Burundi - Population and Health Project

Document of The World Bank FOR OFFICiAL USE ONLY Report No. P-4680-BU MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 11 MILLION TO THE REPUBLIC OF BURUNDI FOR A POPULATION AND HEALTH PROJECT November 24, 1987 This document has a restited distribution and may be used by mrpients oniy In the perfonnmuce of their official duties. Ils conteats may not otherwise be disclosed whout Wodd Bank authmiziul.  CURRENCY EQUIVALENTS Currency Unit - Burundi Franc (FBu) US$ 1.00 - FBu 126 (November 1987) FBu 1 US$ 0.008 MEASUREMENTS 1 Meter 5 3.28 Feet 1 Kilometer 0.62 Mile 1 Square Kilometer = 0.39 Square Mile 1 Hectare 2.47 Acres GLOSSARY OF ABBREVIATIONS AIDS - Acquired Immunodeficiency Syndrome FP - Family Planning HC Health Center IEC Information, Education and Communication MCH a Maternal and Child Health MOA Ministry of Agriculture MOH - Ministry of Health MOI Ministry of Interior PHC Primary Health Care TFR Total Fertility Rate GOVERNMENT OF BURUNDI FISCAL YEAR January 1st - December 31st  FOR OMCIL VE Ony MEMORANDUM OF THE PRgSIDENT BURUNDI POPULATION AND HEALTH PROJECT Credit and Project Summary Borrower: Government of Burundi Beneficiary: Ministry of Health Amount: SnR 11.0 million (US$ 14.0 million equivalent) Terms: Standard IDA, with 40 years maturity Financing Plan: Government: $ 2.9 million IDA: $14.0 million UNICEF: $ 1.8 million Total $18.7 million Economic Rate of Returns Not Applicable Staff Appraisal Report: No. 6829-BU Maps: IBRD 20605 IBRD 20141 I This document has a restricted distribution and may be used by recipients only in the I ';.1..-e or their officiali duties. Its contents may not otherwise be disclosed without World Bank aunorintuou.  MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE REPUBLIC OF BURUNDI FOR A POPULATION AND HEALTH PROJECT 1. The following report on a proposed development credit to Burundi for SDR 11 million (US$14.0 million equivalent) is submitted for approval. The proposed credit would be on standard IDA terms with a maturity of 40 years to help finance a Population and Health Project. The project would be cofinanced by UNICEF for US$1.8 million. 2. Background. With a population density of 180 per km2, Burundi is the second most densely populated country in Africa, after Rwanda. The present population is 4.9 million (95% of which is rural) and will double !a 23 years at the present growth rate of about 3% per year. The Government, aware that rapid population growth is one of the most threatening con-traints to economic development, adopted a policy of population control in 1983, and launched an intensive information campaign. Even the influential Catholic church has accepted the need for planned parenthood through natural methods. Present contraceptive prevalence is estimated at 1.6% (1% in rural areas and 3% in urban areas). To reduce the population growth rate to 2% (assuming a constant mortality decline), the contraceptive prevalence rate should reach 33% by the year 2000--a target which requires massive family planning (FP) efforts. The hi,h under-five child mortality rate (nearly 20%) and the high fertility rate (about 6.2 children per woman) could be reduced by standard Liaternal and child health (MCH) services if they were fully available. While health/nutrition status 4s poor (life expectancy at birth is 47 years), they are similar to those previalent in Eastern Africa. Mortality might rise in the next years due to the spread of Acquired Immunodeficiency Syndrome (AIDS) which is already highly prevalent in urban areas. Whereas physical access to health care is relatively wood by Sub-Saharan African standards (65% of the population lives within 5Km of a health facility; but, due to the mountainous terrain, accessibility varies), availability of primary health care (PHC) services is still too low to have a major impact on mortality, morbidity, or fertility. This is mostly due to: (a) the lack of comprehensive national MCH policies and programs (including FP and nutrition) which would target the activities to the most vulnerable groups (under-five children, pregnant and lactating women); (b) the absence of a structured information, education, and communication (IEC) program; (c) the institutional weakness of the Ministry of Health (MOH); and (d) the lack of financing to expand health activities.  -2- 3. Prolect Obiectives. The overall objectives are to: (a) contribute to the reduction of maternal and child morbidity and mortality; (b) promote and develop birth spacing and family planning among couples; (c) contribute tc AIDS control; (d) improve the overall effectiveness and efficiency of the health system; and (e) improve the national population database. The project objectives are fully consistent with key government objectives to be reached by the end of the fifth Five-Year Development Plan (1988-92): (a) reducing maternal mortality by 20%; (b) reducing infant mortality from 125 per 1000 to 100 per 1000; and (c) increasing contraceptive prevalence from 1.6% to 14%. These objectives are ambitious for a five-year period and will require a strong commitment from the Government and major efforts from the donor community. The proposed project is considered by the Government to be a key element of its strategy toward the achievement of proposed objectives, and IDA involvement in the sector is likely to stimulate both continuous Government cemmitment and other donor collaboration. 4. Project Description. The proposed project has five components which would address the above objectives by: (a) strengtheninx MCH and FP services nationwide through (i) the establishment of a national MCH/FP program and an MCH/FP Division in the Department of Hygiene and Prevention to manage program implementation, (ii) additional staff for health centers (HCs) and technical assistance to the MCH/FP Division, (iii) improvement in medical supplies, including contraceptives, (iv) rehabilitation of 30 health centers (HCs), (v) creation of three regional maintenance workshops, (vi) additional vehicles for supervision, and (vii) monitoring and evaluation; (b) developing a national IEC program through (i) the strengthening of the MOH education division with additional staff, technical assistance, equipment, and vehicles, (ii) the development of IEC material- for the media, schools, and social sector personnel, (iii) the trai .-ng of health staff and social workers, and (iv) supervision and evaluation; (c) contributing to the National AIDS Control Program, through (i) health staff training, (ii) health education materials development, (iii) provision of medical supplies (including condoms) and laboratory equipment, and (iv) research and evaluation; (d) developing the MOH institutional capability through (i) the strengthening of key units, including the planning bvreau and the health statistics unit, (ii) the development of management systems, and (iii) the development of new finauicing mechanisms and better resource allocation schemes for the health sector; and (e) population data development through (i) financing of temporary staff recruited by the Population Department to carry out the population census, (ii) development of census materials, and (iii) funding of seminars to disseminate population data. The health components will be implemented by existing MOH departments, divisions, and units under the overall guidance of the Inspection and Planning Bureau which responds directly to the Minister of Health. The population component will be implemented by the Population Department of the Ministry of Interior in close collaboration with the Inspection and Planning Bureau. The project, to be carried out over five- and-one-half years provides funds for civil works, furniture, equipment, materials, vehicles, training, technical assistance, studies, research, evaluation, and incremental recurrent costs. The total cost of the project is estimated at US$18.7 million equivalent with a foreign exchange component of US$10.5 million (56.0%). A breakdown of costs and the financing plan are shown in Schedule A. Amounts and methods of procurement and of disbursements, and the disbursement schedule are shown in Schedule B. Bank  - 3 - Group operations in Burundi are given in Schedules C and D, respectively. Maps are attached. The Staff Appraisal Report, No. 6829-BU dated November 16, 1987 is also attached. 5. Rationale for IDA Involvement. Long-term IDA strategy in Burundi places emphasis on creating an adequate economic ar.d social framework for sustainable growth for which the development of human resources is essential. In the short-term, IDA is supporting a structural adjustment program which emphasizes population and nutrition factors and provides for a review of publ;c expenditures, including health expenditures. Thus, IDA involvement in the PHN sectors is consistent with overall IDA strategy. It would support Government programs to control population growth, increase health covetage, and improve f4nancing and efficiency of health services while strengthening institutions responsible for these services. The proposed project is a result of an in-depth dialogue with the Government leading to agreements on major sectoral policies and strategies. In this context, the project would also serve as a catalvst for other aid in the sector and contribute to overall donor coordination. 6. Agreed Actions. The following actions would be taken by the Government: (a) recrvitment of four additional nurses for every HC to be rehabilitated under the project; (b) appointment of lI additional provincial public health supervisors; (c) submission for IDA review and comment of a National AIDS Control Program, and agreement on th's program as a condition of disbursement for AIDS activities; (d) appointment of the Director of the Health Education Division (SDEPS) and two deputies; (e) submission for IDA review and comment of a health financing policy paper and a proposal to implement the recommendations; (f) submission for IDA review and comment of the Census Master Plan, and agreement on this Plan as a condition of disbursement for census activities; (g) submission for IDA review and comment of a Plan of Action for developing jointly the civil registration and vital statistics systems; (h) submission for IDA review of yearly audit reports; (i) acquisition of all HC sites by June 30, 1988; (j) appointment of a full-time dep.ity project coordinator by January 1, 1990; (k) submission for IDA review and comment of the annual project implementation plan; (1) annual project performance re"iew, including project management; and (m) yearly discussion and revision with IDA of a 3-year rolling PIP/PEP. 7. Justification. The project would have the following eirect benefits: (a) approximately one million people living in under-served areas would have access to a full range of essential PHC services; (b) nearly one million women of childbearing age would have access to cffective maternal care and family planning methods; (c) about 800,000 under-five children would benefit from an effective MCH service package, including nutrition activities; (d) the National AIDS Control Program would be established; (e) the MOH would benefit from institutional strengthening; (f) new sources of health financing would be developed; and (g) the population database would be developed and integrated into the national planning progress. In addition, the project would address one cf the major constraints to the country's economic development: the high population growth rate. The project would contribute to a contraceptive prevalence target of 14% by 1992, setting in motion a process that would gain momentum and lead to a significant fertility reduction by the year 2000 (from an approximate TFR of 6.1 in 1987  -4- to 4.1 by 2000). In the long run, a steady decrease in the growth rate would have sizeable impact on the populati,.n size (9 million against 12 million by 2015), and alleviate pressures on the social and productive sectors. 8. Risks. The main risk relates to the MOH inexperience in implementing a project of this size. MOH administrative capability is limited at both central and peripheral levels, and may lead to subsequent operating delays. The project is designed to address this risk by distributing the implementation responsibilities among various MOH units to be strengthened under the project by addtional staff ar.d technical assistance. At the peripheral level, the envisaged extensive in-service training and intensified supervision should minimize the potential management shortcomings. Ultimately, Government's commitment, as already demonstrated by the thorough project preparation, would be an important risk-reducing factor. A second risk concerns potential operational problems during the execution of the proposed population census--an inherently complex operation. However, the fact that the Population Department has already carried out successfully the 1t179 census is a strong asset. In addition, technical assistance will be available from several donors, including IDA. The third risk concerns the implementation of the first IDA- supported National AIDS Control Program. At the moment, there are no definite standards, guidelines, or models to develop an effective package of AIDS control activities, particularly since the epidemiological characteristics of the disease in Africa are still unclear. However, Burundi will benefit from worldwide efforts to control the disease and overall technical guidance of the WHO special program. 9. Recommendations. I am satisfied that the proposed credit would comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed credit. Barber B. Conable President Attachments Washington, D.C. November 24, 1987  5- Schedule A BURKYNI POPMATIOR AND HEALTH PROJECT ESTIMATED COSTS AND FINANCING PLA Local Foreign Total ----- US $ million ----- Estimated Costs Strengthening MCHIFP Services 3.55 6.33 9.88 IEC Program Development 0.53 0.78 1.31 AIDS Control Program 1.11 0.87 1.98 Institutional Strengthening 0.66 1.37 2.03 Population Data Development 0.97 0.01 0.98 Project Preparation Facility 0.22 0.57 0.79 Total Baseline Costs 7.04 9.93 16.97 Physical Contingencies 0.20 0.37 0.!7 Price Contingencies 0.95 0.2S 1.20 TOTAL PROJECT COST 11 810.S 18 74 Financing Plan Government of Burundi 2.92 -- 2.92 IDA 4.91 9.08 13.99 UNICEF 0.36 1.47 1.83 Tot&l 8.19 10.55 18.74 11 Inclusive of taxes and duties which are negligible.  -6- Schedule B Page 1 of 2 BURUNDI POPULATION AND HEALTH PROJECT PROCUREMENT METHOD AND DISBURSEMENT (US$ million) Pro3ect Element iCB LCB Other NA Total Cost Civil Works 5.81 (5.81) 6.81 (5.81) Equipment 1.73 (1.29) 1.73 (1.29) Furniture 0.31 (0.31) 0.31 (0.31) Vehicles 0.30 (0.30) 0.30 (0.30) Technical Assistance V 1.31 (0.86) 1.31 (0.88) Training, Studies Resoerch, Evaluation 4.0 (8.44) 4.0 (3.44) PPF 0.8 (0.8) 0.8 (0.8) ModIcal Supplies 0.47 (0.47) 0.97 (0.00) 1.44 (0.47) Other op. costs 3.04 (0.71) 3.04 (0.71) TOTAL 0,78 t0.78) S,81 (5.81) T30T- (1.9) F.16 (6.81) 18.74 (13.99) 1/ Amounts in parentheses represent IDA fInancing. V/ Consultants will be selected in accordance with Bank guidelines.  -7- Schedule B Page 2 of 2 Disbursements Credit Amount % of Expenditures Category (millions) to be financed Civil Works 6.8 100% of Expenditures Furniture, Equipment, Materials, Vehicle and Medical Supplies 2.3 le0% of Foreign Expenditures and 80% of Local Expenditures Treining, consultants A Experts services 1.0 100% of Foreign Expenditures Goods and Services for AIDS Control Activities 1.8 100% of Expenditures and 80% of Local Expenditures. Operating Costs 0.7 60% of Expenditures Personnel (Census activities) 1.0 100% of Expenditures Refunding PPF 0.7 Unallocated 0.7 Total 14.0 Estimated IDA Disbursements (US2 million) FY 88 FY 89 FY 90 FY 91 FY 92 FY 93 Annual 0.71 2.52 3.07 3.20 2.76 1.75 Cumulative 0.71 3.28 6.30 9.50 12.25 14.00  -8- Schedule C BURUNDI POPULATION AND HEAETH PROJECT TIMETABTE OF KEY PROCESSING EVENTS Time Taken to Prepare: 15 Honths Prepared by: MOH with IDA Assistance First IDA Mission: April 1985 Appraisal Mission De?arture: March 1987 Negotiations: October 1987 Planned Date of Effectiveness: March 1988  _9- Schedule D Page 1 of 2 STATUS OF BANK GROUP OPERATIONS IN BWRUNDI A. STATEMENT OF BANK LOANS AND IDA CREDrTS (as of September 30, 1987) Loan or Amount (US$ million) Credit (Less Cancellations 1 Number2 Year Purpos- Bank IDA Und,sbuvsed One Loan2 and 17 Crndits Fully Disbursed 4.80 139.60 1049 BU 1980 Urban Development - 1l.00 0.60 1185 BU3 1981 Kirimiro Rural Development3 - 19.30 2.11 1192 8U 1982 Integrated Rural Developmnt - 18.00 8.82 13S8 8U 19S3 Third Education - 16.80 0.58 1419 BU 1983 Ruzizi II Regional - 15.00 4.35 1456 SU 1984 Third Technical Assistance - 5.10 3.15 1683 BU 1985 Fourth Highway - 18.10 15.78 1593 BU 198S Power Trans. and Distribution - 12.30 10.17 1620 BU 1986 Second Forestry - 12.80 9.73 1625 BU 198S Rural Water Supply - 9.50 7.44 1796 SU 1987 Technl-al Assistance - 7.50 7,60 180S Su 1987 Telecommunications - 4.80 4.80 Total 4.80 291.43 73.03 of wh;ch repaid 1.83 0.84 Total now outstanding 2.i7 290 S9 Less amount sold 2.97 6.27 of which repaid 2.97 5.27 Total I - Total held by Bank and IDA 0 285.32 Total undisbursed 73.03 1/ Prior to exchange adjustments. V/ Extended in 1967 to the Belgian Trust Territory of Ruanda-Urundi for the im provement of the Bujumbura-Muramvy. Road and the expansion of the Lake Port of Bujumbura. The loan, which was guaranteed by the Kingdom of Belgium, has been fully repaid. 3/ Including a NORAD Grant participation of US15.8 million. Note 1. Credit 1165-BU and higher are denominated in SDRs and are shown in USS equivalents, based on the exchange rates in effect at the time of negotiations. Note 2. Total apprcved. repayments, and outstanding balance represent both active and inactive loans and credits.  - 10 - Schedule D Page 2 of 2 STATUS OF BANK GROUP OPERATIONS IN BURUNDI B. STATEMENT OF IFC INVESTMENTS IN BURUNDI EXPRESSED IN USS (as of September 30, 1987) Amount Year Obligor Type of Business Loan Equity Total 1981 Verreries du Burundi Glass Container 4.7 0.8 5.5 Total Gross Commitments Less Cancellations, Terminations, Repayments, and Sales 4.7 0.8 5.6 Total Commitments Now Held by IFC 0.2 1.0 1.2 Total Disbursed 4.7 1.0 5.7  BURUNDI MINISTRY OF HEALTH MINISTERE DE LA SANTE Population and Health Project: Health Centers Network RN Projet Santi Population: Reseou des Centres de Sonte RWANDA ! 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