I M P ROV I N G E F F E C T I V E N E S S A N D OUT C O M E S F O R T H E P OO R I N H E A LT H , N UT R IT I O N , A N D P O P U L AT I O N
Figure 3.3: The Share of HNP Project Approvals with Health Reform Objectives Has Declined in Middle-Income Countries and in Most Regions 90 80
80
74
Percent of projects
70
66
62
60 50
60
45
42
40
40
33
30
31
31 25
26 20
20
20
20
16 7
10 0 All countries (n = 220)
Lowincome (n = 102)
Middleincome (n = 220)
Middle East Europe and North and Central Asia Africa (n = 40) (n = 8)
Latin America and the Caribbean (n = 46)
East Asia and Pacific (n = 25)
Africa (n = 73)
South Asia (n = 28)
Country income and Region Fiscal years 1997–2001
Fiscal years 2002–06
Source: IEG portfolio review. Note: The decline in share of health reform projects overall and in middle-income countries is statistically significant at p < .01, and the decline in Latin America and the Caribbean and in Africa at p < .05. Eight Regional projects are excluded from the tabulation by country income.
Table 3.1: Outcomes and Bank Performance Are Lower for Health Reform Projects than for Other HNP Projects in Middle-Income Countries IEG rating– satisfactory Outcome
Health reform projects (n = 29)
Other HNP projects (n = 14)
71
86
a
Bank performance
69
Borrower performance
72
93a 79
Source: IEG portfolio review. Note: In low-income countries there are only 8 completed health reform projects that were approved during fiscal 1997–2006 and 37 other completed HNP projects. Both outcome and Bank performance are substantially higher for health reform projects than for other projects in low-income countries, but these differences are not statistically significant because of the small sample. Borrower performance is similar for the two groups. a. The difference between health reform and other HNP projects is weakly significant at p = .08.
Bank performance for health reform projects in middle-income countries is substantially and significantly lower than for HNP projects with other objectives. The Bank’s performance—including quality at entry (preparation) and super42
vision—was satisfactory in only 69 percent of health reform projects, compared with 93 percent of other HNP projects. IEG reviews of Implementation Completion Reports (ICRs) found the following factors associated with good Bank performance: • A design based on strong sector work23 • Thorough institutional and stakeholder analysis24 • Use of local experts, consultation with stakeholders, good communication, and full ownership of the reforms25 • Creative use of other instruments to backstop reforms26 • Strong and active dialogue with government throughout implementation. Poor Bank performance was often linked to weaknesses in these same areas, as well as inadequate institutional analysis or risk mitigation plans, over-