in Education (NAPE). * Raise transition rate from primary to sec/voc to 65% Net and gross enrolment Secondary by 2OG3 * Indicators of quality Secodar Set:acherratio at 30 by 20Q3: :Incidence of benefits, including access * Set pupil-teacher ratio at 30 by 2003 of poorest 20%. Vocational . Increase number of trainees to 100,000 by 2003 Enrolments and completion education ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~* Employment of graduates . Expand enrolment from 25,000 to 50,000 by 2003 : Ensure women make up 40% of enrollments Total enrolment in tertiary education, Tertyeducation 0 Eliminate disparities by district & increase access and gender breakdown Tertiaryeducahon among lower socio-economic groups . Enrolment by socio-economic group, : Provide places for 8,000 government students at and district of orgin :X::MakrerUniversity Adult literacy I mplement 5-year program to achieve 85% . Literacy rates, by sex literacy rate Source: Based on Government of Uganda 2000 (Annex Table 1). ENHNCI.NG HUMAN DEVEl OPMENT IN THE HIPC/PRSP CONTEXT 31 Table A3 Uganda's PEAPIPRSP First Year Progress Report 2001 Sector/sub- Assessment of progress and challenges sector • The PEAP/PRSP interim targets for child immunization and trained staff not met in 1999/2000 * Child malnutrition has declined, but HIV/AIDS and malaria continue to pose serious threats • Significant increase in the demand for health services, met mostly by private providers * Access to safe water has increased, but problems with maintenance remain. PEAP/PRSP interim targets for the number of springs and shallow wells not achieved • Challenges: Health Recruiting health personnel in districts and getting them onto the government payroll Finalizing the national policy on user fees for health services Providing adequate drugs and medical supplies to health facilities Expanding coverage of and access to minimum health care package services; this has been limited (for example, only 25 percent of deliveries take place in health facilities; contraceptive prevalence rate is only 15 percent; only 30 percent of malaria patients have access to treatment within 24 hours of the onset of symptoms) * Progress achieved in creating awareness about transmission of HIV,AIDS * Progress achieved in enhancing treatment of sexually transmitted diseases (STDs) HIV/AIDS * Challenges: Making health care affordable for a large proportion for people living with AIDS Limited integration of HIV/AIDS activities in all sectoral programs * Primary enrollments remain high (6.1 million pupils), with net enrollment ratio at 77% in 2000 * Student achievement appears to be declining with recent massive increase in enrollments * PEAP/PRSP indicators not met for ratio of pupils to teachers, to classrooms, and to textbooks Prinmary * Challenges: education Making access to primary education universal, while raising the quality of standards Recruiting adequate numbers of qualified teachers Ensuring that newly recruited teachers access the payroll Improving the availability of textbooks * Strategic plan completed * Initial activities to expand access and improve quality started, including: Secondary 4 sites identified for first pilot secondary schools Secondary 73 secondary schools given grants for construction and rehabilitation education 16 secondary schools identified to serve as centers for Comprehensive Secondary Education 36 functional Teacher Resource Centers established to offer in-service teacher training Guidelines and incentives developed to enhance community contribution for secondary education • Policy has been developed Vocaftional a Funds secured from the German Government to support private Vocational Training providers all over the education country * Standardization of the curriculum requires further attention * Excellent progress as university level education expanded without overburdening state budget: public spending on education doubled between 1995 and 2000, but allocation for Makerere University rose by only Higher 7% education * Increase in enrollment and its composition at Makerere University especially noteworthy: number of students rose from 9,369 in 1995/1996 to 20,368 in 1999/2000 & share of privately-sponsored students exceeds 70 percent in 1999/2000 • Slow progress a problem Adult literacy * Funding increased to implement nationwide adult literacy program * Training of literacy instructors begun and resources pay them secured Source: Government of Uganda. 2001. "Uganda Poverty Reduction Strategy Paper. Progress Report 2001. Summary of Poverty Status Report," Ministry of Finance, Planning and Economic Development, February, Kampala. al Shows information relating directly to the health and education sectors only. 32 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Table A4 The role of health and education in Burkina Faso's 2000 Poverty Reduction Strategy (PRSP) Pillar of the PRSP Health Education Primary Post-primary Literacy Accelerate equity based growth iGuarantee Sthat the poor have access to basic social services Expand opportunities for employment and income- generating activities tor the poor Promote good goverrance Source: Government of Burkina Faso, Ministry of Economy and Finance, May 25, 2000. Poverty Reduction Strategy Paper. Based on text discussion and annexes. Table A5 Health sector strategy/objectives and monitoring indicators in Burkina Faso's 2000 PRSP Strategy/objectives Monitoring indicators (2000-2003) Improve life expectancy by at least 10 years by 2010 . Vaccination coverage ratio (in %) by 2003: BCG increases to 85% Prioritize interventions addressing health problems of the DTCP3 increases to 70% poorest segments of the population Measles increases to 70% Yellow fever increases to 70% Decrease infant mortality from 105 to 50 per thousand by 2009, and IMR in rural areas from 113 to 75 per thousand and [MR in . Rate of use of health facilities : number of new contacts urban areas from 113 to 45 per thousand per person and per year in first level health centers (CSPS, CMA) increases to 0.27 Protect underprivileged groups through policies designed to make essential health care affordable . CSPS meeting the standards in terms of staffing 100% by 2003 Supports participation of users and communities in the development and management of health care activities . Essential drugs breakdown rate (%) <8 * Cost of medical interventions in first level health centers Source: Government of Burkina Faso, Ministry of Economy and Finance, May 25,2000. Poverty Reduction Strategy Paper. Based on text discussion and annexes. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 33 Table A6 Education sector strategylobjectives and monitoring indicators in Burkina Faso's 2000 PRSP Strategy/objectives Monitoring Indicators 2000-03 Enhance public spending on education Gross enrollment rate: Raise education share from 21.6 % currently to 26.0 % in 2010 --Overall Maintain share of basic education at 60%/o of education spending -- among girls --in least privileged rural areas Allocate 7°% of basic education spending to literacy programs Enrollment rate in grade 1: Improe managemet of teacher recruitment -- among girls Decentralize hiing oer the next 10 years -- in rural areas -- in the 20 poorest provinces Set salaries of new hires at 3.5 to 5.0 times per capita GDP Literacy rate: Reform organizational structure of the ministry of education -- among women Improve service delivey to the poor and to disadvatged groups -- among women in the 20 poorest provinces Stimulate demand for education through comprehensive approach Average cost per child in primary school Target school construction to rural areas Construct toilet facilities in all new schools Construct of water supply points in schools Support for school canteens Fee exemption for girls in 20 provinces with lowest enrollments Continue distrbution of textbooks free-of-charge Improve student flow Raise survival rate from grade 1 to grade 5 from 600/o to 75% by 2010 Reduce repetition rate in primary education from 18 to 10% by 2010 Expand literacy programs Target services to women Establish permanent literacy and training centers Incorporate literacy activities as part of other social services Source: Government of Burkina Faso, Ministry of Economy and Finance, May 25, 2000. Poverty Reduction Strategy Paper. Based on text discussion and annexes. 34 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Table A7 The role of health and education in Mauritania's 2000 PRSP Pillar ot the PRSP Health a Education b, Vocational training Accelerated and redistributive growth Growth anchored in the economic environment of the poor X Developing human resources and ensuring universal access : to ba4icirifrastructure and service Strengthening institutional capacities and governance Source: Islamic Republic of Mauritania December 13, 2000. Poverty Reduction Strategy Paper. a/ Includes nutrition b/ Includes all levels from pre-school to higher education, as well as literacy programs; excludes vocational education and training. Table A8 Health and nutrition strategy/measures and monitoring indicators in Mauritania's 2000 PRSP Objectives/strategies Actions (to be monitored during 2001-04) Improve health services provided to population groups, particularly the * Develop and provide a minimum care package of health care services at all levels oft poorest health system to improve maternal and child health and address major health problems Reduce morbidity and mortality (e.g., AIDS, malaria, TB, diarrhea, ARI, shistosomiasis, Guinea worm, micronutrient aeduce morbidity and moealitY deficiencies) through: associ;ated withmajor diseases: 0: o construction and equipping of health centers and health posts o hiring of medical and paramedical personnel o establishment of specific payment systems for health post personnel in disadvantaged areas o establishment of a sustainable system of supplying good quality drugs based on recommendations emerging from studies in progress and consultations with donors. Strengthen the equity, quality, efficiency . Solidity and extend system of cost-recovery at all levels within the system of and sustainable access to essential . Study and establish a system to care for the indigents in collaboration with the care departments concerned c Involve the poorest users and communities in health decisions * Strengthen and equip outlying health care facilities to provide services to preven and Improve H;iV/AIDS prevention care for opportunistc infections Xm" H.V/AlDS prevention s Develop AIDS detection and counseling in category A health centers • Provide psychological-medical-social counseling for people living wth HiV Improve sectoral guidance, planning & . Complete study on health sector costs and performance and implement its management recommendations m Establish budget-program and system to monitor performance Improve nutritional status of population * Implement the Taghdiya community nutrition program groups * Extend recovery centers for malnourished children Source: Islamic Republic of Mauritania December 13, 2000. Poverty Reduction Strategy Paper. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 35 Table A9 Education sector strategylmeasures and monitoring indicators in Mauritania's 2000 PRSP Sub-sector Objective/Strategy Actions (monitored during 2001-04) Raise enrollment rate to 100% by Ensure schools have facilities to offer flufl-cy isruction (construct 1,533 new classrooms; rehabilitate 584 classrooms} .. . . FlHire 409 new teachers Reduce regionallgender dfisparities in ie 0 e tahr Institute bonuses for teachers posted to Basic acess areas Improve quality and reduce * Provide all schools with pedagogical materals disparties in schoolirg outcomes a Equip all schools with desks Inprove caliber of teachers * Maintain ongoing teacher training Expand lower secondary cycle & . Construct and rehabilitate classrooms ensure adequate access for girls . Hire 600 new lower secondary teachers Secondary education Improve quality esp. in rural areas & . Equip all schools with desks exam results & Install computers and provide teaching materials s Maintain ongoing teacher training Improve labor force qualfication Technrcal/ X Construct & rehabilitate training centmers voanal Enhance inclusion of rural * Purchase specialized equipment eatinm populatons' inclusion in the economic * Train trainers fabric * Purchase of pedagogical materials Higher . . . . Complete study of the supply, quality and relevance of education Tighten fit wih the labor market higher education * Introduce measures to enhance quality * Introduce school mapping Central a Create a good staff managerment system managemnt Improve management the system a Modemnize & decentralize administran - .~~~~~~~~~~~~~~ Strengthen institutional capaicity : a Develop & distribute literacy manuals Literacy Develop adapted literacy program . Establish incentive system for literacy personnel * Strengthen "mahadras" contribution to the literacy effort Source: Islamic Republic of Mauritania December 13. 2000. Poverty Reduction Strategy Paper. 36 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Table A10 Role of health and education in Tanzania's 2000 PRS Pillar of the PRSP Health Education Reduce income poverty Improve human capabilities, survival and social well being X X Source: Government of Tanzania. 2000. Poverty Reduction Strategy Paper, Ministry of Finance, October. Table All Health sector strategylmeasures and monitoring indicators in Tanzania's 2000 PRSP Poverty reduction strategy Indicators Actions Long Term Rai%of th l ppulaiowtaeso Provide quality health services through essential Raise Life Expectancy to 52 years by the saf ac waterfm48% i2000 to health package delivery year 2010 55% in 2003 Strengthen and reorient the delivery of Medium Term Raise % secondary and tertiary health services, to Lower Infant mortality rate from 99 per od :from 71%in 200t 8%in 203 ensure more effective support of primary health 1000 to 85 per 1000 by 2003 care tCIncreas cveag o irthsattnded0Q; by$i0 Reduce under-five mortality from 158 to trainedpr efrom 50%to 0% Train health personnel 127 per 1000 by 2003 Raise % of districts with active HIWA;Q $ Promote and coordinate private sector and civil Lower maternal mortality from 529 per awaren ssc gns to 75% by 2003 society activities in health 1000 to 450 per 100,000 by 2003; (NB: this is a non measurable target) Rehabilitate malfunctioning water supply schemes, protection of water sources Reduce malaria related fatality for under 5 children from 12.8% to 10% by 2003 Promote nutrition education especially to mothers and reinforce reproductive health and family planning Raise % of the rural population with access to safe and clean water Promote HIVIAIDS and public health awareness, including through peer education in schools Strengthen the program of integrated management of Childhood illness Source: Government of Tanzania. 2000. Poverty Reduction Strategy Paper, Ministry of Finance, October. Based on text discussions and annexes. ENHANCING HUMAN DEVELOPMENT IN THE HIPC/PRSP CONTEXT 37 Table A12 Education sector strategylmeasures and monitoring indicators in Tanzania's 2000 PRSP Povert reduction strategy Intermediate indicators Actiom p*vwiduIio Moy (2000-2003) Atot Long Term . Gross primary enrolment ratio rises to 85% Abolish primary school fees starting 2001102 Reduce lteray by 100% by 201 Net primary school enrolment ratio rises from Strengthen the management capacity of Medium Term 57% to 70% dists, schools, TTCs and adult education Achieve gender equality in pimary and centres secodary edueationb 205 Transition rate from primary to secondary level rises from 15% to 21% Cormplete school mapping and improvement fne share ofschof l age cen plans successfully completing primary Primary dropout rate falls from 6.6% to 3% educaton. Increase capacity & improve inspection No. of students passing at specified mark in services overage Increase she of sudents passig standard 7 examination rises from 20% to Standard 7 examination at a sped 50% Improve quality and distribution of primary sore school teachers through in-service training Secondary gross enrollment ratio rises from at annual rate of 10% up to the year 2003 Expanddemanddri skills 5% to 7% develpment Improve learning environment at all levels (textbooks, materials, furniture, sanitation, classrooms, teachers houses, etc.) Promote private and community based secondary education Imprve & protect basic education spending share Providelconstruct adfitional classrooms and rehabilitate existing ones Source: Government of Tanzania. 2000. Poverty Reduction Strategy Paper, Ministry of Finance, October. Based on text discussion on pages 19 & 26, and Annex II. 38 AFRICA REGION HUMAN DEVELOPMENII WORKING PAPER SERIES Table A13 Examples of health indicators for cross-country comparisons Life ~Infant Under Five Matnerinal Fertility Rate HVChild Life Infanity Underaivey Mortality (number of PreVaec Malnutrition Countries Expectancy (per 1000 (deaths per 1000 (deaths per children per Prevalence (weight per live births) live births) births) woman) age) Africa a, 52 91 151 822 5.6 8% 32 Mauritania 53 92 140 930 5.5 0.5% 23 i; 46k 00000000 105 219 484 :6.8 : 33 Guinea 46 122 220 880 5.7 2%/o 24 0 ;00;96 : 162 596 6.0 0.5%/* 36 Mali 50 120 192 577 6.7 1.5% 31 ct,ted fvoWe 55f.0000j 0000000;88 138 597 5.6 10%hDO 24 Ghana 60 71 110 740 5.0 3.6% 27 ; U t- 00000nda00400000f004; 40 0 000i 99 141 506 6.7 8.3%D0 26 a/ Averages for 1990-96. ENHANCING HUMAN DEVELOPMENT IN THE HIPc/PRSP CONTEXT 39 Table A14 Selected best buys in health al Outcome Conditions and Services Interventions Reduction of IMR and Integrated Management of Case management of ARI, diarrhea, malaria, measles and malnutrition; U5MR Childhood Illness immunization, feeding/breastfeeding counseling, micronutrient & iron supplementation, antihelminthic treatment, and referral Immunization (EPI Plus) BCG at birth; OPV at birth, 6,10, 14 weeks, DPT at 6, 10, 14 weeks, HepB birth, 6 and 9 months (optional), Measles at 9 months TT for women of child bearing age Improve nutrition Child Protein Energy Promotion of Breast feeding with appropriate complementary feeding, IEC Malnutrition (communications for behavior change) b Vitamin A Deficiency Vitamin A suppiementation: for women, within 60 days post-partum; for children 6 - 59 months, twice-yearly; fortification of staples with vitamin A, iEC (communications for behavior change) Anemia Iron and folic acid supplementation for women of reproductive age, iron supplementation of infants 6 to 24 months; fortification of staples with iron, IEC (communications for behavior change) Iodine Deficiency Salt iodization, IEC (communications for behavior change) School heaith and nutrition Health and nutrition education, de-worming, iron supplementation Reduce maternal Reproductive health/ Safe Family planning, prenatal delivery care, clean/safe delivery by trained birth mortality and fertility motherhood attendant, post-partum care, and essential emergency obstetric care for high risk pregnancies and complications Family Planning Information & education and availability and correct use of contraceptives Control commuricable Sexually Transmitted Diseases Case management using syndromic diagnosis and standard treatment algorithm diseases (STD) HIfV/AIDS prevernion program Education on safe behavior, condom promotion, STD treatment, safe blood supply, prevention of Mother To Child Transmission 'including counseling on infant feedng options for HIV+ mothers Malaria Case management (early assessment and prompt treatment), and selected preventive measures (e.g. impregnated bed-nets, presumptive treatment) Tuberculosis Direct Observed Treatment Short-course; Case detection by sputum smear microscopy among symptomatic patients. Standardized treatment regimen of 6-8 months. Directly observed treatment for at least initial 2 months. a/The list is based on the work of technical group at the World Bank and WHO documentation. b/ Supplementary feeding can be considered in addition to but not as a substitute for, the above nutrition interventions, where inadequate access to food by vulnerable groups [pregnant and lactating women, children under2] in food insecure households, is a causeof malnutrition. Food supplementation can serve as an incentive to attend health clinics and as an 'educational tool' to improve capacity to care for children and women in the household. Given the costs and risks involved in food supplementation programs, other means to increase attendance or improve caring practices should first be considered. Food supplementation of vulnerable people cannot substtute for measures to address household food insecurity, and should therefore be accompanied by safety net measures, such as food stamps, income transfers, income generation for women, asset generation, etc. Similar considerations apply to school feeding: School feeding can have educational benefits, because it can improve learning, enrollment and attendance. Integrated programs that combine school feeding with nutrition and health education, deworming, and micronutrient supplementation are more likely to have nutritional benefits than school feeding alone. 40 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES Figure A I Grouping of the Heavily Indebted Poor Countries Status as of end-December 2000 Decisr Poirt Courtries lThrca End-2JCC 41 HIPC Courtries 37 Ur&tstarble Cases Aropa 'Burundi APPROXVED (22) Berin Berin Beliva Bolivia B Burina Faso Burhria Faso BiMa Mauritania Bund i amTerCon Buria Faso Mobque Carren GoCetra Afiican Filic Canrocn Ncaragu Cstral Afrcan PFxlic '-Cad TheGania Chad CorX, Dem FPp. of GTrea. NArda Congo C1`0, R9d GuinreBssa Saeg Cngo, Dom Rep. Cotecdkvire GLTm SaoTome andPRincpe C&ed lvire Etlc,ia Hnas Tanzana EBhorJa -The Canbia M3a91 TheuC4ia GhanMdcar Ghania GCinea Guinea Gunea,Bissau GireaBissau ' Gyana/ Guyana IlFbnduras Hodrxas Lao PDR/ Kenya Liberia Lao FDR t Madr /tt Ubsria' Malasm Post-2000 Decision Paint Countries MaacarMl/ PMaW Mnaritaria Contlict Affected (9) Others (4) Mali MM/zariTqLe Majitania Aan1Ia/ Baurdi aCad ozarTcque Ncaragua Central Africa, Piiic C5te d lwre MIVnrnar I Ngsr Congqo, Dem Rn p d Ethoia" Ncaragu Far\ Con, Rep. d Togo Nger Sao Ton-e and Rincipe , Libria Fhoanda. Serra Lmex I'Manra Serra Leore ' \ sarEGa Se rraLeone SW Tome aard Rircipe Smuia Sm arlia 9 lA Sudan \ Sudan Somaia' Tanzana Sudan ' Togo\ Tanzara LUanda Togo Zabia Llganda \ Vietnarnm YeITr 1, Fea of_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Zwara At Gavernmant Request 4 S9usteirabedeCases 1/ Not9Seeking DelttRelief 4Sanc1 1/Ghan Nyda La PR Ksnya Vetrna Yeman, Fbp. of Conflict affected. Cessation of hostilities signed on June 18, 2000. A peace agreement was signed with Eritrea on December 12, 2000. 1/ These countries are expected to achieve debt sustainability after receiving debt relief provided under traditional mechanisms. 2/ Countries which reached their decision points under the original HIPC framework (i.e. prior to the endorsement of the enhanced HIPC framework during the Annual Meetings of the World Bank and IMF in September 1999). Bibliography Government of Burkina Faso. 2000. "Health and Government of Uganda 2001. "Uganda Poverty Poverty in Burkina Faso," background document Reduction Strategy Paper. Progress Report 2001. for the draft PRSP, Ministry of Health. Summary of Poverty Status Report," Ministry of Government of Burkina Faso. 2000. Poverty Reduc- Finance, Planning and Economic Development, tion Strategy Paper, Ministry of Economy and Kampala, February. Finance, Ouagadougou, May 25. Government of Uganda. 2000. Poverty Reduction Government of Cameroon. 2000. "Health and Strategy Paper. "Uganda's Poverty Eradication PovertyinC'background document for Action Plan. Summary and Main Objectives," oedrfty in Mero Ministry of Finance, Planning and Development, the draft PRSP, Ministry of Health. Kampala, March 24. Government of Guinea. 2000. "Health and Poverty The World Bank. 2000. Grouping of the Heavily in Guinea," background document for the draft Indebted Poor Countries posted at website: http:// PRSP, Ministry of Health. wwwl.worldbank.org/prsp/ Government of Islamic Republic of Mauritania. PRSP_Related_Documents/hipcs_groupings.pdf. 2000. Poverty Reduction Strategy Paper, Decem- The World Bank. "Education and Training in Mada- ber 13. gascar: Towards a Policy Agenda for Growth and Government of Mali. 2000. "Health and Poverty in Poverty Reduction." Human Development Depart- Mali," background document for the draft PRPS, ment, Africa Region. Washington D.C.: World Bank Ministry of Health. (forthcoming). Government of Mauritania. 2000. "Health and World Bank & Benin Education National Team. "Le Poverty in Mauritania," background document systeme educatif beninois Performance et espaces for the draft PRSP, Ministry of Health. d'am6lioration pour la politique 6ducative." Government of Niger. 2000. "Health and Poverty in Washington, D.C.: World Bank (forthcoming). Niger," background document for the draft PRSP, World Bank & Mauritania Education National Team. Ministry of Health. 2000. "Le systeme educatif mauritanien: Elements Government of Tanzania. 2000. Poverty Reduction d'analyse pour instruire des politiques nouvelles. Strategy Paper, Ministry of Finance, October. "Washington D.C.: World Bank (forthcoming). 42 AFRICA REGION HUMAN DEVELOPMENT WORKING PAPER SERIES World Bank & Niger Education National Team. World Bank. 2000. "Mali. Initiative for Heavily "Contraintes et espaces de liberte pour le Indebted Poor Countries (HIPC). Document for developpement en quantit6 et en qualite de the Completion Point Under the Original Frame- 1'education au Niger." Washington, D.C.: World work and Decision Point Document under the Bank (forthcoming). Enhanced Framework." Washington, D.C.: World World Bank (various years). Africa Live Data Base for Bank. Government social expenditure statistics. Wash- World Bank. 2000. "Mauritania. HIPC Debt Initiative: ington, D.C.: World Bank. President's Memorandum and Recommendation World Bank. 2000. "Benin. Decision Point Document and Decision Point Document, under the Enhanced Heavily Indebted Poor Corrigendum."Washington, D.C.: World Bank. Countries (HIPC) Initiative." Washington, D.C.: World Bank. 2000. "Niger. Enhanced HIPC Debt World Bank. Initiative: President's Memorandum and Recom- World Bank. 2000. "Burkina Faso. HIPC Debt Initia- mendation and Decision Point Document." tive: President's Memorandum and Recommenda- Washington, D.C.: World Bank. tion and Completion Point/ Second Decision Point World Bank. 2000. "Republic of Mozambique. Document." Washington, D.C.: World Bank. Decision Point Document for the Enhanced World Bank. 2000. "Cameroon. HIPC Debt Initiative: Heavily Indebted Poor Countries (HIPC) Initia- President's Memorandum and Recommendation tive.' Washington, D.C.: World Bank. and Decision Point Document." Washington, D.C.: World Bank. 2000. "Rwanda. Enhanced HIPC Debt World Bank. Initiative: President's Memorandum and Recom- World Bank. "Cost and Financing of Education. mendation and Decision Point Document." Opportunities and Obstacles for expanding and Washington, D.C.: World Bank. improving education in Mozambique." Washing- World Bank. 2000. "Sao Tome and Principe. En- ton, D.C.: World Bank (forthcoming). hanced HIPC Debt Initiative: President's Memo- randum and Recommendation and Decision Point World Bank. "Cou~ts fmnancement et fonctionnement Dcmn. ahntn .. ol ak du systeme educatif du Burkina Faso; contraintes et espaces pour la politique educative." Washington, World Bank. 2000. "Senegal. HIPC Debt Initiative: D.C.: World Bank (forthcoming). President's Memorandum and Recommendation World Bank. 2000. Financial Impact of the HIPC and Decision Point Document. Washington," D.C.: World World000 Bank.Imat f hHP Initiative posted at website: http:// World Bank. www.worldbank.org/ hipc/ Financial_Impact.pdf World Bank. 2000. "Tanzania. HIPC Debt Initiative: World Bank. 2000. "Guinea. Enhanced HIPC Debt President's Memorandum and Recommendation Initiative: President's Memorandum and Recom- and Decision Point Document" Washington, D.C.: mendation and Decision Point Document." World Bank. Washington, D.C.: World Bank. World Bank. 2000. "The Gambia. Enhanced HIPC World Bank. 2000. "Guinea-Bissau. Enhanced HIPC Debt Initiative: President's Memorandum and Wol .Bn. 20. ".ie-isu nacdHP Recommendation and Decision Point Document." Debt Initiative: President's Memorandum and Recommendation and Decision Point Document." Washington, D.C.: World Bank. Washington, D.C.: World Bank. World Bank. 2000. "Uganda. HIPC Debt Initiative: World Bank. 2000. "Madagascar. Enhanced HIPC Second Decision Point Document." Washington, Debt Initiative: President's Memorandum and D.C.: World Bank. Recommendation and Decision Point Document." World Bank. 2000. "Zambia Enhanced HIPC Debt Washington, D.C.: World Bank. Initiative: President's Report and Recommenda- World Bank. 2000. "Malawi. Enhanced HIPC Debt tion and Decision Point Document." Washington, Initiative: President's Memorandum and Recom- D.C.: World Bank. mendation and Decision Point Document. Wash- ington," D.C.: World Bank. THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. Telephone: 202 477 1234 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: afrhdseries@worldbank.org In recent years, the World Bank, in collaboration with its partners, has de- veloped new concepts and operational instruments to support govern- ments in their fight against poverty. Among the most notable of these new approaches are (a) debt relief through the Highly Indebted Poor Countries (HIPC) Initiative, (b) country-led plans for reducing poverty through Poverty Reduction Strategy Papers (PRSPs), and (c) World Bank financial support for these strategies through Poverty Reduction Support Credits (PRSCs). During the year 2000, eighteen countries passed their "decision points" in the debt relief process -that is, the Executive Boards of the IMF and the World Bank had formally approved the countries for debt re- lief. This study presents basic facts on the countries involved, foresees the possibility of newcomers in the process, and analyzes the content of HD policy measures included in the debt relief agreements. Readers will also learn of the Bank's efforts to engage country counterparts in the HD sectors in an effective dialogue about sector development, particularly in health and education. The report is divided into three parts: the first summarizes HIPC/PRSP processing; the second part examines the analytical work that the team is developing to strengthen capacity for designing sector policy measures in the HIPC/PRSP documents; and, finally, the report re- flects on the lessons learned so far.