Burundi - Population and Health Project

Document of The World Bank FOR OFFICIAL USE ONLY c-p- l8Uz-sW Report No. 6829-BU STAFF APPRAISAL REPORT BURUNDI POPULATION AND HEALTH PROJECT November 16, 1987 South Central and Indian Ocean Department Population and Human Resources Operations Division This document has a resiricted distribution and may be used bp recipients onlv in the perfonnance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  BURUNDI: POPULATION AND HEALTH PROJECT CURRENCY EQUIVALENTS Currency Unit = Burundi Franc (FBu) US$ 1.00 = FBu 126 (November 1987) FBu 1 - US$ 0.011 MEASUREMENTS 1 Meter = 3.28 Feet 1 Kilometer = 0.62 Mile 1 Square Kilometer 0.39 Square Mile 1 Hectare - 2.47 Acres GOVERNMENT OF BURUNDI - FISCAL YEAR January 1st - December 31st This Report is based on the findings of an appraisal mission which visited Burundi in April 1987 and consisted of Dr. J. Baudouy (Bank staff), and Ms. L. Dunaway, Mrs. M. Lioy, Mr. B. Hubert, Dr. D. Beghin, and Mr. J.-B. Rasera (Consultants). The report was written by Dr. J. Baudouy, with contributions from other mission members.  FOR OFFICIAL USE ONLY BURUNDIt POPULATION AND HEALTH PROJECT ABBREVIATIONS AfDB = African Developnent Bank AIDS - Acquired Immunodeficiency Syndrome BEPES = Bureau d'Etudes Pedagogiques de I'Enseignement Secondaire BIP Bureau de l'Inspection et de la Planification BRB Bank of the Republic of Burundi (Central Bank) CCCD Combatting Children Communicable Diseases CHUK Centrr Hospitalier Universitaire de Kamenge: Teaching Hospital CPR = Contraceptive Prevalence Rate CRS - Catholic Relief Service CURDES = Centre Universitaire de Recherches pour le Developpement Economique et Social EDF European Development Fund EPI - Expanded Program of Immunization FAC - French Aid and Cooperation Fund (Fonds d'Aide et de Cooperation) FAO - Food and Agriculture Organization FOREAMI = Public Health Clinic at Prince Regent Charles Hospital (Fonds de la Reine Elisabeth pour l'Assistance Medicale Indigene) FP = Family Planning HC Health Center HIS Health Information System HIV Human Immunodeficiency Virus HPRC - Hopital Prince Regent Charles (Central Reference Hospital) IEC = I-formation, Education, and Communication IPPF International Planned Parenthood Federation IUD = Intrauterine Device JHPIEGO = Johns Hopkins Program for International Education in Gynecology and Obstetrics KAP = Knowledge Autitude and Practice (type of survey) MCIn Maternal and Child Health MOE = Ministry of Education MOH = Ministry of Health MOI Ministry of Interior MOP - Ministry of Planning MSA Ministry of Social Affairs NGO = Non-Governmental Organization PEP Public Expenditure Program PHG Prlmary Health Care PHN = Population, Health and Nutrition PIP Public Investment Program This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed arithout World Bank authorization.  BU1TUtDI; POPULATION ANID HV1ALTH PROJECT ABBREVIATIONIS ( Cont inuecd) SDEPS - Sous Direction de 1'Educatron Pour la Sante SDSMIJPF Sous Direction Sante Maternelle et Infantile/ Plan1fication FamilfaJe (MCH/FP Division) SNES = Service National d'Etuees St-tiritlques STD = Sexually Transmitted Diseasc TBA - Traditional Birth Attendant TFR = Total Fertility Rate UNDP - United Nations Development Program UNEPA - United Nations Fund for Population Activities UNICEF United Nations Children's Fund UNIPAC = United Nations PackJng and Assembling Center UPRONA National Unity and Progress, the Burundi Political Party (Unit5 et Progres National) USAD = United States Agency for International Development WHO World Health Organization  BUIRUNDIM POPIflT-ION AND HEALTH PROJECT DEFFINITIONS Adult L'terz~.cy Rate: 'ihe percentage of persons aged 15 and over w7ho can read and write. Case Fatality Rate: Plercentage of deaths due to a disease among the total number of peoiole who hiave contracted the disease. Child Death Rate: The number of deaths among children one to four years of age per 1,000 children in that age group in a given year. Contraceptive Prevalence The percentage of married women in Rate: reproductive ages who are using (or whose husbands are using) any form of modern contraception at any given point in time. Crude Birth Rate: The number of births per 1,000 population in a given year. * ~~Crude Death Rate: Thie number of deaths per 1,000 population in a given year. Dependency Ratio: The ratio of the economically dependent part of the population to the productive part, arbitrarily defined as the ratio of the young (under 15 years of age) and the elderly (those 65 years of age and older) to the workirg age population (those 15-64 years of age). Incidence Rate: The number of new cases of a disease which occur in a population during a specified period of timie. Usually expressed as the number of cases per 1,000 persons. Infant Mortality Rate: The number of deaths of infants under one year of age in a given year per 1,000 live births in that. year. Life Expectancy at Birth: The average number of years a newborn would live if age/sex-specific mortality trends prevailing at the time of birth were maintained.  l * BURUNDI: POPULATION AND HEALTH PROJECT DEFINITIONS (Continued) Low Birth Weight: Infant weight at birth less than 2,500 grams. Matet.aal Mortality Rate: The number of deaths of women who die due to pregnancy and childbearing complications in a given year per 1,000 live births in that year. Morbidity Rate: The frequency of disease in a population in a given period. Parity: The number of children previously born alive to a woman. Prevalence Rate: The total number of people affected by a disease estimated either at a specific time (point prevalence) or over a stated period (period prevalence) expressed per 1,000 population (in case of low figures, prevalence is expressed per 100,COO population). Rate of Natural Increase: The rate at which a population is increasing (or decreasing) in a given year due to a surplus (or deficit) of births over deaths, expressed as a percentage of the total population. Rate of Population Growth: The rate of natural increase adjusted for (net) migration, and expressed as a percentage of the total population of a given year. Stunting: A method of assessing a person's nutritional state, based on the deficit in height-for-age compared to a reference chart. Total Fertility Rate: The average number of children that would be born alive to a woman during her lifetime if _he passed through her childbearing years conforming to the age-specific fertility rates of a given year. Wasting: A method of assessing a person's nutritional state, based on the deficit in weight-for- height compared to a reference chart.  BURUNDI: POPULATION AND HEAL"H PROJECT BASIC DATA (All figures apply to 1987 estimates unless otherwise indicated) General Total Area 27,835 km2 Area (Land Only) 25,000 km2 Total Population 4.9 million Current Growth Rate (per annum) 3.0% Density per km2 180 Total Fertility Rate 6.2 Crude Birth Rate 48 per 1,000 Crude Death Rate 18 per 1,000 Life Expectancy at Birth 47 years Infant Mortality Rate 125 per 1,000 Child Death Rate 185 per 1,000 Rural Population 92% Adult Literacy Rate 35% Primary School Enrollment 60% Secondary School Enrollment 4% GNP per capita (1985) US$ 240 Health Population per Physician (1986) 23,000 Population per Nurse (1'386) 4,800 Population per Hospital Bed (1986) 1,600 Population Wi'.hin Reach of Health Services (1986) 65% Proportion of Children Fully Immunized (1986) 50% Contraceptive Prevalence Rate (Modern Methods) (1986) 1.6% MOB Share of Government Recurrent Expenditures (Average 1978-86) 5.2% Daily per capita Calorie Supply (as percentage of requirements) 88% (UNICEFIWHO Standards)  BURUNDIt POPULATION AND HEALTH PROJECT TABLE OF CONTE:.TS. Page No. CREDIT AND PROJECT SUMMARY ......................... i-i I. BACKGROUND .................... 1 A. Economic and Social Setting ............................... 1 B. Population, Health and Nutrition Status .................. , 2 C. Population Policy and Activities ...... .................... 6 D. Health Policy and Services ........ ........................ 8 II. SECTORAL ISSUES AND BANK ROLE ............... 15 A. Current Major Sector Issues ......... ...................... 15 B. Sector Strategy ................. . , 16 TIII THE PROJECT ............ #.*.. ..18 A. Project Objectives and Design ..... 18 B. Summary Description ...... 19 C. Detailed Project Description... 20 IV. PROJECT COSTS AND FINANCING .................... 33 A. Costs ... . ... .. o... *.. ...... * .. ... ... 33 B. Project Affordability ................................... 35 CS. Financing ......O*..**..... o....36 D. Procurement ............................. 37 E. Disbursement ....."6........... 38 V. PROJECT IMPLEMENTATION ......... 39 A. Project Preparation .. **.. ..39 B. Organization and Management ....,., 40 C. Monitoring and Evaluation 42 VI. PROJECT BENEFITS, JUSTIFICATION AND RISKS ..................... 42 A. Benefits .......................... **** .... ****.*.. .... 42 BV . JustificationMMENDA.IONS ... .. .*.* . *.*., 44 C . R isks . 4............... . 44 VII. ASSURANCES AND RECOMMENDATIONS ..............45  BURUNDI: POPULATION AND HEALTH PROJECT TABLE OF CONTENTS. (Continued) Page No. LIST OF TABLES 1.1 Projected Population Size and Growth ..................... ..... 3 1.2 Educational Indicators 8......... .... .......... .....* 8 4.1 Project Costs By Expenditure Category and Accounts Cost Summary .. ..............................* 34 4.2 Price Contingencies .. ..............*...................... . 34 4.3 Project Costs By Financing Source............................ 36 4.4 Procurement Arrangements . *.... . . . . . * . * * * ..*.........*.*...*.*.....*.*.37 ANNEXES 1 - TABLES Table 1: Population of Burundi and Density by Province, 1985 Estimates ..............................4 Table 2: Demographic Projections, 1980-2015............... .....49 Table 3: Prevalence of Child Malnutriton in Burundi from Selected Surveys. ..... ................... . . 50 Table 4: Contraceptive prevalence in Burundi, December 18 .................................... 51 Table 5: Health Personnel Distribution in Burundi ............ 52 Table 6: Health Staff Distribution in Hospitals ............... 53 Table 7: Health Staff Distribution in Health Centers .......... 54 Table 8: Output from Paramedic Schools, 1982-86, and projections with the three additional schools, 1987-91 *.* ... ... ........ ...... 55 Table 9: Bed distribution by Facility and Province ............ 56 Table 10: Total Health Sect r Recurrent Expenditures, 1986... ............*.......... # ..... 57 Table 11: List of Proposed Project Facilities .......... ......... 58-59  BURUNDI: POPULATION AND HEALTH PROJECT ANNEXES (Continued) Table 12: Projection of Contraceptive Users, contraceptive prevalence, and births averted .................................. 6 Table 13: Projection of Contraceptive Method Mix ............... 60 Table 14s Draft Health Sector PIP/PP, 1998-92 ................... 61-62 Table 15: Recurrent Cost Implications of the Proposed PIP on MOH Recurrent Expenditures .......... 63 Table 16: Summary of Technical Assistance..*.*...*#*..........64 KEY PROJECT INDICATORS-o-ooo ... . .... o.... ... .. .65 2 - Summary Account by Project Component. ........... ... ............ ..66 Project Componenits by Year .................................... . 66 3 - Implementation Schedule .......................................69 4 - Estimated Schedule of Disbursements....oo .... ... 70 5 - Selected Documents in Project File...............................71 CHARTS 1 MOH Organizational Chart ....... .......... . ........... 72 2 SDEPS Organizational Chart . .......................... 73 MAPS 1 Population Density ........................ .... 74 2 PHC Coverage ... ........... ..... .*.. . ..... 75  BURUNDI: POPULATION AND HEALTH PROJECr CREDIT AND PROJECT SUMMARY Borrower: Republic of Burundl Beneficiar: Ministry of Health (MOH) Amount: SDR 11 million (US$ 14.0 million equivalent) Terms: Standard IDA Terms Prolect Description: (a) Objectives. To: (i) improve Maternal and Child Health (MCH) status by strengthening nationwide MCH services, including Family Planning (FP) and Nutrition activities; (ii) increase contraceptive prevalence to 14% by 1992; (iii) assist in controlling the AIDS epidemic; (iv) strengthen the institutional capability of the MOH; (v) improve the financing and efficiency of health services; and (vi) improve the demographic data base for population policy development and socio- economic planning. (b) Components. The project would provide for: (i) the development of MCH/FP services, through the Primary Health Care (PHC) network (establishment of a national MCH/FP program, health staff training, intensified supervision, contraceptive supplies, health center (HC) rehabilitation, and maintenance); (ii) development of an Information, Education, and Communication (IEC) program (strengthening the Health Education Division, material development, health staff training, audio-visual equipment); (iii) support to the National AIDS Control Program (staff training, IEC material development, purchase of medical supplies and laboratory equipment, and operating costs to carry out control activities); (iv) institutional strengthening of the MOH (strengthening of key MOH units, staff training, health financing policy development, operational research and studies, and development of project management capabilities); and (v) population data development (financing of additional temporary staff, census materials development, and seminars to disseminate the census results). (c) Benefits and Risks. The project would have the following benefits: (i) approximately one million people living in under-served areas would have access to a full range of essential PHC services; (ii) nearly one million women of childbearing age would have access to effective maternal care and family planning methods; (iii) about 800,000 under-five children would benefit from effective nutrition services as part of a comprehensive MCH package; (iv) the entire nation would benefit from the increasing contraceptive prevalence which would ease the demographic pressure; (v) the spread of AIDS would be reduced through the support to the National AIDS Control program; (vi) MOH would benefit from institutional strengthening; (vii) new sources of health financing would be developed; and (viii) the population database would be improved and used for population policy development and socio-economic planning. The main risks relate to: (i) the limited administrative capacity of the MOH; (ii) the complexity of the census operation; and (4ii) the lack of experience in AIDS control.  - it - BURUNDI: POPULATION AND HEALTH PROJECT PROJECT COST SUMMARY Local Foreign Total