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p. 12 of 27 BACK | NEXT Executive summary Introduction Regional health context The Bank’s involvementin the health sector Trends in Bank lending Performance of health sector lending Relations with bilateral and multilateral organizations Issues and options The Bank’s health policy

Policy for the Health Sector : The Bank’s involvementin the health sector

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Performance of health sector lending

Overall performance

The performance of health sector lending in the Bank has been comparable to other sectors. Based on formal evaluations carried out by the Operations Evaluation Office, there have been no unsuccessful health sector projects, while the average for the Bank is 11 percent (see Appendix 2). The amount of delay has been slightly higher than other sectors, and there have been fewer “generally successful” projects (33 percent compared with the Bank average of 57 percent). Possible reasons for the lower proportion of generally successful projects include (i) 50 percent of the health projects that have been postevaluated were the first Bank-sponsored health sector projects in the country, while the comparable figure for all postevaluated Bank loans was 32 percent; and (ii) all the postevaluated health projects were approved more than 13 years ago, and therefore do not reflect the newer focus on PHC, which the Bank has been utilizing since the beginning of the 1990s. As indicated in Appendix 2, there has been a substantial improvement in the design of Bank loans since the early 1990s.

Monitoring and evaluation

A major factor complicating the evaluation of completed health sector projects is the lack of objective indicators of success contained in the original designs. Of health projects approved prior to 1994, only 52 percent had chosen one or more objective indicators of success during appraisal (none had indicators for each component), 28 percent had collected benchmark data, and only 17 percent presented data for nonproject areas even though all had components that were limited to a specific geographic area. In the projects where the executing agency was supposed to develop indicators after appraisal, this rarely occurred. Overall, few of the projects approved before 1994 complied with the Bank’s guidelines on benefit monitoring and evaluation. The picture has improved sig-nificantly since 1994 (see Appendix 2) as a result of increased recognition by health sec-tor staff of the importance of monitoring and evaluation (M&E). Nonetheless, much work still needs to be done, particularly in ensuring the collection of baseline data and consistent use of appropriate comparison groups.

Other aspects of project design

A sector synthesis conducted by the Bank’s Operations Evaluation Office based on findings from 12 postevaluated loans, and a separate in-depth analysis of all 35 health sector loans approved until December 1998 carried out by the Bank for this paper (see Appendix 2), point to the following conclusions:

1. There has been a substantial change in the design of projects since the 1991 publication of the Bank’s health sector strategy paper Health, Population and Development in Asia and the Pacific. Generally, it appears that health sector loans are now more carefully designed (brief descriptions of some recent health sector loans are in Box 4, 5, 7, and 8).

2. Recent health sector loans have addressed the Bank’s crosscutting concerns about women and population planning. There has been a significant increase in the number of projects with components or subcomponents related to women’s health issues, and this may understate the attention given women’s health. Other projects that support PHC included specific indicators related to women and emphasized activities intended to improve women’s health. Similarly, there has been a substantial increase in family planning activities.

3. Early health sector loans either did not involve consultation with beneficiaries or did not document it if it occurred. More recent projects have displayed greater interest in conferring with beneficiaries; however, there is clearly a need for greater beneficiary involvement in all aspects of project design and implementation.

4. Use of alternative approaches and the testing of innovations has become an important aspect of health sector loans. Unfortunately, the pilot tests, as designed, often have not been able to provide definitive answers about the effectiveness of the innovation they were testing. Most lacked clear indicators of success and most did not include a comparison group.

5. Most loans (86 percent) addressed the lack of capacity in the executing agencies (almost entirely, ministries of health). However, the analyses were of a general and nonsystematic nature and virtually the only response was additional training and consulting services. Unfortunately, the training and consultant inputs were designed in such a way that it would be impossible to tell whether they had any beneficial effect.

6. Recent health sector loans have generally paid more attention to public goods such as health care research, health education of the general public, and regulation. However, the funds allocated to health care research have been minimal, and the activities in health education have only recently included proper evaluation techniques.

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