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Populatilon, Health, and Nutrition

Population andHuman Resources Department TheWorld Bank November 1992 WPS1046

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World Bank Project-Financed Researchon Population, Health,and Nutrition

J. PriceGittinger and CarolBradford

Public Disclosure Authorized

Mostpopulation,health,and nutritionprojects providefinance for research.Personalities- of both borrowersand Bank staff - make a differencein the qualityof research. Supervision and peer group review also make a difference, and more bestpracticesworkshopsare in order.

PolicyReah WongPapcudminatthefmndings ofwinpn ndM numgetheehan8cofide amongBankstaffand asldbexinciead dopeuuic&Thaspapw,& dbytuxbythReRab hAdvisoyStaff.cynamc thsnfescauthwusrcfl a 1ythdrvwsandsbohdbtWad ndcitodaoconigly.Thefindings, intutadons,andconc1usoaetheauthomeown. Theyshould
act be aunbud to the Wodd B o , its Baud of Dims, its managmemat,or any of its mamber couantri

r_ Policy R orh
Poualn, Health,andNutrition WPS 1046

Thispaper-aproductofthe HealthandNutritionDivis-n, PopulationandHumanResourcesDepartment is partof a largereffortin the departmentto dissemLa&te Bank-funded population,health,and nutrition research.Copiesof thepaperareavailablefreefromtheWorldBank, 1818H StreetNW, Washington, DC 20433. PleasecontactOtilia Nadora,room S6-065,extension31091(November1992, 16 pages). researchcomponenton time and of good quality. For quality researchto be completed,it is importantthat those responsiblefor supervision attacha high priorityto researcheven if it is not a large part of the project in terms of budget.
* Researchthat leads to a project outcomesuch as researchneededto justify releaseof fundsor for a follow-onproject - is morelikely to be undertakenand completedthan is research with a moregeneral objective.

This report on WorldBank project-financed researchon population,health, and nutrition (PuN) iLbased on a reviewof 109staff appraisal reports for projectsfinarnced in fiscal 1980-91 and on selectedinterviewswith task managers. The report looks at only the simplestdimensions of project-financed researchand examines researchoutcomesof only a few projects. Amongconclusionstentativelyreached:
* More than 90 percentof PHN projectsfrom fiscal 1980-91financedresearch. * Bank experiencewith project-financed

researchin the PHN sectorhas beenextremely variable:quite successfulin some countriesand almosta total failure in others. Evenso, some strikingsuccessesjustify continuedefforts to incorporateresearchinto projects and to encourage use of that researchto improveboth national PHN policy and follow-onBank-financed projects. * Personalitiesmake a difference,both among borrowersand withinthe Bank. Oftensuccesses are associatedwith a particularpersonwithinthe govemmentor the Bank who has taken a continuingpersonalinterest in encouragingresearch. * Supervisionis crucialto good results. Supervisionmust be frequentenoughto keepthe

in countrieswhere the institutionalcapabilI ity exists, using a nationalinstitutionto review researchproposalsand to administerresearch grantscan be quite effective.Experienceindicates that some sort of peer-groupreview oroducesbetter research.
* There is probably room for more bestpracticesworkshopswhere PHN staff can exchangeexperiencesaboutsuccessfuldesign and supervisionof project-financed research components.But usuallyit will be necessaryto retainexperiencedconsultantsto help design substantialresearchcomponents.
* More systematic collectionand dissemination of project-financed researchis justified, giventhe considerableamountsof moneyand effortdevotedto it.

ThePolicyResearchWorkingPaperSeriesdisseminates thefmdings of workunderway im theBank.Anobjectiveof theseries is to get these findingsout quickly,even if presentationsare less than fully polished.The findings, interpretations, and conclusions in thesepapersdo notnecessarilyrepresentofficialBank policy. Producedby thePolicy ResearchDissemination Center

World Bank Project-Financed Research on Population, Health, and Nutrition


J. Price Gittinger and Carol Bradford

Table of Contents

Proportion of Projects wlth Research Categories of Research Financed .............................


1 1

Total Value of Project-Financed Research ............................. . Project-Financed Reseach EBperlence ............................. Conmnon Theme and Condusions ............................. Other Sector Project-Flnanced Rescarh .......................... Annex Projects Reviewed...........................

4 4
10 11 13

World Bank Project-Financed Research on Population, Health, and Nutrition

This note reports on World Bank project-financed research on population, health, and nutrition (PHN). It is based on a review of 109 staff appraisal reports (SARs) for projects fLiancedin fiscal years 1980 through 1991 and selected interviews with task managers. The projects reviewedinclude47 in the Africa region; 13 in the East Asia and Pacific region; 15 in the South Asia region; 14 in the Middle East and North Africa region; and 19 in the Latin America and Caribbean region. In tbis note, Tu,rkeyis tabulatedin the MiddleEast and North Africa region. There were no operations in the Europe and Central Asia region during the period reviewed. (A list of the projects reviewed is given in the Annex.) The projects represent essentiallyall Bank financingin the PHN sector during the period under review. The World Bank encouragesPHN research Word Bnkenow gebaseuPoNresech to tostrengthen to strengthen the kcnowledge base upon Which to design cost-effective investments in population, health, and nutrition; to strengthenthe analytical capacity of borrowing governments to undertake policy-related PHN research; and to evaluate program and project performance as a basis for improvingfuture design. four of the five regions covered, the proportionof projectswhich includeda research componentwas over 90 percent; in MENA 80 percent of the projects includeda research component.

Categories of Research Financed

For every project reviewed, the research proposed in the SAR was dassified by one of six categoriesor else was noted as uncategorized(see box). Projectswere reviewedand tabulatedBankwide and on a regional basis (Table 1). The categorieswere medical, demographic/ epidemiological, human resources (including studiesrelatingto personnelpractices),managerial (including operational research), financial, and researchneededto prepare information,education,

andcommunication (IEC)programs.

This note is an initial,exploratory survey.

It looks only at the simplestdimensionsof projectfinancedresearchand examinesresearchoutcomes of only a few projects. Hence, the conclusions reached must be consideredtentativeand subjectto , revision in the light of fuller investigation.




so 0

. ...

.. ....

.. ...
.. _

.. ....
.. _ .


Proportion of ProjectswithResearch
Virtually every project in the PHN sector during the period reviewed containedsome provision for research (Figure 1). Bank-wideand in

A_ "t





WFigure 1. Proportion of projects with research componentsby region and Bank-wide.

& r"i54


FHNResearch Project-Financed
Frequencyof Categories

Research Categories Researchproposedin the 109 SARs reviewed for this note was categorized in one of six categories or else notedas uncategorized. Researchwas taken to mean special studiesof some sort, either as part of project impleir :tationor for a broaderpurpose.
MEDICAL. Includes biological research,clini-

Bank-wide,the most common research component was a managerial studyor operational research. Seventy-two percent of all projects reviewed included oneor anotherkindof managerial research. The next most commoncategories of research were demographic/epidemiological included in 48 percentof all projectsandfinancial studiesincluded in 47 percentof all projectsreviewed. Researchturning on human resources issues,including training of personnel, wasincludneeded to ed in 30 percentof theprojects. Studies prepareIECmaterials wereincluded in 16percent of theprojectsreviewed. (Preparation of the IEC materials themselves wasnotcounted as research.) In some 13 percentof the projectsthere was a medical researchcomponent.

cal studies,medical trials, etc.


ers surveys,censusts,studiesdone withlarge groupsto determine the effectof a program, etc. Includes epidemiology. earchcarriedout HUMANRESOURCES. Res to determine numbers of personnelneededor to assess the skills of individuals providing careor otherservices.Includes assessments of additionaltraining needed or how existing skillsmightbe improved. MANAGERLi. Studies assessingadministrative issues, includingoperational research and means to increase program efficiency. Includes stand-alone evaluations of projects or programs. However, it was assumedthat everyprojectwouldhavea management informationsystem,so MISintended primarily as a management tool duringprojectimplementationwas not included.
FINANCIAL. Researchon programcosts or

means of financinghealth care or nutrition interventions. Includesstudieson cost-recovery and healthinsurance.


tion neededfor IEC programs,but notpreparationof the materials themselves.

Whilethere are regionaldifferences in the frequency in whichcategories are included in projects, they are not strikingand p:obablyare not significant. In every region except MENA, managerial studies werethemostfrequent category encountered. Demographic/epidemiological or financial researchwere the secondand third most common. It is interesting to note that financial studiesin the Africaregion frequentlyrevolved aroundcost recovery,a topicwhichwas of great concern to healthadmniistrators and governments during the decadeof the 1980s. On the other hand, studiesof medicalinsurancewere concentrated in Asia. Researchfor EECmaterialsand programs rangedfrom 7 percentin MENAto 40 percentin SouthAsia. The reasonfor the variation is not clear, and it may be insignificant; it proveddifficult to separate outtheresearch needed to prepare IECmaterials fromthe workof preparingthe materials themselves.Whileno projectin MENAincluded medical research,morethan one in five LACprojectsdid so.

Project-FinancedPHN Research Table 1. Projectswith Research Components by Region and Category, FY'80-FY'91 (Percent)East Asiaand Pacific 15 54 31 54 38 8

Research Category Medical Demographic/ Epidemiological Human Resources Managerial Financial IEC a. Includes Turkey.

Africa 13 43 28 74 55 17

South Asia 13 47 47 93 27 40

MENA' 0 60 20 53 40 7

LAC 21 47 32 74 53 5

Bankwide 13 48 30 72 47 16

Other 7ypes of Research

Researchfor Follow-OnProjects

The rangeof research proposed in the SARs

reviewed was extremely broad, even within the tabulatedcategories. In populationprojects, it was knowledge,attitude, and practice (KAP)research. Population projects also included research on

Bank-wide, 21 percentof the SARsincluded

some explicit provision for research intended to facilitate preparation of a follow-on project percent, in East Asia and Pacific 23 percent, in South Asia 20 percent, in MENA 7 percent, and

commonto find provisionfor family planning (Figure2). The proportionin Africa was 28 maternamortality andon contraceptive use (classified as demographic/epidemiological research). Researchintodrug prescriptionpractices,distribution, or formulation figured in several projects. 100Pat ...... Structural adjustment loans with PHN activities oftenincludedresearchto look at the socialdimens ...... sions of adjustment. Nutrition projects, not surprisingly, generally included nutrition-related o research, especially the extent of malnutrition (classified as demographic/epidemiologicalre- . ................... search). The importanceof malaria in the Amau zon basin led to inclusion of entomologicalre20 search in the Brazil AmazonBasin Malaria Control Project. O MA. At


........ _..............
t MC



Figure 2. Proportion of projects with follow-on project research componentsby region and Bank-wide.

-4of projects in LAC 16 percent. The proportion proto supportfollow-on with researchintended by these understated considerably jectsis probably likelythatmanySARsmight tabulations.It seems be written in the expectationthat all research of a to the preparation wouldcontribute included projectandthat it wouldbe unnecessary follow-on to mentionit explicitly. Further, many SARs generalpopulafor strengthening madeprovision planningandthat would tion, health,andnutrition projects. of follow-on supportpreparation Total Value of Project-Financed Research The sourcesof data for this note do not of permitmore than a very roughapproximation the total amountof Bankand IDA fundsusedfor research. The SARsoftendo not project-financed for reincludeexplicitlythe amountenvisioned search; instead research is often includedwith other items such as trainingor the management system. SARs, of course, are stateinformation were the fundsenvisioned mentsof intent;whether is not knownon thebasisof the actually expended used in this study. Even the documentation oftendo notreportthe Reports ProjectCompletion unlessit wasa veryimportant outcome of research of the project. Frecomponent or contentious to be aboutthe amount quently wheninformation in an SAR,it is not spenton researchis included clear to what extentloan funds will financethe fromthe entirely or if it willbe financed research to the project. contribution government in theselimitations whilekeeping However, of the amountof mind, a gross approximation fundsdevotedto PHN researchfrom Bankloans and IDA creditsis attempted. In a largenumber of the cases where it is possibleto identifythe for between amountspenton research,it accounts one and two percent of the total project costs. to Bank it applies thisrange,andassuming Taking an approxito make andIDA funds,it is possible mation. Total SAR proposedlending for the in this studywas aboutUS$4.6 projectsincluded

PHNResearch Project-Financed billion. If the amountfor healthand other PHN researchis betweenone and two percentof this, that wouldcome to betweenUS$46millionand US$92million,or some US$4 millionto US$8 are valid, it millionannually. If these estimates would make the Bank, after the World Health the largest externalfinancierof Organization, health and other PHN researchin Third World countries.In the late 1980s,the WHObudgetfor $60 millionto $70 researchwas runningbetween million annually. However, accordingto the WHO Officeof Research Promotionand Development,in 1988only 3 percent of this was for areaswhichmightincludepolicyresearch,or on the order of $2 million. Since Bank projectin the areas of financedresearchis dominantly or fimanagement, demography/epidemiology, researchis probablythe nance, project-financed leadingsourceof externalfinancefor thesekinds of research. Project-Financed Research Experience are presentedto Eight countryexperiences of projectthe effectiveness insight into provide research. Theywere selectedto give a financed range of differentkinds of projects,a range of regions, and both successfuland unsuccessful effortsto promoteresearch. Bangladesh Populationand The Bank-ledBangladesh includgrouping13financiers Health Consortium, plusthree executing ingIDAandthe Government United Nations agencies, was instrumentalin workingout the Fourth Populationand Health in fiscalyear 1991. The Fourth Projectapproved part of the Project is a crucial and significant Plan whichextendsfrom 1990 FourthFive-Year are to 1995. Almostall of theprojectcomponents and healthelementsof the Five-Year population is probablythe longestPlan. The Consortium themost andperhaps lived,largest,mostcomplex,

Project-FinancedPHN Research successful exampleof donor coordinationand cofinancing in the history of Bank operations. Preparation of the Fourth Population and Health Project was marked by an extensive series of workshopswhere the issuesand priorities were debated. There was, for example, a three-day high level seminar for senior officials from the Bangladesh Planning Commission, Ministry of Health and Family Welfare, and Ministry of Finance. Another three-day seminar permitted field-level staff to articulate their views about issues and priorities. Representativesof donor agencies met in a workshop to coordinatetheir views about issues and priorities. Finally, yet another three-day workshop brought together donors and government officials to agree on the broad-brush outline of the major approaches and priorities for the five-year implementationperiod of the Fourth Project. There was a three-day workshop in May 1990 in conjunction with the World Health Assemblywhere donor representatives and senior governmentofficialsdiscussedthe directions and activities to be included in the Governmentof Bangladesh'sFive-YearPlan. This process of extensive consultationwas greatly facilitatedby the availabilityof a set of 24 extensivestudies on various aspectsof the population and health sector that had been includedin the Third Population and Family Health Project approved in fiscal year 1986. Preparation of the Third Project was not nearly so consultative in nature as was the Fourth Project, and it was recognizedat the time that in many areas information needed for jointly planningand settingpriorities was incompleteor unavailable. During implementationof the Third Project, the 24 studieswere carried out either directly by the ExternalEvaluation Unit of the Planning CommissionOater the Population Developmentand Evaluation Unit) or on contracts supervisedby the Unit. Thesestudies were critical backgrounddocumentsfor the various workshopsthrough which the approachesand priorities of the Fourth Population and Health Project were agreed upon.
Brazil: Malaria Control

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Project-financedresearch in Brazil has had a substantial impact in changing malaria control 'irograms, has provided a substantial input to a follow-on project, and has influenced thinking about malaria control strategiesworld-wide. When preparation began for the Northwest Region Integrated DevelopmentProgram Project financed in fiscal year 1982, there was limited interest among Governmentagencies in including provision for research in the project. However, the division chief concernedhad visited research institutesin Brazil and wasconvincedmore operational research conducted by these institutions of the anti-malaria couldimprovethe effectiveness campaigns implementedby SUCAM, the semiautonomousorganizationresponsiblefor planning and implementingcontrol programs for all the endemicdiseases in Brazil. At Bank urging, a research component was included in the project; US$2.8 million of the $37.7 was allocated for "research and evaluation." As the project was implemented,SUCAM, using predominantlyproject funds, commissioned research at local institutions. The results of this research made it possible to adapt and adjust the SUCAM anti-malarial campaigns to be more specific to particular areas and, thus, more effective. By 1987, a sizeable body of research on malaria had been financed by project funds. SUCAM,usingproject funds,sponsoreda "Malaria Days" conferencein Brazil, which proved to be highly successful. For three days, researchers from all over the country presented the results of their research. The collected papers were later published in a volume which presents one of the more comprehensive views of malaria control operationsever undertaken. The"Malaria Days" conferencewas also one of the first steps in the preparationof the followon Amazon Basin Malaria Control Project, a

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PHN Research Project-Financed

appreof Healthexpressed the Ministry however, withtheloancommitmnent aboutassuming hension responsibility.A outhavingdirect administrative was workedout by whichthe Miniscompromise relationship try wouldenter into a "consultative" for the Project withIPEA,but woulditselfbe responsible The AmazonBasinMalariaControl of the proposed to be administered contractingand administration fundsfor research alsocontains in the studies. It was decidedto makea separateUS$2 as grantsto researchinstitutions.Changes of researchinstitutesin Brazilhave millionloan for the project. organization of the grantprogram,but slowedimplementation was slow. From the start implementation recentlyprogresshas been made in fundingrein June 1984to loan signing FromBoardapproval searchproposals. sixmonths,andit wasanother tookapproximately in January 1986. Six The research financedby the Northwest year beforeeffectiveness scheduled beforetheprojectwasoriginally ProgramProject months Development RegionIntegrated far beyondBrazil. The emerg- to close,41 percentof the loan funds had been hadrepercussions to 20 studies,but actualdisbursements basedon committed ing patternof malariacontrolstrategies US$270,000. The project was only totalled in the thinking influenced substantially theresearch two years, and closed on an additional efforts extended Previous malariacommunity. international as December 31, 1989 with the cancellationof to 'eradicate' malariawere being recognized that US$279,000.At closing,the Bankhad received appreciation unrealistic.Therewasa growing study. it wouldbe necessaryto shift to malariacontrol, onlyone completed The wouldbe needed. strategies andthat different wasput Early in 1989,a new administrator success of the Brazilianproject in using opin the Miniserationalresearch to shape effectivelocal pro- in chargeof scienceand technology grams made it a model closelyobservedby the try. He felt that policy researchwas important and that the loan funds should be utilized to community. international supportthe research. As a result, 64 research under the project. As of projectswere identified US$198millionprojectfor whichthe Bank lent project, 10 US$150million. For the follow-on operationalresearchstudies were commissioned funds. facility withprojectpreparation
Brazil: HealdtPolicy Studies this writing, reports for 23 studies have been

problems can be Many implementation attributedto thg fact that the Ministryis not a with norhad it any experience researchinstitution, IPEAdidhave Although administration. research rolesandresponsitherespective suchexperience, were not well debilitiesof the two institutions fined, and coordination problems persisted design the project. The compromise throughout to study proposals of evaluating the role jointly with the assigned The project was appraised withinthe Minisgroup, CIPLAN, Sao Paulo Basic HealthProjectapprovedat the a coordinating and delayeddecisame time in fiscal year 1984. As originally try, whichfurthercomplicated by sion-making. discussed,the projectwas to be administered the GovernmentPlanning Institute (IPEA) or anotherresearchinstitution.Duringnegotiations,

The NationalHealthPolicyStudiesProject part of the SecondHealth in Brazil,a stand-alone in fiscalyear 1984,is oneof the Projectapproved few Bankprojectsin anysectoraimedexclusively the at fundingpolicy research. It also illustrates importanceof carefil project design and close draws extensively supervision. (This discussion Reporton the from a draft Project Completion project.)

by the Bank,but manyresearchprojects received have simplybeen left uncompleted.

PHNResearch Project-Financed affectedby The projectwas also adversely rate. Since and a high inflation politicalchanges werenot indexedand the earlyresearchcontracts by the there were long delays in disbursement Ministry, many researchers abandoned their projectsfor lackof funds. In retrospect,Bankhandlingof the project couldhavebeenbetterandmighthavecontributed TheBankcould to moreeffective implementation. designof have been more carefulin institutional the the project, and more forcefulin persuading government of the meritsof the originaldesign. of Healthwas Onceit wasagreedthatthe Ministry body, the Bank should to be the administering moreoften, and in greaterdetail, have discussed viewed exactlywhat sorts of studiesthe Ministry The Bankshould as helpful to policyformulation. in its supervision and have been more consistent wasperformed at different follow-up.Supervision withdifferstaffmembers timesby four different missionswere and supervision ing backgrounds, often chargedwith other activitiesso that they time to the prowere unableto devotesufficient ject. Health policy studies were importantfor and Brazilat the time theprojectwas formulated, continue to be so at present. As a result,withthe are lessons of this project in mind, discussions a majorpolicy witha viewto including proceeding loan. in a forthcoming researchcomponent Cidna In China,theBankhashad a verysuccessfil research. withproject-financed experience The first PHN lendingoperationin China was the Rural Health and Medical Educatirnwas to supportthree Project. One component research institutions,the National Center for Preventive Medicine,the ResearchCenter for Health Planningand Statistics,and the Sichuan Institute of Chinese MateriaMedica.

-7 Medicine Center for Preventive TheNational of five existinginstitutes, was an amalgamation Now distinguished. noneof whichwasparticularly Medifor Preventive as the Academy reorganized cineso that it can awarddoctoraldegrees,it has in the eyes of the Bank becomequite successful for the project. It has developed staffresponsible one of the best reportingsystemson causesof death and morbidity in the developingworld, publishesseveraljournalsof high standard,and studiesin morethan 300 scholarly has completed such areasas operational researchon the Chinese health system, vector and parasite control, and treatment regimes. effective The ResearchCenter for Health Planning and Statisticshas also become quite successful, a highstandard. it wasslowerin reaching although appreciate Initially,the Centerdid notsufficiently system nor for a health information the need for better statistics upon whichto do researchanalyunder a newhead, and renamed sis. Revitalized it andInformation, the Centerfor HealthStatistics systemandis nowhas an effectivedatacollection well positionedto do effective operationalresearch. A very interestingoutcomeof the Bank credit was the broad rangeof researchwhichhas withprojectfundsnotenvisioned beenundertaken by thestrong in the SAR. Thiswasmadepossible of the SDR againstthe dollar which appreciation for sumsbecoming available resulted in substantial research. One researchactivitybeing additional projectin Tianjin financedis a community-based whichhas institutedthe world's largestchronic diseasecontrolexperiment. The studyis tracing cholesterollevels, smokingbehavior, and heart attackand strokemanagement. The Communicable DiseaseCentersin the UnitedStates,initially in the research,has now retainedas a consultant become a full partner, along with the Finnish Ministryof Public Healthand the Academyfor PreventiveMedicine. The study thus combines countrywith researchworkersfrom a developing risingratesof strokeandheart disease,the industrialized country with the highest incidenceof

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Project-FinancedPHN Research

stroke and heart disease (Finland),and an industri- asis and tuberculosiscontrol. The TB treatment alized country which has succeeded in reduciz.g regime to be extended on a wide scale is one developedwith project-financedresearch from the stroke and heart disease (the United States). fiscal year 1984Rural Health and Medical EducaAnother successful health research effort tion Project. established with the additional project funds is being carried out in Beijing in cooperationwith India-Tami Nadu Oxford University. The study Is tracing the effects of different regimes of treating stroke on The Tamil NaduIntegratedNutritionProject mortalityand recovery time. in India was an innovativeand hi'ghlysuccessful Yet another study made possible with the project. It showed that large-scale, communityadditionalprojectfunds is the world's largest study level interventionsin the social sectors can work. linkinghealth practicesand cause of death. More (rhe credit became effective in August 1980 and than 500,000 people have been identifiedand will closed at the end of March 1989. This section be. monitored over a twenty-yearperiod. Of key draws heavily on the Project CompletionReport interest will be the information the study yields for the project.) about the link between smoking and mortality, The project as designed included provision sincenearly all the existk g studiesof smokingand mortality have been carried out in industrialized for a baseline survey and formal mid-term and countries and may have limited applicabilityin a final evaluations. Partly because the mid-term evaluationfindingswere not readyuntil 1986,they developingcountry. were not acted upon by project managementuntil Finally, the project has financed part of an work began on the design of the Second Tamil ongoingstudy of adult-onsetdiabetes with cooper- Nadu Nutrition Project approved in fiscal year ation from researchers in the United Kingdom, 1990. However, the results of both the mid-term and final evaluationsdid have a significantimpact Finland, France, Italy, and the United States. on the design of the second project. Other Chineseprojects have also resultedin The ProjectManagementUnit (PMU)had at successfil project-financed research. The Rural fundsto commissionsmall, stand-alone disposal its (Second Project Medicine Health and Preventive and some 40 to 60 such studies projects research ChinaHealth Project)approvedin fiscal year 1986 financed research into alternative insurance were authorized. Most were judged by Bank staff schemeswhich has influencedChineserural health to be of poor quality and had only a limited impact policy. The IntegratedRegional Health Develop- on the redesign of the project. In retrospect, the ment Project approved in fiscal year 1989 has fact that the PMU had great freedom in commisfunded research to determine if school-based sioningresearch and so could act rapidly and with programs influencesmokingbehavior amongpar- great flexibigityalso contributedto poor research ents. Cartoon books aboutthe health risks associ- design and limited usefulness. It indicatesthat a ated with smoking were the basis for an experi- more formal research committee with qualified mental curriculum.The result of the program was members which could review proposals for relean immediatesharp drop in smoking among the vance and methodologicalsoundness would have parents of the childrentaking part in the program. been a better mechanism. The fact that the standalone research component was not a very significant part of the total project may have meant that to continue will research Project-financed influence Chinese health policy. For example, a Bank staff couldnot devote sufficient supervision fiscal year 1992Bank loan focuseson schistosomi-

Project-Financed PHNResearch


time to improve the qualityof the stand-alone policyandmedical research. The project provides researchprojects. for a US$4millionPopulation Research Fundto financeresearchinto a rangeof topics,including It should be notedthat a distinguished group the socio-cultural andeconomic supports for large of evaluation studieshave been publishedabout families and the determinantsof fertility and thisproject. Theyshowed largedropsin undernu- contraceptive use in Nigeria. An interesting tritionand mortalityamongchildren. However, feature is that the Fund is administered by the thesestudieswerenot fundedby theproject. NigerianInstitutefor Social and EconomicResearch through a Technical Committeewhich includes representatives of the majorusergroups. Mgerla Theprojectalsosupportsextension to otherstates of researchworkat the University CollegeHospiNigeria is another country where Bank tal of the University ofIbadan. The hospitalwas experience withproject-financed research hasbeen the first WorldHealthOrganization collaborating quitesuccessful. In part this is due to the avail- researchcenterfor humanreproduction in Africa. ability of able Nigerianresearchersand senior TheHealthSystem FundProject,alsoapproved in officials interested to fosterresearchandto use the fiscal year 1991,and whichbecameeffectivein resultsin policyformulation and to preparenew March 1992, has provisionto support studies. projects. In part, it is dueto a continuing interest Even beforethe projectbecameeffective,some in researchamongthe Bankstaffresponsible. studieswere alreadyunderwayto supportanticipatedrequests for grantsfromthe Fund. The first PHN lending operationof the 1980sin Nigeriawas the SokotoHealthProject approved in fiscalyear 1985. The projectincludPhilippines ed US$1.4 millionearmarked for studies. The moneywasusedto preparefollow-on projectsand The Philippine HealthDevelopment Project for majorhealthcarefinancing studiesin Sokoto, approved in fiscalyear 1989includes a significant Ogun,andOyo states. The surveyworkin Ogun policy research component. A contract for was used extensively by Bank staff to preparea US$1.2millionfor 36 studieswassignedbetween
majorsub-sectorreport, FederalRepublicof Nge-

The project builds upon the successful implementation of a grantmade in 1988to PIDS by the International Health Policy Program (IHPP), a program to encouragehealth policy A secondlendingoperationin Nigeria,the researchsupported by the Pew Charitable Trusts Imo Health and PopulationProjectapprovedin and the CarnegieCorporation of New York, in fiscal year 1989, includedfunds to establisha cooperation withthe WorldBank andthe World Population StudiesCenter at ImoStateUniversity. HealthOrganization.That grant resultedin six The Centerhas been established, a director ap- substantial studies,mostlyby younger researchers pointed,anda research program isbeingprepared. not previouslyworkingon healthpolicy, which have been widely disseminatedand carefully The National Population Project,approved reviewed by the DOH. in fiscal year 1991, is intendedto supportboth

ria-Health Care Cost, Fnancingand Utilization, whichappeared in October1991. The resultsof the researchand the sub-sectorreport are being used as a basis for the First Referral Hospital Projectanda nutrition projectnow underpreparation.

the Departmentof Health (DOH) and the Philippine Institutefor Development Studies(PIDS)in

mid-1991, and workis proceeding.

- 10For the Bank-financed research,the DOH, in cooperation withthe University of the Philippines Schoolof Economics and PIDS, developed terms of reference for baseline studies to be conducted in relation to the design of a corepolicy reform package for the health care financing system. Fromthis emerged the specificstudies to be supervised by PIDS. A ProjectSteering Committeechairedby a DOHunder-secretary has been established. The topicschosenfor the research studiesincludebeneficiaryand providerprofile andbehavior,financialresourcebase and institutions, the healthcarefinancing environment, and planning models for the health care financing system. In addition, Bank-financed research would collect, generate, and disseminatedata pertinentto the healthcare financing systemand the healthsystemin general. A secondary data inventory and primarydata collection are part of the projectactivities.The primarydatacollection is aimedat gathering baselinedatawhichare not collectedby governmentor private statistical agencies. The data base is expected to be maintainedaftercompletion of the projectby the DOH with USAIDassistance. Monitoring andconsultation activitiesare built into the projectimplementationand several local and national level workshops are plannedfollowing a patterndevelopedunder the earlierIHPPprogram. Zaire Finally,theexperience inZairedemonstrates once againthat the Bank can be of only limited effectiveness in situations wherethe overall political and ecenomicenvironment is adverse. The Social Sector Project and the National AIDS Control Program AssistanceProject, both approved in fiscal year 1991, containedbetween them provision for some US$1.5 million for research. Yetconditions havebeensuchthat asof this datevirtuallyno researchhas been undertaken.

Project-Financed PHNResearch Common Themes and Conclusions The information on whichthis noteis based can only support preliminary conclusions about project-financed research. There are, however, severalgeneralizations whichcanbe made: * Bankexperience withproject-financed researchin the PHN sectorhas beenextremely variable,quite successfulin some countries andalmosta totalfailurein others. Even so, some strikingsuccesses can be noted,as the country experiences outlined here have demonstrated.These successes certainly justify continued effortsto incorporate researchinto projects and to encourageuse of that researchboth to improveoverallnational PHNpolicyandfollow-on Bank-financed projects. * Personalitiesmake a difference, both amongborrowersand withinthe Bank. Quiteoftenwhen there has been a successful experience,a particularperson withinthegovernment or withintheBank has taken a personal and continuing interestin encouraging research.
0 Supervision is crucial to good results.

Supervision must be frequentenoughto keepthe research component on time and of goodquality. It is importantif good qualityresearchis to be completed that thoseresponsible for supervision attacha highpriorityto researcheven if it is not a large part of the project in money terms.
0 Research that leadsto a projectoutcome

-such asthat neededtojustifyreleaseof fundsor for a follow-on project-is more likely to be undertakenand completed than is research with a more general objective.

PHNResearch Project-Financed capawherethe institutional * In countries institution to bilityexists,usinga national andto adminreviewresearchproposals be quite effecister researchgrants c;un indicatessomesort of tive. Experience peer-group reviewresultsinbetterquality research. * There probablyis room for more "best practices"workshopswherePHN staff can exchange experiences aboutsuccessof projectful design and supervision financed research components. However, in most cases it will probablybe necesconsultants to sary to retainexperienced reassist with the designof substantial searchcomponents. collection and dissemi- More systematic research is nation of project-financed amounts justified,giventhe considerable to of moneyand effortwhichis devoted it. Other Sector Project-Financed Research Two other recent studies of World Bank project-financed research havebeenpublished, one eachin the education and agriculture sectors. Education The education studyis WorldBankLending for Education Research, 1982-89 by Marlaine E. Lockheedand Alastair G. Rodd. The authors reviewed 146 Bank educationprojects inidated between fiscalyear 1982andfiscalyear 1989. Of these, 116 includedresearchcomponents. The authorsfound that 2.2 percent of the loans and creditsof these 116projectswas allocated to research, an outcomenot muchdifferentfrom the PHN resultsreportedin this note. They found, however,that researchas a percentage of total loan commitment declinedsharplyfrom 1982to

- 11 by this study not demonstrated 1989,an outcome for the PHN sector. Of the 436 plannedstudies the authors identified,only 184 (or 42 percent) and of theseonly 84 were availwerecompleted able through Regional Information Centers. Examination of the SARs in the PHN sectordid closeto sucha preciseestimate not yieldanything in projects,but of the number of studiesincluded fromtalkingto taskmanagthegeneralimpression ers is that in the PHN sector,too, manyplanned studiesare not completed. One would be hard pressedto collecta completeset of reports for those PHN studieswhichwere completed. The authorsof the educationstudy were particularly criticalof the fact that only 5.6 percent of the to do withassesscompleted studies"hadanything outcomes." ingeducational that more attenThe authorsrecommended of tion be paid to the designand implementation research componentsin educationprojects, a feel valid whichmanywouldprobably conclusion for PHN projects. To facilitatethis, they recthat the Bankdevelopa programto train ommend withappropriate operational staffto designstudios methodologies andwhichwoulddevelop domestic researchcapacity. In the PHN sector, it would appearmore appropriate to assureaccessto suitableconsulting servicesfor the designof research components rather than to undertakea training enoughto teach operational programsubstantial staff how to designresearchcomponents. They recommended free-standing educational research projectsin larger countries.Exceptfor theBrazil HealthPolicyStudiesProjectthat waspart of the SecondHealthProject,no PHNprojectreviewed for this note was a free-standing research project, nor have interviewswith task managersfounda substantial measureof support for free-standing PHN research projects. Finally, the authors recommend muchmore attentionbe paid to dissemination of research reportswithintheBankand within the borrowingcountry, and that project completion reports containa bibliography of the studiescompleted under a project, both suggestionswhichwouldbe applicable to thePHNsector.

- 12 -

Project-FinancedPHN Research

agricultural researchsystems;(2) an examination on a regional basisfor thelackof effectiveness of The othermajorrecentlypublished studyof researchcomponents; (3) evaluation of the effecproject-financed researchis Lending by the World tivenessof policy-based lendingin the developBankfor AgriculturalResearch-A Review of the mentof agriculturalresearch; (4) trainingfor Bank Years 1981through 1987by Anthony J. Pritchard. staffto increase skillsin supervision andappraisal of researchprojects;(5) expansion of the timeThe extent of Bank lending to support frameof agricultural research projects; (6)analysis researchin agriculture is muchgreaterthan it is in of therelationship between component sizeandthe the PHN sector. From 1981through1987,the successof research programs; (7) development of Bank lent for 21 free-standing researchprojects Bank policy regardingsupportof biotechnology and 209 agricultural and rural development pro- research for developing countries; (8)reassessment jects withresearchcomponents.The totalcostof of the Bank'sinfluenceon researchprogramsat theagricultural research elements in Bank-financed the international agricultural researchcentersto agricultural projects was $2.1 billion-25 to 50 ensureefficient use of resources; (9) developing a timesthe amountof project-financed researchin methodology to determinecosts and benefitsof PHNprojects. Additional supportfor agricultural agriculturalresearch projects and components; researchwas provided through 12 education pro- (10) an evaluation of the contributions of consuljects, 16 policy-based loans, and grants to the tant expertsin agricultural researchprojects;and Consultative Groupfor International Research and (11)a reviewof the conceptsand procedures for otherinternational institutions. extension-research linkages. Because of differencesin the history of agricultural lendingand PHN lendingwithinthe Bank andbecausefree-standing researchprojects are morecommonin the agriculture sector, agriculturestaff have a tendencyto be much more directlyinvolvedin the establishment of research institutionsand programs and in supervising researchactivities. Pritchardfound that free-standing research projectswere generallysuccessful 'in institutionbuilding and in financingproductiveresearch programs." However,"problems in implementing research componentsin agriculturaland rural development projectswere sometimes severeand thelimitedsuccess of thesecomponents is a cause for concern." Pritchard hada number ofrecommendations, manyof whichwouldbe inappropriate if applied in the PHNsectorgiventhedifferent emphasis and scale,butsome of whichwouldsoundfamiliar to PHN staff. He recommended: (1) continued emphasis on developmentof strong national To increasethe chancesof successin agricultural research projects and components, Pritchard suggestedincreasedattentionto: (1) administrative and proceduralproblems during projectstart-up;(2) adaptive and applied research needsfor the complete farmingsystem;(3) developing national agriculturalresearch plans; (4) supporting regional research initiatives; (5)allocating project funds for contractand collaborative research;(6) definingstaffingneeds,identifying requirementsfor support staff, and providing adequate trainingand education opportunities; (7) developing publicawareness programs to broaden publicsupportfor agricultural research;(8) providing incentives for researchworkersto assure retentionof high calibrestaff; and (9) exploring alternative meansof providing operating fundsfor research. J. PriceGittinger CarolBradford


Project-Financed PHN Research

-13 -

Annex. Projects Reviewed

Total Amount of Project (USS million) 32.0 26.6 28.0 18.7 85.7 26.9 3.1 29.7 43.9 20.8 15.1 16.0 34.3 22.5 4.4 61.0 28.3 41.3 7.4 22.1 42.5 8.7 24.9 74.3 17.6 61.4 42.5 29.3 53.0 36.8 85.1 94.5 93.6 14.5 26.1 Amount of Loan/ Credit (US$ million) 8.6 11.0 26.6 14.0 21.5 13.4 2.8 22.2 33.0 5.6 7.0 15.0 27.0 19.7 4.2 23.0 12.2 35.0 3.5 12.1 31.0 6.8 11.0 55.5 16.7 26.6 27.0 27.8 34.0 27.6 68.1 70.0 78.5 10.8 19.6

Region/ Country AFRICA Benin Botswana Burkina Faso Burundi Cameroon Chad Comoros C6te d'Ivoire Ethiopia Gambia Gambia Ghana Ghana Guinea Guinea-Bissau Kenya Kenya Kenya Lesotho Lesotho Madagascar Malawi Malawi Malawi Mali Mali Mozambique Niger Nigeria Nigeria Nigeria Nigeria Nigeria Rwanda Rwanda

Project Health ServicesDevelopment Family Health Health ServicesDevelopment Populationand Health Social Dimensionsof Adjustment Social Development Action Health and Population Health and Demographic Family Health National Health Development Womenin Development Health and EducationRehabilitation Second Health and Population Health ServicesDevelopment Population,Health and Nutrition Integratd Rural Health and Family Planning Third Population Fourth Population Health and Population Second Popation, Health and Nutrition Health Sector Improvement Health SecondFamily Health Population, Healdth and Nutrition Sector Credit Health Development Second Health, Populationand Rural Water Supply Health and Nutrition Health SokotoHealth Imo Health and Population EssentialDrugs Health SystemFund NationalPopulation Family Health First Population

Fiscal Year 1989 1984 1985 1988 1990 1990 1984 1986 1988 1987 1990 1986 1991 1988 1987 1982 1988 1990 1985 1990 1991 1983 1987 1991 1984 1991 1989 1986 1985 1989 1990 1991 1991 1986 1991

- 14 -

Project-FinancedPHN Research
Total Amount of Project (US$ million) 16.7 37.8 5.7 70.0 52.7 65.5 37.0 21.9 37.0 52.6 116.9 322.8 177.4 113.0 72.6

Region/ Country Senegal Senegal Sierra Leone Tanzania Togo Uganda Uganda Zaire Zaire Zambia Zimbabwe Zimbabwe

Project Rural Health Human ResourcesDavelopment Health and Popuation Sector Support Health and Nutrition Populationand Health Sector Adjustment First Health Social Costs of Adjustment NationalAIDS Control Program Assistance Social Sector Social Recovery Family Health SecondFamily Health

Fiscal Year 1983 1991 1986 1990 1991 1988 1990 1989 1991 1991 1987 1991 1984 1986 1989 1980

Amount of Loan/ Credit (USS million) 15.0 35.0

47.6 14.2 42.5 28.0 8.1 30.4 20.0 10.0 25.0 85.0 80.0 52.0 35.0

EAST ASIA AND PACIFIC China Rural Health and MedicalEducation China Rural Health and PreventiveMedicine China Integrated RegionalHealth Development Indonesia Third Populadon
Indonesia Provincial Health

Indonesia Indonesia Indonesia Indonesia Indonesia Korea Korea Philippines

Fourth Population Second Health (ManpowerDevelopment) SecondNutrition and Community Health Third Health Fifth Populadon Population Health Technology Health Development Third Populaton and Family Health Fourth Populationand Health SecondPopulation

1985 198S 1986 1989 1991 1980 1991 1989

94.4 65.9 57.5 103.5 148.4 93.4 81.2 108.4

46.0 39.0 33.4 43.5 104.0 30.0 60.0 70.1

Bangladesh Bangladesh India 1986 1991 1980 213.8 601.4 96.0 78.0 180.0 46.0

lidia Ildia

TamilNaduNutrition ThirdPopulation
Fourth Population

1980 1984
1986 1988

66.4 123.5
89.9 182.0

32.0 70.0
51.0 57.0


Fifth(Bombay andMadras) Population

Project-FinancedPHN Research Total Amount of Project (US$million)

- 15 Amount of Loan/ Credit (US$million)

Region/ Country India India India India Pakistan Pakistan Sri Lanka Sri Lrank

Project Sixth(National FamilyWelfare Training and Systems Development) Population Seventh Population Second TamilNaduNutrtion Integrated ChildDevelopment Services Population FamilyHealth Healthand FamilyPlanning PovertyAlleviation

Fiscal Year

1989 1990 1990 1991 1983 1991 1988 1991 1991 1991 1985 1985 1990 1987 1981 1991 1991 1989 1983 1983 1989 1990 1991 1990 1990 1982 1984 1986 1988 1989 1990 1986 1990 1991 1990

182.0 141.5 139.1 157.5 28.2 62.9 21.4 85.0 26.7 572.0 30.5 47.6 171.3 30.6 63.2 49.5 146.7 15.9 10.4 7.6 19.1 59.5 38.6 95.6 149.0 123.6 129.7 218.0 198.0 610.6 118.0 40.2 35.6 33.7

124.6 86.7 95.8 106.0 18.0 45.0 17.5 57.5 16.0 140.0 13.5 28.4 104.0 13.3 12.5 26.0 30.0 75.0 10.5 7.6 4.5 15.0 33.0 20.0 10.0 13.0 57.5 59.5 109.0 150.0 267.0 36.5 24.0 26.0 28.2

MIDDLE EASTANDNORTHAFRICA Algeria PilotPublicHealth Egypt SocialFund Jordan Primay HealthCare Morocco HealthDevelopment Morocco HealthSectorInvestment Oman Health Tunisia Healthand Population Tunisia Poplation and FamilyHealth Tunisia Hospital Resctudring and Supply Turkey Health Yemen ArabRepublic Health Yemen PDR HealthDevelopment Yemen PDR Second HealthDevelopment Yemen HealthSectorDevelopment Yemen Emergency Recovery LATINAMERICA ANDCARIBBEAN Bolivia Integrated Health Development Bolivia SocialInvestment Fund Brazil Northwest RegionIntegrated Development ProgramFirstPhaseHealth Brazil Second Health Brazil Northeast BasicHealthServices Brazil Northeast Endemic DiseaseControl Brazil Amazon BasinMlarda Control Brazil ondNortheast BasicHealthServices Colombia HealthServices Integration Colombia Community ChildCareandNutrition El Salvador SocialSector Rehabilitation Haiti First Health

16 -

Project-Financed PHN Research

Region/ Country Haiti Honduras Jamaica Jamaica Mexico


Project Economicand Social Fund Social InvestmentFund Populationand Health Social Sectors Development Basic Health Care
Primary Health Care

Fiscal Year 1991 1991 1987 1990 1991


Total Amount of Project (US$ million) 23.6 60.0 12.4 67.0 249.8

Amount of Loan/ Credit (USS million) 11.3 20.5 10.0 30.0 180.0


Social Development




Policy Research Working Paper Series Title WPS1 019 HowEffective areDirected Credk Policies in the United States? A Literature Survey WPS1020 Another Lookat Population and andGlobal Warming WPS1021 Measuring Welfare Changes from Commodity PriceStabilization in Small OpenEconomies Author AnitaM. Schwarz Date November 1992 Contact for paper M.Raggambi 37664 S. Rothschild 37460 D. Gustafson 33714 M. T.Sanchez 33731 M. T.Sanchez 33731 D. Gustafson 33714 D. Ballantyne 38004

Nancy Birdsall Jonathan R.Coleman ChrisJones

November 1992 November 1992

WPS1022 A NewApproach to Evaluating Trade James E. Anderson Policy J. Peter Neary WPS1023 TariffIndex Theory James E. Anderson

November 1992 November 1992 November 1992

WPS1024 An Exact Approach for Evaluating WillMartin theBenefits fromTechnological JulianM.Alston


WPS1025 Openness andEconomic KaziM.Matin Performance in Sub-Saharan Africa: Evidence fromTime-Series CrossCountry Analysis WPS1026 Financial Liberalization and PaulD.McNelis Adjustment in ChileandNewZealand Klaus Schmidt-Hebbel WPS1027 Lessons fromBankPrivatization InMexico WPS1028 Socioeconomic andEthnic Determinants of Grade Repetition in Bolivia andGuatemala Guillermo Bames

November 1992

November 1992 November 1992

A. Marahon 31450 W. Pitayatonakarn 37664 L. Longo 39244 P. Pender 37851 P. Pender 37851 P. Pender 37851 0. Nadora 31091.

HarryAnthony Patrinos November 1992 George Psacharopoulos November 1992 November 1992

WPS1029 Controlling Tropical Deforestation: Robert T.Deacon An Analysis of Alternative Policies WPS1030 Measuring the Effects of Urban Transportation Policies on the Environment: A Survey of Models WPS1031 Measuring the Possibilities of Interfuel Substitution WPS1032 EastAsiaand Pacific Region, South AsiaRegion Population Projections, 1992-93 Edition AlanJ. Krupnick

Robert Bacon Eduard Bos MyT.Vu Anr.Levin

November 1992 November 1992

Policy Research Working Paper Series Contact for paper 0. Nadora 31091

Title WPS1033Latin Americaand the Caribbean Region (andNorthernAmerica) PopulationProjections,1992-93 Edition

Author My T. Vu EduardBos Ann Levin

Date 1992 November

David H. Scott 034 RevisingFinancialSectorPolicy WPS1 in TransitionalSocialistEconomies: Will UniversalBanksProveViable? WPS1035How ImportProtectionAffects the Philippines'Motor VehicleIndustry WPS1 036 OutputDeclinein Hungaryand and Polandin 1990-91:Structural Changeand AggregateShocks Wendy E. Takacs


K. Waelti 37664


D. Ballantyne 37947 0. del Cid 35195

SimonCommander FabrizioCoricelli

November 1992

Ana-Maria Arrlagada WPS1037 VocationalSecondarySchooling, Choice,and Earnings AdrianZiderman Occupational in Brazil

1992 November

C. Cristobal 33640

November 1992 Workers' IbrahimA. Elbadawi of Expatriate WPS1038 Determinants Rocha Robertde Rezende Remitancesin NorthAfrica and Europe WPS1039 Education,Extemaliies, Fertiliy, Growth and Economic in WPS1040 Lessonsof Trade Liberalization in Latin Americafor Economies Transition WPS1041Family PlanningSuccessStoriesin Bangladeshand India WPS1042 FamilyPlanningSuccessin Two Citiesin Zaire MartinWeale November1992

A. Maraiion 31450

PHREE 33680 D. Ballantyne 37947

Jaimede Meb Dhar Sumana

November 1992


November 1992

0. Nadora 31091 0. Nadora 31091 R. Vo 33722

Jane T. Bertrand Judith E. Brown

1992 November

Stijn Claessens Country WPS1043 DerivingDeveloping Capacityfrom the Market GeorgePennacchi Repayment Pricesof SovereignDebt Cost Functionsfor WPS1044 HospRtal Developing Countries AdamWagstaff Howard Barnum

1992 November


0. Nadora 31091 M. Abundo 36820 0. Nadora 31091

Subbarao 045 SocialGainsfrom FemaleEducation: Kalanidhi WPS1 LauraRaney Study A Cross-National WPS1046 World BankProject-Financed Health, Researchon Population, and Nutrition J. PriceGittinger Carol Bradford

November 1992

1992 November