The role of aid in the development of low- and middle-income countries (LMICs) has been extensively studied, with many scholars adopting a critical viewpoint. For instance, Easterly (2002; 2006) argues that despite substantial investments and efforts, donors, including the World Bank (WB), have often fallen short of achieving meaningful impacts. Similarly, Sachs’s (2015) findings suggest a tenuous relationship between official aid and economic growth. Within this discourse, the role and effectiveness of the WB in fostering development have come under intense scrutiny.
While the WB aims to address global challenges, promote sustainable development, and reduce poverty through its interventions, concerns have been raised regarding its effectiveness in addressing the unique needs of different countries and varied sectors (Heyneman, 2003; Mosley et al., 1995). A critical determinant of its effectiveness lies in the organisational commitment to continuous learning (Ravallion, 2016). However, the extent to which the WB adheres to this criterion in practice, particularly in social sectors, remains uncertain. In these sectors, “where lending and policy operations have had to work hard to justify themselves”, the WB encounters challenges compared to other sectors, such as infrastructure (Ravallion, 2013, p. 27).
This article explores the WB’s lending projects for health financing reforms in post-communist Albania from 1994 to 2022 and addresses the research question:
There are two compelling justifications for focusing on the WB’s health projects. First, the WB is the largest funder of health-related projects in LMICs (Ruger, 2005). This significant financial contribution underscores the WB’s influence on health policies (Noy, 2017; Sridhar et al., 2017), making it a crucial area to examine. Second, the WB is also the second-largest funder of global health initiatives (Lancet, 2023). This highlights the WB’s substantial involvement in shaping global health policies and programmes, making it imperative to understand its approach and learning activities in the context of health projects.
Additionally, paying attention to post-communist Central Eastern Europe (CEE) – by focusing on Albania, an under-researched country in the region – is noteworthy due to the WB’s involvement in the political, economic, and social transformation of the CEE alongside the criticisms it has faced. Scholars studying the post-communist healthcare reforms in CEE have highlighted the WB’s “politico-ideological” approach and its tendency to overlook domestic contexts when shaping policy changes (Nemec & Kolisnichenko, 2006; p. 24; Deacon & Hulse, 1997; Wedel, 2015).
The selection of lending projects in Albania’s health financing reforms is particularly relevant, as the WB has been involved in four health projects in the country from 1994 until 2022, offering a rich and comprehensive basis for deep analysis. The Health Services Rehabilitation project (1994–2001) initially focused on infrastructure reconstruction and healthcare service rehabilitation, with limited attention to health financing policy reform. The Health System Recovery and Development project (1998–2005) continued this focus on infrastructure while also targeting institutional capacity building. In contrast, the Health System Modernization project (2006–2012) marked a shift towards structural healthcare reforms, moving away from infrastructure reconstruction. The Health System Improvement project (2015–2022) focused extensively on health financing reforms, addressing issues in all financing policies: revenue collection, pooling, purchasing, coverage, and benefit entitlements.
For detailed information on these policies, see Kutzin et al. (2010).
The analysis employs a sociological lens on International Organisations (IO) by incorporating insights from management studies into International Relations (IR) scholarship. The interest is in scrutinising
The qualitative analysis of data obtained from the WB project documents revealed three types of learning during lending operations in Albania:
The article elucidates the challenges the WB faced in supporting Albanian health financing reforms, thus enriching debates on the effectiveness of the WB’s lending activities and its ability to meet the specific needs of the healthcare sector (Ravallion, 2013). It offers insights into the WB’s involvement in post-communist healthcare reforms in CEE, particularly focusing on health financing, an area marked by inconclusive findings (Kaminska et al., 2021). It also sheds light on an under-researched country, Albania, within this context (Druga, 2022). Moreover, the study advances our understanding of organisational learning in IOs, an area underexplored in existing literature (Lindenthal & Koch, 2013; Koch, 2015). Notably, it empirically illustrates IOs’ challenges in balancing standardised approaches and customisation, particularly in operational knowledge (rather than policy recommendations). What sets this study apart is its unique perspective. While past research has primarily focused on examining the impact of IOs’ activities on national contexts, this study addresses a notable gap (Zapp, 2020, p. 1038) by exploring IOs’ responses to country-specific demands and contexts.
The article is organised into six sections. The following section outlines the state of knowledge in the current literature, analysing both WB lending projects and WB learning processes. It underscores the limitations of existing studies and informs the conceptual framework applied in the analysis. Next, the method section explicates the multiple case design, the strategy for document collection, and how data analysis proceeded. Based on the conceptual framework, the fourth section examines the WB’s learning processes in the four projects. Section five discusses the findings, and the paper concludes with final remarks in the sixth section.
Researchers have employed various theoretical perspectives to analyse and understand the dynamics and impact of the WB’s lending projects. For instance, relying on dependency theories, scholars have examined the WB’s use of lending arrangements to impose preferred policies on recipient countries. They have delved into the intricate power dynamics that unfold between the WB and recipient countries, seeking to gain insight into how conditionality affects domestic policy processes and shapes policy outputs (Mosley et al., 1995; Paloni & Zanardi, 2006; Cormier & Manger, 2021). Other researchers have provided valuable insights into the factors influencing the performance of WB projects, such as project characteristics, staff expertise, and country-specific factors (Heinzel, 2022; Ika et al., 2012). They suggest that a substantial analytical input during the preparation stage is positively associated with project quality and improved outcomes, particularly in lower-income countries and fragile settings (Bulman et al., 2016). Honig (2020) emphasises the importance of staff presence in recipient countries, stating that “[I]n the most fragile states, the presence of senior personnel is associated with greater project success” (p. 749). On the recipient side, higher institutional quality correlates positively with successful project outcomes, while economically unstable environments are associated with poorer outcomes (Denizer et al., 2013; Geli et al., 2014). This article introduces a different perspective by zooming in on organisational learning processes and scrutinising how the organisation navigates and responds to the environment in which it operates.
The exploration of knowledge and learning processes in the WB is not novel. Learning is a broad concept, encompassing policy and social learning (Heclo, 1974; Hall, 1993), lesson drawing (Rose, 1991), and organisational learning (Haas, 1990). However, current research predominantly focuses on analysing processes generating policy-oriented knowledge (Hall, 2007; Heneghan, 2022). For instance, Hall (2007) investigated the evolution of the WB’s social policy agenda, revealing its responses to internal and external stimuli (p. 166). He underscores the challenges of integrating an enhanced social policy framework conceptually and operationally, stressing the need for political support to integrate the social agenda into mainstream operations (p. 169). Similarly, Heneghan’s (2022) study examines policy learning dynamics and consequential policy changes within the WB’s Social Protection and Labor department following the abandonment of its flagship pension policy. However, despite their valuable contributions, these studies provide limited analysis of organisational learning and related processes.
In contrast, another group of studies informing this study examines the WB’s organisational learning processes by applying management concepts to IR literature. Notable examples include Lindenthal and Koch’s (2013) investigation into forty years of WB-financed development projects, exploring the role of organisational learning in environmental protection, and Siebenhüner’s (2008) study on how the WB’s deliberate reflection and learning led to a fundamental re-evaluation of strategies related to environmental issues. This article builds upon and synthesises insights from this perspective, aiming to contribute to understanding organisational learning at the operational level – specifically lending activities – in the context of a different policy area, health.
The sociological perspective on IOs has significantly enriched IR studies by examining how these entities leverage their legal autonomy to establish authority and wield influence (Barnett & Finnemore, 1999). This perspective underscores the importance of knowledge and learning in shaping and governing IR, facilitating a more profound analysis of IOs’ activities and their ability to adapt to dynamic environments (Aldrich, 2008). Learning is a fundamental aspect of IOs’ functioning, and organisational learning is crucial in integrating learning within these organisations (Haas & Haas, 1995, p. 259). The WB is a notable example of an IO that emphasises knowledge management and organisational learning, positioning itself as a repository of knowledge and a continuously learning organisation (Dethier, 2007; Kramarz & Momani, 2017).
Research on organisational learning in IOs has drawn upon two main approaches: Principal-Agent (PA) theory and Sociological Organisation (SO) theory (Weaver, 2007, pp. 495–8). PA theory, rooted in economics, focuses on understanding the interaction between IOs and their principals (such as creditors and borrowers, as seen with the WB) to investigate why IOs engage in processes of learning and change. Conversely, SO theory, grounded in the constructivist perspective of IOs, explores how bureaucratic culture influences IOs’ organisational behaviour and practices.
Addressing the WB as an organisation (see Ness & Brechin, 1988) and a collective actor in its own right, which involves considering its shared rules, norms, goals, resources, and autonomy (Barnett & Finnemore, 1999), this article relies on SO theories and is complemented by theoretical insights from organisational and management studies. The following section explores these theoretical insights and presents the conceptual framework.
In this article, organisational learning is understood from a process and a product perspective (Meyer, 2002). The process refers to how the organisation produces and integrates new knowledge; the product refers to “the knowledge as an outcome” of the learning process (Duncan & Weiss, 1979, p. 85). Such understanding recognises that organisational learning involves acquiring and utilising new knowledge, as delineated in the framework section below. The aim is to enhance an organisation’s performance or achieve desired results (Bennett & Howlett, 1992).
Some theoretical clarifications are, however, needed. Knowledge can be explicit or tacit, individual or collective. Explicit knowledge, easily shared through signs and symbols [including written documents (Nonaka, 1994, p. 16–7)], contrasts with tacit knowledge, which resides in an individual’s mind or is embodied in know-how, making it challenging to express. Additionally, individual knowledge is a straightforward concept – specified as “private, i.e., non-communicable” – while collective knowledge is considered “communicable, consensual, integrated knowledge” that is generally stored in a knowledge repository (Duncan & Weiss, 1979, p. 87) and linked with shared knowledge. This article relies on explicit and collective knowledge, termed here
Learning processes are categorised into
Adaptation is another crucial dimension of organisational learning, referring to the organisation’s ability to make incremental adjustments to activities in response to changes in the external and internal environment (Fiol & Lyles, 1985, p. 811). However, it is essential to note that the assumption that learning always enhances future performance is not always supported by evidence. Learning can be effective or ineffective depending on the theory of action adopted (
Drawing on the abovementioned concepts, Siebenhüner (2008) distinguishes between three forms of organisational learning in IOs:
I employed the The IEG is part of the World Bank Group (WBG) and independent of the Management of the WBG. Instead of reporting to the President, the IEG reports directly to the Executive Board.
The
The study employed a descriptive and exploratory approach, utilising qualitative research methods (Yin, 2017, p. 39). A multiple case study method (Stake, 2013) examined four WB health projects in Albania between 1994 and 2022, as depicted in Table 1, to understand the commonalities and differences in learning across these cases. First, each case was analysed individually to gain insights into the specific learning processes within their contextual setting. Subsequently, through cross-case analysis, the study explored the commonalities and differences in learning across these cases, offering insights into how learning manifested in different temporal contexts (p. 27).
The World Bank’s health lending projects in Albania (1994–2022).
May 1998 | The objective did not change |
Revision of components: - Reallocation of un-disbursed funds to new studies: one was on Health Financing |
One year | |||
August 2000 | Objectives did not change | New activities to align with the new government strategy | One year | |||
May 2002 | The project scope was revised |
Additional technical assistance: - Establishing a monitoring and evaluation system to support policy and planning in the Ministry of Health - Implementing a financial and health management information system for the Health Insurance Institute |
One year | |||
December 2008 | No changes | No changes | No changes | |||
April/May 2010 | Objectives did not change |
Changes in Results Framework and Monitoring: - Two indicators related to the financial sustainability of the Health Insurance Institute and hospital governance were removed |
18 months (until March 2012) | |||
September/October 2011 | - |
Changes in activities: - Cancellation of funds for procurement and installation of software for implementing the information system at the Health Insurance Institute |
- | |||
February 2012 | - | - | Until June 2012 | |||
May 2018 | Project objectives were revised to reflect the simplification of the Project Design |
- Revision of results framework - Revision of project activities, timelines, and cost activities - The project component “Improving the Health Financing System” was dropped |
- | |||
October 2020 | - | Reallocation of funds to prioritise civil works in response to an earthquake and the COVID-19 outbreak | 22 months (beyond December 2022) | |||
November 2021 | - | Additional financing (effective from April 2022) | Until December 2024 |
Source: Author’s compilation based on the analysis of documents listed in the annex.
Before elucidating the criteria employed to select documents for qualitative content analysis and elaborating on the analysis process, it is essential to offer an overview of the WB’s lending instruments and associated processes. This overview facilitates reflection on the nature of the project documentation retained for analysis, recognising that lending project documents encompass various types, each characterised by specific attributes and tailored to address distinct issues (like presentations to governing boards).
The WB employs three instrumental approaches in its lending projects: policy-based lending, investment project loans, and programme-for-results lending. Policy-based lending involves conditionality, requiring borrowers to implement specific policies. Investment project loans are tied to particular projects, with the WB providing funding based on the agreed plan. Introduced in 2004, programme-for-results lending emphasises borrower needs, local contexts, and aid coordination (Cormier, 2015; Mosley et al., 1995).
The lending project cycle consists of three overarching phases: preparation, implementation, and evaluation.
For detailed information on the project cycle framework used by the WB, see
While the roles and contributions of local and international project team members are significant in shaping project outcomes, the research interest in this article is on examining the WB’s organisational learning process by specifically focusing on
Documentation plays a crucial role in each stage of the WB’s project management, serving as a resource for learning and accountability. Various reports are produced at different stages, including Staff Appraisal reports and Program Documents during preparation, Implementation Status Results reports and Restructuring reports during implementation, and Implementation Completion and Results reports, Implementation Completion Report Reviews, and Project Performance Assessment reports during evaluation.
The logic of the WB project cycle (preparation, implementation, and evaluation) and the respective line of documentation, Staff Appraisal reports and Program Documents (preparation), Implementation Status Results reports and Restructuring reports (implementation), and Implementation Completion and Results reports, Implementation Completion Report Reviews and Project Performance Assessment reports (evaluation) for the four WB health projects in Albania, comprise the first set of criteria for the document collection and data analysis. Next, following the
To collect relevant documents for analysis, a two-step approach was employed. The initial step involved gathering health project-related documents using the WB’s projects and operations database,
Data analysis was undertaken manually. The process began with screening all documents and excerpting the relevant text passages about
The WB’s learning process showed progression over time. The initial project in 1994 relied on limited knowledge. Between 1998 and 2005, a notable shift towards a “learning by doing” approach led to more experience and lessons. This growth trend continued with further enhancements in the WB’s learning from 2006 to 2012 and 2015 to 2022. In addition, as presented in Table 1, the four projects underwent various changes during implementation. These processes are analysed in the following subsections.
The war in Kosovo in 1999 had an impact on Albania, which welcomed more than half a million war refugees.
Once again, learning while lending involved adjusting project activities on the basis of analytical work outside the health sector, such as the Growth and Poverty Reduction Strategy (WB, 2005a, p. 4). The project’s scope was revised, several activities were restructured, and additional technical assistance needs were identified. Furthermore, the government was granted a one-year extension for project completion.
Learning from lending highlighted two issues that could have been anticipated earlier according to the WB. First is the Albanian government’s reluctance to allocate funds for technical assistance activities. Second is the insufficient attention given by the WB to “the severe capacity limitations” based on the available knowledge of the situation in Albania at the time (WB, 2005a, pp. 4–5). A key learning point was identifying the varying commitment levels of the government to different project activities, which resulted in lower-priority actions negatively impacting higher-priority ones. Additionally, the WB acknowledged that including large infrastructure investments in social sector lending projects (including health) was risky because they could divert attention from the significant sectoral reforms. Implementation problems were also attributed to internal factors, such as frequent changes in Ministers of Health and key staff (p. 9). Lastly, the sole reliance on WB financing to support technical assistance activities was recognised as a lesson learned. Project implementation revealed that commitments from other donors did not materialise, and the WB’s financing designated for physical work could not be redirected to cover the technical assistance activities (p. 12).
Another noteworthy aspect of
In this third case,
Similar to the previous case,
Due to changes that followed the national elections in June 2017, including: (i) the change in the institutional setup of the implementing agency (under the new Government structure, the Ministry of Health merged with the Social Protection departments of previous Ministry of Labor and Social Welfare, becoming Ministry of Health and Social Protection, MHSP) and (ii) the revision of the internal structure of the MHSP, project implementation has continued to suffer delays
Monitoring activities resulted in several changes. In December 2018, the project components and result framework were revised, leading to the removal of the component related to improving the health financing system with the argument of “the excessive complexity of reforms included under that component” (WB, 2021, p. 6). Furthermore, there were subsequent restructuring efforts. In October 2020, funds were reallocated to address urgent reconstruction needs following the November 2019 earthquake in northern Albania. Additionally, in 2021, additional financing was provided in response to the COVID-19 outbreak (WB, 2021). The implementation of this additional financing commenced in April 2022, resulting in a revised project closing date of December 31st, 2024 (WB, 2022, p. 5). As the project is still being implemented,
At the time of writing.
The study investigated the WB’s learning processes in lending in the context of health financing reforms in Albania from 1994 to 2022. Through a multiple case study approach, the analysis examined the unfolding of these processes within four specific health projects. The findings revealed the applicability of the
The findings demonstrate the type
The findings also show that not all sorts of learning gained from previous projects were considered during the design of the subsequent project. For instance, a key piece of
The type
The final type,
Across cases, the findings highlight a striking pattern in the WB’s organisational behaviour – increased supervisory and reporting activities – indicating that adjusting activities during project implementation was a prevalent practice. In the first and second cases, these activities included mid-term reviews, with one in the former and two in the latter. In the third case, five supervisory and reporting activities took place in addition to mid-term reviews. Finally, nine such activities have been conducted for the ongoing fourth case up to 2018.
These results indicate an adaptive behaviour of the WB during project implementation (Fiol & Lyles, 1985, p. 811) and highlight the WB’s attention towards project oversight and reporting activities. As a result, short- and medium-term modifications to project implementation plans followed. Nonetheless, while identifying and correcting errors, the findings show that various planned activities changed significantly (in scope and financing) and were even dropped. In line with Argyris and Schön (1978), in each case (project), the WB’s learning processes followed a
These arguments lead to the conclusion that even though the most frequently manifested behaviour in the WB’s organisational learning was in the form of
Did the WB’s organisational learning processes in Albanian health projects imply a “learning to learn” (Meyer, 2002, p. 464) approach? Not at all. On the contrary, in some cases, the organisation even failed to learn. Did the WB’s learning enhance the project’s implementation? The present analysis, although not delving deeply into this aspect, is able to provide a modest answer. Effectiveness, that is, the fulfilment of the project’s purposes and objectives, was achieved, sometimes with changes in the activities’ scopes and funding with deadline extensions, and sometimes with terminating activities and even entire project components. This organisational behaviour aligns with Meyer’s statement that “effectiveness … is a good criterion for single-loop learning” (2002, p. 465). Further studies are needed to investigate and quantitatively assess the effectiveness of the WB’s health projects in Albania, as this was beyond the scope of this article. Future studies could also explore the potential for the WB to engage in double-loop learning processes that lead to
This study has provided valuable insights into the WB’s learning processes in an operational context. However, it is essential to acknowledge its limitations. By focusing on
The importance of learning in aid and development organisations has long been recognised as a critical concern (Cassen Report, 1986). In line with this recognition, the WB has emphasised the role of learning in enhancing the effectiveness of its lending operations. However, one issue that warrants attention in these remarks is the relationship between accountability and learning. For instance, an evaluation report on the WB’s lending projects (IEG, 2014) sheds light on weaknesses in the organisation’s operational culture concerning the role of learning in achieving projected results, as it criticises the tendency of using accountability mechanisms, such as supervising, monitoring, and evaluating activities, which are critical tools for organisational management, to improve project ratings rather than as valuable sources for learning.
In other words, although effective learning requires robust feedback loops that allow the organisation to gather input from all stakeholders involved in a lending project, evaluate the project results, and adjust project activities accordingly, accountability mechanisms focused on compliance with predefined targets may, however, not prioritise the proper collection and analysis of feedback from beneficiaries and partners. As the IEG report reveals, lessons learned from previous projects are not consistently integrated into subsequent project designs, and preparing appraisal documents for new projects is sometimes a mere copy–paste process, disregarding the lessons drawn (IEG, 2014).
Balancing accountability and learning within aid and development organisations is paramount, especially amid ongoing debates on aid effectiveness. While accountability often revolves around meeting predetermined objectives and demonstrating results, learning involves a deeper understanding of effectively promoting development. Kogen’s analysis sheds light on the prevailing tendency to conflate these two concepts, where accountability is sometimes prioritised at the expense of fostering learning. She emphasises that learning should not be seen as a byproduct of accountability practices but as the primary objective of evaluation. Rather than viewing success solely through achieving predetermined targets, Kogen advocates prioritising learning to understand how best to promote development effectively. According to her, the focus should shift from whether aid works to the more critical questions of why and how aid works, particularly when it works (Kogen, 2018, pp. 101–2; p. 105).
This is a noteworthy conclusion when discussing the distinction between evaluation practices and accountability mechanisms in relation to aid organisations, particularly the WB or organisations in general. While both types of organisations strive for efficiency and effectiveness in achieving their goals, aid and development organisations, such as the WB (also UN agencies), have a unique mandate for “the betterment of the world at large as their task” (Forss et al., 1998, p. 52). Learning is, therefore, vital for such IOs to effectively address complex development challenges and fulfil their mandate.