2 7 1 2 4 Human Development 17 2 December 2000 Findings reports on ongoing operational, economic, and sector work carried out by the World Bank and its member govemments in the Africa Region. It is published periodically by the Knowledge and Leaming Center on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Building National Capacity in the Health, Nutrition and Population Sector: A Perspective wow xperience has clearly shown that ness of Bank's HNP investments it is neither lack of money nor (Stout, Johnston, circa 1998/1999). lack of technological packages These observations and experience that constrains the World Bank's ef- have energized the development of a forts to design and support effective new framework for institutional as- health sector investments with tan- 4i:x ~~~~~~~~~~sessment and design of interventions gible and sustainable results. Rather, th rnia ontan etr for capacity building that have been the principal,constraint centers fine-tuned through their application around the issue of national capacity, in various countries The framework _ ~~which is both limited and whic is both l ed d defines capacity very broadly to en- underutilized. This has been docu- Uri compass the enabling environment, mented as early as 1991 in the Popu- lation, Health and Nutrition Fiscal syst ems/andzprocse and 1991 Sector Review. While this review wr,ssesadpoess n skills. It is also expansive in its inclu- of the Bank's Health, Nutrition and sion of all actors and stakeholders Population (HNP) portfolio noted posi- x ~~~~~~~~~~~~~(non-governmental as well as govern- tive evolutions in both the quantity ~~~~~~~~~~~~~~mental, non-health sector as well as -1 t ~and quality of HNP projects in the and quality of HNP projects in the health sector, and clients/communities a | ~~portfolio since'the Bank began lend- portfolio since the Bank began lend- as well as providers). Finally, it begins ing for health in 1980, it also high- s ' ~~~~~~~~~~~~to frame the question: " the capacity lighted the issue of serious and per- . E r: ~~~~~~~~~~to do what?" sistent weaknesses on the part of the Bank in the assessment of national Application of this framework in the capacity to implement health projects countries in which the author works F k;* and programs and in the design and has shown interesting and promising implementation of institutional results. The World Bank team's efforts strengthening support that is needed to support decentralization and to enhance the outcome and impact greater district autonomy in Niger of Bank investments in the sector. Un- have succeeded in institutionalizing fortunately, this weakness in the participatory district planning and * .' Bank's analytical and operational strategic sector management, most work persists, as is documented in notably quarterly reviews of district Operations Evaluations Department's plan implementation led by the dis- recent review of development effective tricts that evaluate expenditures as well as performance vis-a-vis indica- ments between the various levels of the effort. In the case of Burkina Faso, tors. The successes and lessons the Ministry of Health system that lay the Bank is disbursing $1.5 million learned are incorporated into the fol- out clearly the roles, responsibilities, annually directly to districts to cover lowing quarterly plan. Slowly, but obligations and accountabilities of the costs of critical activities to fight surely, the planning process and plans each party. Quarterly reports and re- communicable diseases for which are evolving away from being input- views of performance against a few, there had been no reliable financing. oriented to results oriented. This carefully selected indicators, as well These amounts are over and above the framework has also led to the design as of the proper utilization and ac- large procurement packages for infra- and implementation of an innovative counting of financial resources pro- structure rehabilitation and expan- partnerships component whereby dis- vide the basis on which future dis- sion and for central and regional-level tricts contract out tasks included in bursements are agreed. This was support. In both Niger and Burkina their action plans to local actors who achieved because: (a) critical Bank Faso, the learning-by-doing approach offer both a comparative advantage as expertise and advice was brought to has proven far superior to the more well as a lower price for carrying out the field in areas where there was po- limited and traditional approaches to such work. Successful examples of tential for resistance or obstacles (pro- "capacity building', including: techni- such contractual arrangements with curement, disbursement, financial cal assistance, training and work- local actors include the cleaning and management, legal); and (b) the gov- shops, reorganization exercises, study maintenance of health facilities by a ermnent was encouraged to take the tours, and purchase of equipment and local youth organization that has at- lead in designing the tools and mecha- supplies for units responsible for sec- tracted more clients, and outreach nisms relating to questions of capac- tor management. work undertaken by a local women's ity, institutional set-ups (within and While the experience thus far is en- association to encourage women to outside MOH) and the decentraliza- couraging, serious challenges remain, utilize prenatal and preventive services tion policy. In essence, the team lis- and these relate also to the present available in the local health center, tened to the needs and constraints of emphasis on Communicable Disease with documented increases in the use the government and found ways to Control and the new Bank-assisted of these services directly attributable accommodate them within the Bank's HIV/AIDS umbrella operation for Af- to this initiative. rules. As a part of the final evaluation rica. In Burkina Faso, for example, the In Burkina Faso, the team has process (Implementation Completion Bank needs to ensure that the Com- worked with the government to sup- Report), which is being initiated, the municable Disease agenda is well ar- port their efforts in decentralizing government is already seeking ways ticulated in the government's national health services and health services and means to institutionalize this pro- health policy and strategic framework. management to the district level cess and apply it to the allocation and The Bank also needs to ensure that through the design and implementa- use of other financial resources for its support is not conceived as being tion of tools and processes for a per- health, both public budget and other "vertical" in nature. Such an approach formance-based management system. donor funding. would risk encouraging and support- This system allows the direct dis- Such approaches entail paradigm ing the resistance (of central-level di- bursement of International Develop- shifts both for the Bank as well as for rectors, responsible for various dis- ment Association (IDA ) funds to dis- the government. The experience to eases) to ongoing reforms for decen- trict commercial bank accounts to top date reveals that such approaches do tralization and integration of pro- off funding from other sources so as in fact build capacity and have the grams. The performance-based man- to give districts the means, as well as potential for expanding the limited agement approach facilitates a suc- the responsibility and accountability, absorptive capacity of MOH and for cessful decentralization and integra- to implement their action plans. It has the more effective utilization of funds tion effort through the choice of ap- also established contractual arrange- for health, and, as such, are well worth propriate performance indicators for Communicable Diseases ( CD ) for The nature of the Bank's HNP work which local actors will be held ac- is evolving in the context of innova- This article is extractedfrom a countable. The Bank is challenged to tions and policies of governments and presentation by Denise go beyond the district with regard to of the Bank itself. Support for public Vaillancourt at a Communicable decentralization and empower and expenditure reviews and capacity Diseases Retreat, August 23-24, establish partnerships with the building support (institutional assess- 2000. This perspective comesfrom myriad of actors and stakeholders ments, assisting governments in ca- the application of her expertise in who have an important part to play in pacity-building efforts and in institu- Management and Public Policy, in the fight against CD: communities, tional reform) are now indispensable a number of settings inside the NGOs, other sectors. The donor to being a critical player in improving World Bank and outside - the US community's emphasis on health and health in Africa. These tasks focus on public sector and a secondment CD demands that coherence and con- the costs, cost-effectiveness and finan- position at UNDP designing and sistency be maintained with regard to cial requirements of medium-term implementing a management the history and rationale of sector dia- expenditure frameworks for health as networking initiative in Sub- logue, working and partnership pro- well as on the assessment and ulti- Saharan Africa. For more informa- tocols and commitments, policy mat- mately the expansion of the absorp- tion, please e-mail: ters, priorities, conditionalities, and tive capacity of governments. Dvaillancourt@worldbank.org rigor in setting targets and in moni- toring and evaluation. Fr II *11 fl%l :S Findings can be accessed via the World Bank Group's website at http://www.worldbank.org/ Click on Publications, then Periodicals. Or, Findings would also be of interest to: click on Countries and Regions, then Africa Name Institution Address Letters, comments, and requests for publications not available at the World Bank Bookstore should be addressed to: Editor, Findings Operational Quality and Knowledge Services Africa Region, The World Bank 1818 H Street NW, Room J-5-055 Washington, D.C. 20433 e-mail: pmohan@worldbank.org