T H E C O N T R I B UT I O N O F OT H E R S E C TO RS TO H E A LT H , N UT R IT I O N , A N D P O P U L AT I O N OUT C O M E S
Box 4.2: Greater Selectivity in Sectoral Participation Can Improve Multisectoral Performance
Experience from two communicable disease projects suggests that the complexity and efficacy of multisectoral projects can be improved by enlisting a smaller number of priority sectors and by stronger collaboration with the Ministry of Health. In Eritrea, for example, the HIV/AIDS, Malaria, STD, and TB (HAMSET) Control Project engaged a limited group of priority ministries with a direct stake or comparative advantage in preventing and treating the HAMSET diseases—health, education, defense, transport, and labor and human welfare—under the leadership of the Ministry of Health and built on past collaboration. While the project nevertheless challenged the Ministry, by avoiding creation of new institutions, scarce human re-
sources were conserved, duplication avoided, and complexity reduced.a In contrast, the Ghana AIDS Response Project (GARFUND) was managed by a newly formed Ghana AIDS Commission under the president and financed at least 16 non-health ministries and public agencies, in addition to research institutions, regional coordinating councils, district assemblies, parliamentarians, traditional councils, and chiefs. The National AIDS Control Program (NACP) in the Ministry of Health retained responsibility only for implementing activities falling within a very narrow mandate. As a consequence, “GARFUND subprojects continued to suffer from poor technical quality and inadequate public health content.”b
Sources: IEG 2007c, 2009a. a. The project nevertheless remained highly complex, addressing four diseases, the zoba-level line ministries, and a community-driven component. b. IEG 2007c, p. 32.
Since 1997, the World Bank has committed $5.0 billion in the form of 350 HNP components of projects managed by other sectors. In contrast to the part of the portfolio managed by the HNP sector, which is relatively flat, approval of projects in other sectors with HNP components is growing, while the size of the components is relatively small—amounting to only 30 percent of all HNP commitments since 1997 (figure 4.7). This part of the portfolio has grown steadily and steeply since 1988 and reflects lending for social funds,12 initiated in fiscal 1989, and of poverty reduction support credits (PRSCs), begun in fiscal 2001. Until 2001, almost all projects with HNP components were investment projects; since then, the majority have been development policy lending.13 The efficacy of these HNP components is not easily assessed unless they reflect explicit objectives for which the projects are accountable. IEG evaluated social funds in 2002,14 and an ongoing evaluation of PRSCs will look at the adequacy of these instruments for achieving HNP results (box 4.3). This section examines in greater depth the extent to which lending in two key sectors—water sup-
Figure 4.6: Multisectoral Projects Had Lower Performance than Other HNP Projects 100 Perent of projects rated moderately satisfactory or higher
Health in the Lending Portfolios of Other Sectors
80 69 67
63 63 57
60
69 61
63 58
43 40 31 20
17
0 Outcome rating
Bank performance rating
All multisectoral (n = 28) Multisectoral HNP (n = 16)
Borrower performance
Multisectoral AIDS (n = 12) Other HNP (n = 71)
Source: IEG portfolio review.
ply and sanitation and transport—has been used to improve HNP outcomes. The selection of these two sectors for evaluation is illustrative, because there are many others with large, demonstrated 63