Burkina Faso - Health and Nutrition Project (PDSN)

cA AS5s t-A/+-)/A< Document of The World Bank FOR OFFICIAL USE ONLY Report No. 12416-BUR STAFF APPRAISAL REPORT BURKINA FASO HEALTH AND NUTRITION PROJECT (PDSN) MARCH 11, 1994 MICROGRAPHICS Report No: 12416 BUR Type: SAR Population and Human Resources Operations Division Sabelian Department Africa Region This document has a restldted diskibu_on and may be used by rdpients only in the perormanoe of their official duties. Its contents may no otherwise be disclosed wtout World Bank autiorizlion.  CURNCY OUIVLENT Curncy Unit = CFA Franc (CPAF) I US$1 = 270 CFAF (Rate prior to Janyary 12, 1994) Curmnt Rate = CFA FranclUSSI = 580 CFAF WEIGHTS AND MEASURES Metric System I m. = 1.O9yd. 1 sq.m. = 10.76 sq. ft. FISCAL YEAR July 1 - June 30  -~~~~~~~~~~~~~~~~~~~~~ 01 . ceescee. m e... . * e m ...... me mm. egg,, mu * a em m m d, . e e . .. H.m. . 'tf1 S tI tlirlliEI . Wt E' r IE 1,1' a I .r '['I i W Wr ' W t " r 11 1 "'  MCH Mtderal and Child Haelth ME - MM6ad wn endeka I Entia Drg MmFF Mnre d& l'EConoea Ja nFMa at dil I Minisr of FAMe NW Planng MO - Min y of ealth MPR MA- uwi"proa4&qAue MSPSF - Mbslsalra hit swutM .Vle aciode ll,c sdc akde lakmd& I Mitry of Health, SoCW Developmet and th Famy MST - M ainduas zuuae awran I Sexaly Tauaitd Dsee NGO - Non-Pgove ntal Orgniatio OCCGB - Orgw ar d ceoniltnaon aetds coeprusn pour la bc c L gmanduw and&a / Or1anizatod of Coordinato and Cooan for the Fight apgnt Mjr Endeic Di_a OCP Onchoceciaads Contl Pogam OCS - Organtrclion ommunauatr d saw I community Healt Orgaiaons OMS - Oryosak nondlal dc. toa a I World Health Oaiza OR - Opeationa Reseah OSr - Ofca de sang ha auvai&ers I Bureau of Worker' Health PASE - Pogramme dppa a la su4WeillanCa ipUdhmlgi q I Epidemiological Surveillaem Support ProjeAt PCU - Proect Coordinang Unit PDDS - Pk ide &wlppain & dibct WaE I Dit Healh Development Plan PDSN - Proj.: devloppamaude saWn ade nurton I Hea and Nuti Development Poject PDSS - Proj es 4 dioppamaemes * ansfa de sam / Health Serviea Deveowmen Project PEG - Prevuuona Lc conrak dha and es goelsr a I Training Comm. on c e Prvenon of Endmc Gown PEV - PrOgruMnsaEgi di ~-acccaon I Expanded Pognrame on Imn_iao PHC - Prmry Health Care PMA Paqua ibm d actdvts I MInimum Actvie Pacage PM - Proeion maaerne at bWfana I Mate:aal and Child Health PNUD - Pgrm des Nadtons Unapowrkd.Aoppmam I Unied Nat;ons Development Progrmme PitA Pha-acs rgonala d'approvs omnem / Regiowal Supply P bamAci PSP - Pos. de sad pdmr I Primaq Health Care Post SA - Specal Accou SAFER - Soc#W ajHcbw d'icda a de Maksanom I Afica Firm for Stue sa Achievemnt SeP - Save the Childr Fund SPE - Sagqe mm d'di I GovernmentCertified MiA SIDA - Syndv me d'lmw Jfic cqids I AIDS SMI - Sawt mamelk aet infundk / Mote and Chld Heath SOEs - State of Expends_ SONAPHARM - Soc-M nanalk d'aPPAvonMantph Iadque National Pharmaceul Supply Company SOSUCO - SociEt acsQ,v de Ia ComoE I Como6 Company of Sugar Manufetus 3SP - Soins de sanapfar / Primary Health Care mSu - Seually Trnmited Disea TDCI - Troubes Du ear Carncas an de Iodine Deficiency Diseses TRO - IhErapk de rfda"en par voe oral UCP - Unit d oorfinaton du projet 1 Project Coordini Unit UNDP - United Nations Development Programme UNFPA - Unitd Nations Fund for Populatn Acvies UNICEF - United Nations lntemaonad Children's Fund USAID - United Se Agecy for Inrnatinal Developm USC - UnW de souin des comosa VHW - Vllage Health Worker VITAL - Viamin A Fidd Support Project (JSAID) WHO - Wodtd Health O:anizaton WID - Women in Dealoment  BURKINA EAS ',ALTH AND NUTRITON PROJECT fPDSN) TABLE OF CONTENTS ClrET AND PROJCT SUMMARY ...........................,.i I. RODUCTION . .................... . t I1. SECTORALd CON EXT .................... 1 A. Health Status .................. I B. Sector Organization and In stitu tio n s ................................................. 3 C. Health Sector Financing and Staffing . .................................................5 D. Sector Development Issues .......................... ... ... ........."....I...6 1. Issues with regard to Health Services ..................................................6 2. Issues with regard to Nutrition and Endemic Disease Control .................... 8 E. Government's Strategy ................................................9 F. The Bank Group's Role ................................................. 11 G. Lessons Learned ................................................. 13 m.IT BPOECT ...................................................... 13 A. Project Rationale ...................................................... 13 B. Project Objectives ...................................................... 14 C. Project Summary ...................................................... 14 D. Project Scope ...................................................... 15 E. Project Description..............16 B. Project Description ~~~:.........I............................................. 1 1. Improve Quality of Health Services .................................................... 16 2. Reduce Micronutrient Deficiencies ............................................. 20 3. Achieve and Maintain Control of Parasitic Diseases ................. .............. 22 4. Strengthen MSASF ............................................. 23 F. Project Costs and Financing ............................... 25 IV. PROJECT ...............M...IEMENTAT.ON................................. 26 A. Status of Project Preparation and Readiness ................................................... 26 B. Project Coordination and Management ................................................... 26 C. Monitoring and Evaluation ................................................... 27 D. Procurement and Disbursement ....................... ............................ 27 E. Disbursements ................................................... 30 F. Acco mting, Auditing and Reporting ................................... ................ 31 V. PROJECT BENEFMTS AND RISKS ........................................ 31 A. Benefits ................................................... 31 B. Risk ...................................................R 33 VI. AfREEMENTS TO BE REACHED AND ........................... 33 Ts M R s p d bo ft fidingo pa Bank appranisa sim h w sed B u Fina In un 19. cAbg mesma bm ,gmB Cras Mnage d =wi io dr). Saedd Be-Hahm (Opar Officer). Yva Gns (ulic Haft Spe,a . TOO Mar*l (Nute SpecW4. D1ai Bm m (I_ Specas, ad JenFhPire Uer (Publc Heat SPeia. 1Ma Badd 1. a _ B_Ute w eer p iw. Pncips ppartoly docm-nt fr te t were pmpard by Caa M EMm Golde (&4ka Far. P*We EV wV R : bh W Sw W e S , a M. P Cli (a Waiw S o U E S. u_ 1 Heat NedIn &u9ia Pam's Rra C.uuada) folowing mrio to Ruh PIwo in 192 Ms Katede Mara ad Mr. Ptw Pr&mm we te Dqm Diror nd mgi Divion Chbe, rtlve*.  TABLE OF CONrENIS (Cont'd) ANM-=EPaee No. 1.1 Socio - Economic Indicators 36 2.1 Annual Bank Staff Report to -the Executive Directors on the OCP 37 2.2 Organigramme du Ministere de la Sante, de l 'Action Sociale et de la Famille 42 Organization Chart of the Ministry of Health, Social Development and the Family 2.3 Background on the Micronutrient Component 43 2.4 Projet de Politique Ginmrale pour le secteur de la santd 48 Draft Letter of Health Sector Policy 3.1 Organisation du systeme des districts sanitaires 62 Organization of the Health District System 3.2 Les Plans de DUveloppement du district sanitaire 73 Development Plans for the Health District 3.3 Le systOme d'organisations commautaires partclpa a 1e'ffort de sante 76 Community Organizations participating in the Health Movement 3.4 Formation du personnel des districts sanitaires 80 Health District Personnel Training 3.5 Programme de reddplolement et de recrutement du personnel de SanW Publque 92 Redeployment and Ree.ruitment Programme of Public Health Personnel 3.6 Approvisionnement du pays en m&Iicaments essentiels : La CAMEG 94 Supplying the country with Essential Drugs: the CAMEG 3.7 Micronutrient Component: Detailed Implementation Plan and Objectives 99 3.8 Programme de lutte contre les dfflences en micron*rlents 101 Micronutrient Deficiency Control Program 3.9 Projet de note technique sur la reorganisation de la direction de la mddecine preventlve 104 Draft Technical Note on the Reorganization of Preventive Medicine Directorate 3.10 Projet dorganisation du service de maInenance 106 Draft Organization of the Maintenance Service 3.11 Financement des services de sante dans les districts sanitaires 108 Health Services Financing in the Health Districts 4.1 Plan de supervision 120 Supervision Plan 4.2 Termes de RNfUrences de l'UCP 122 Terms of Reference for the PCU 4.3 Procurement Plan and Timetable 130 4.4 Disbursement Profile 131 4.5 Project Cost Tables 131 MAPS: IBRD 25394, 25476, and 25477  BURKINA FASO BALTH AND NUIRB N PROJECr (PDSN) CREDIT AND PROJECT SUMMARY Govemment 'f Buddna Faso Beneficians:. Ministy of Public llealth and Social/Family Action Credit Amount: US$29.2 million (SDR 21.2 million) Terms: Standard, with 40 years maturity Description: The project would assist the Govemment in its efforts to: (a) improve significantly the quality, coverage and utilization of basic health services for the Burkwnbe popuation, (b) enbance the nutritional status of the population, and (c) develop a national capacity for achieving sustainable control of endemic parasitic diseases. To achieve these bjectives, the projcct would support policy reforms and investments designed to: (1) improve galitX. coverage. and utilization of health semices by: (a) strengtheninh the health system nymd through: (i) fimutional upgading/cotuction of health facilities and increased uopervon of staff operations and refefls at the pnmary and secondary levels (CSPS and CMAs) which comprise the 'health district; (ii) establishing an effective mainenance system for "district facilities, and (iii) improving operafions of regional and national hospitals (CHRs and CHNs); (b) ationalizing a_ff use and nromotinu staff development by: (i) establishing re and efficient staffing norms and formulating and implementing a staff redeployment action plan; (ii) supporting n-semrice training for district medical officers in supervision pmcedures; and (iu) upgading s of district level physicians in emergency surgical procedures; (c) dcnlm iming. Ihe .bkhmealthjam bv: (i) defining a county-wide system of health districts; (ii) providing for increased autonomy in planning and budgeting at the district and sub-district levels; and (iii) providing for community co- management of primary health services; and (d) inCreasin availability of essentil drugs by: (i) supporting poliey reforms and implementing actions to promote importsaion and diribution throughout the health system of low cost quality generc drugs as a substut for high cost specialty drugs; (ii) establishing an effective cost recovery policy which vould ense a sustned supply of essential drugs at the primary and secondary levels; and (iii) supporting the Expanded Program of Immumizaon (EPI) for imnts and young children. (2) Reduce micronutrient deficiencies by: (a) supporting supplemention of vitamin A, iodine, and iron in severely deficient areas; and (b) developing a longer-term, durable national strategy for reducing micronutnient deficiencies, which would include inter alia food fortification and dieta"y modification. (3) Achieve and maintain control of endemic gaMsitic diseases bm : (a) ste ing the cpacities of the health system to carry out epidemiological surveillance and treat detected cases of onchocerciasis (riverblindness), trypanosomiasis (sleeping sickness), and dtacunculiasis (Guinea worm) trough training and supervision of mobile teams and local health workers; and (b) sensitizing tagot populations regardig prevention of trnsmission of these three diseases through tanumg and IEC campaigns, and (4) Strenethen the Ministra of Public Health and Social/Family Action (MSASF) by: (a) enhancing and rationalizing its capacity to more effectively control endemic parasitic diseases, (b) strengthening its capacity to implement the reform of the pharmaceutcl sector, (c) estabishing a management information system to track physical asset and health personnel throughout the public health system; (d) improving capacity to coordinate and monitr donor-suorted health prqjects; and (e) enhacing cavactv to coordinate implementation of PDSN.  ii Bnfits and Riaks: By revermng prest tends of low utiliztion of prmary healt care centers, the project will help provide affordable basic health services of adequate quality to some of the poorest segments of the Buinabe population. The health comn_ nent would dirjct benefit about three million people (30% of Bukidna Faso's population) who will gain access to quality health care. Second, policy teforms in the ars of low-cost essential drugs, decentlizaon and cost recovery will-together Witb tning of health and supervisory staff-improve the quality of health car delivqy nationwide. The project's emphasis on substituting expensive brand-name drugs with low coast generic drugs will both benefit patients by reducing their financial burden during sckness episodes, and make possible ths implementation of a cost ecovery system, which is required for more sutnable and efficiently funetioning health services at all levels of the system. Third, provision of additional swugical facilities at the district level and trmg of general pmrtitioners in swrgey should contibute to more immediate medical/surgical interventions in emergecy cases, and at the same time, reduce clogging at Hospitals. Fourth, the nutrition comRonent would help reduce the high rates of anemia among expectant mothers which are a major cause of low birthweights. Furthermore, dispensing of iodine and vitamin A should greatly reduce the incidence of goiter and mental retardation, and blindness resudting from vitamin A deficiency. Fifth, by sustining the achievements of the Onchocerciasis Control Programme (OCP), the endemic disease control comnponent would ensure that about 17% of Buddna's agricultural lands-with fertile soils-would remain available for the production of foodstuffs and other important agncultural commodities. It would also prevent recurrence of onchocerciasis and major outbreaks of human trypanosomiasis as well as eradicate draunculiasis which affects about 34% of the villages in Burlina-the highest prevalence of any Sahelian country. The ptoject faces thee major risks. The first risk is that the expected procurement of essential generic dgs and their distribution may be slow to matialize. To address the procuement risk, the Government bas aprroved the required legislation and, with Bank assistance, establisbed CAMEO, an orgnizaon designed to undertake the importation and distribution of essential geric dregs. The Govemment has provided assurances that %he CAMEG will meet performace criteria agreed upon by IDA and the Governent. Furthermo, supervision during the first half of the poject (through 1997) will focus heavily upon satisfactory implementation of training and drug stock/financial management arrangements in the health facilities so as to ensure adequate cost- recovery and hence the continuous availability of essential drugs. The second risk is that tesistance to redeployment of doctors and other medical staff into ural areas will prevent adequa staffing of district health centers. To address this risk, the Goverment has, prior to negotiations, developed a-d begun to implement an action plan, acceptable to IDA, to eosute the required redeployment and that the peonnel concerned reman where posted and carry out their assigned responsibilities. 3bh third risk is the time required for regaining confidence of the population in the health car centers, especially in light of the proposed cost recovery scheme coupled with the recent devaluation of the CFA franc. To mitigate this risk, a moderate level of cost recovery would be gradually implemented so as not to result in a disincentive for people to utilize the primary level of the health care system. Initially, essential, generic drugs will be provided free of charge in a large number of mral areas pending the establishment of workable cost-recovery mechanisms. Success in ensurng the wide availability of low cost generic drugs via the CAMEG wil be critical in addressing this risk.  iii BUR1A ESO HIEALT AND NUTRMON PRO13a SYl Z AND PRORECT cos (US$ million)' ESTIMATED BASE PROJECr COSTS2 LOCAL FOREIGN TT Jmprove Quality of HeaMth Servies 2.1 21.7 23.8 Reduce icrnutrient Defidiencds 0.5 3.4 3.9 Achieve Control of Endemic Parasitic Diseases 0.6 ItS 1.1 Stengthen the Mnistry of Health (MSASF) 0.6 3.5 4.1 TOTAL BASE COSTS 3.8 29.1 32.9 Physical Contingencies 0.2 1.7 1.9 Price Contingencies 1.6 2.6 4.2 TOTAL IPROJECT COSTS S.6 33.3 38 FS4g I!lan IDA 29.2 GOV 2.0 KfW 4.1 UNICEF 3 TOTAL 38.9 Estimated IDA Disbursements: US$ million._ _ _ IDA PY 95 96 97 98 99 2000 Anmual 1.5 5.5 7.6 8.1 4.8 1.7 Cumulative 1.5 7.0 14.6 22.7 27.5 29.2 1. Total, may nt add up due to audhg. 2. Net of tn d_uh.  plJRKINA FASO HE2.THAND NtJTRlllON IFR03ECT 1. IQN 1.1 The Government of Burkina Faso has requested IDA's assistance in fiancing a project designed to (a) Improve dramatically the coverage and quaity of basic health services for the Burkine population; (O) enhance the nutritional status of the population; and (c) develop a national capacity fr achieving and maintaing control of certain endemic, parasitic diseases. 1.2 Total proJect costs are estil-ted at US$38.9 million equivalent (net of taxes and duties), with a foreign exchnge compown.. f US$33.3 miliion. lhe Government and local communies would contribute US$2.0 million. The Federal Republic of Germany will contribute approximately US$4.1 million (up to the equivalent of 9 million DM) and UNICEF will contibute US$3.6 million in parallel cofinancing during the period FY95-FY99. The project would be lIDA's tird contribution to the development of the health and nutrition sectors in Burkina Faso. The investments under the proposed project would be complemented by support to be provided by IDA under the Population and AlIDS Cotrol project which is being prepared in pa 4lel to this proposed project. 1.3 e al. Burkina Faso is a landlocked country with a pop ilation of about 9.5 million. With a per capita GNP of about US$290 in 1991, Burkina Faso is among the poorest counries in the world. In particular, the level of human resources development is extremely low (see Ann 1.1 for basic social indicators). In a 1993 UNDP rankdig of 173 countries according to their level of human resources development, Burkina ranked 170th. Basic social services are relatively undeveloped. The economy is dominated by the agricutural sector, which accounts for about 30% of GDP, generaes over 60% of export earnings and employs almost 90% of the economically active population. With the other 12 countries of the CFA franc zone, Burkina Faso devalued its curency by 50% relative to the French franc in January 1994. . SECRAL CONM A. Healt Status 2.1 The health status of the Burkinabe population is poor with a life expectancy at birth of only 48 years (1991), compared with the average for Sub-Saharan Africa (SSA) of 51 years (1991). A major contributing factor to this low life expectancy is high infant and child mortality caused by widespread cotious diseases, unfavorable hygienic conditions, malnutrition, and the limited capacity of the health system to prevent these conditions and to treat them effectively once contracted. 2.2 Infant mortality of 133 per 1,000 (1991) remains high even by SSA standards, where the average is 104 (1991). About 18% of babies suffer from insufficient birthweight which limits their canaces of survival. Malaria is the primay cause of death for children under age one, while measles and diarrhea are the leading causes of death for children aged one to five. Less ta  2 25% of one-year olds are vaccinated against DPT(Diphtheria, Pertussis, Tetanus), meases, and polio. 2.3 Maternal mortality is also high with 810 per 100,000 births (1988). High infant and materWal mortality levels are associated with inadequate pre-natal services, a low proportion of isttutionalized deliveries, and low detection and referral of high risk cases from the villages, where most deliveries are overseen by untrained traditional birth attendants under unsafe conditions. 2.4 Among adults, malaria is the leading cause of death, followed by respiratory diseases, mainly tuberculosis. AIIDS is rapidly becoming a major threat to the population's health status. Recent data indicate that HIV sero-prevalence is approaching 7.5% among pregnant women in Burkina-a reasonably accurate indicator of prevalence levels among the adult pordation throughout the country. Data from neighboring countries with high levels of Burkinabe in- migrion and out-migration suggest that, in the absence of vigorous, preventive actions within this dew-de, AIDS could reverse much of the progress made during the past 25 years and prevent fiture advances in reducing infant, child, and adult mortality rates in Burkina. 2.5 Malnutrition, especially among children and pregnant women, is a serious problem in spite of the theoretical availability of sufficient food in normal rainfall years. Approximately 46% of children under five (1990) suffer from chronic malnutrition, with severe malnutrition affecting as many as 5% of pre-schoolers. In nine provinces surveyed in the Central Plateau in 1987, the rates of moderate to severe malnutrition for children 0-4 years old were below 30% in one province, between 30 and 50% in four provinces, and between 50 and 65% in the four remaining provinces. Malnutrition varies among age groups, the most affected being the 6 month to 2 year olds. Primary school atendees had rates of malnutrition of 50% in 1987, after two years of a severe drought. Malnutrition rates among pregnant women are also very high, reselting in the high rate (18%) of children born with weights below 2.5 kg (1984, delayed child development, and high child morbidity. In addition, 40% of pregnant women suffer from moderate to severe anemia. 2.6 Prior to the start of the regional, multi-donor Onchocerciasis (Riverblindness) Conwtrol Program (OCP) in 1975, (background provided in Annex 2.1) riverblindness consttuted a serious health hazard in Burkina Faso, particularly in areas having excellent agricultural soils, with available water from adjacent rivers. About 10% of villagers had become blind and ihabins above 40 years of age were afflicted with blindness at rates of up to 60% in riverine "front-line villages. Many of Burkina Faso's river valleys contained the most serious foci of endemic onchocerciasis in the world. Eighty-five percent of Burkina Faso's land mass was afflicted with this disease, and the average infection rate nation-wide was approximately 15%. in addition to its debilitating effects, the disease was a major obstacle to socioeconomic development. About 17% of Burkina Faso's best agriculural land had been abandoned by the mid-1970s due to the severity of the disease. 2.7 Following years of aerial spraying of the breeding sites of the disease vector (blackfly), onchocerciasis is now under control. Seven million people once at risk are now protected from contracting onchocerciasis. Also, a new drug which kills only the infant worms in the body, ivermectin (brand name-Mectizan) has been recently developed and was made avaiable to the Program, free of charge by the producer, in 1987. One annual dose of is microfilaricide over the life cycle of the adult worm (14 years), reduces the individual's infant worm load to levels  3 which will not lead to ocular complications. Ivermectin is considered to be an invaluable tool in preventing widespread recurrence of the disease. 2.8 Although the incidence of trypanosomiasis (sleeping sickness) has been reduced to relatively low levels-200 cases have been reported in the last five years-its epidemiological characteristics can result in explosive outbreaks if the disease goes undetected for long periods. The danger of trypanosomiasis "imports" is serious, especially through immigrants setfling on lands cleared from onchocerciasis. Dracunculiasis (Guinea worm disease) is also considered a significant health problem in Burkina Faso. Although not life-threatening, the worms cause wounds which, if not cared for properly, will become infected. A nationwide survey in 1990 found more than 42,000 cases, spread throughout the country. Tbis temporarily disabling illness causes substantial economic losses-estimated by the Organisadon de coordinaion et de coopOratlon pour la lutte contre les grandes enddmles (OCCGE) to include US$3 million per annum in lost agriculural production-due to the afflicted being unable to work the fields or atend school. B. Sector Organization and Institutions 2.9 The Ministry of Public Health and Social/Family Action (MSASF) is responsible for formulating health policies and providing most national health services. The public health care system in Burkina Faso is pyramidal in shape, with about 600 health centers (Centres de santr et promotion socdale - CSPS), as well as 130 dispenseries and 21 maternities, at the base, extending upwards through about 67 medical centers (Centres ntdicaux - CM) spread throughout all of the country's 30 provinces, nine regional hospitals, and two national hospitals. In addition, primary health posts were established between 1985 and 1987, in all of the country's 7,000 villages, staffed by village health workers and traditional birth attendants. Local communities select and support these staff while the MSASF provides training and supervision. The program, however, does not work well since less than 2,000 of these health posts are estimated to be currently operational. 2.10 At the provincial level, health services are coordinated by the Provincial Directorate of Health (DPS), headed by a medical officer. Responsibility for the national health budget, procurement, personnel mnagement, and training is at the central MSASF level. The Ministry's headquarters recently underwent a reorganization, the major feature being the establishment of a Public Health General Directorate responsible for a Directorate of Family Health (DSF) and a Directorate of Preventive Medicine (D)MP). ITe DSF coordinates all nutrition programs, family planning, and the Expanded Program of Immunization. The DMP coordinates transmissible disease programs, mental health, dental health, and sanitation programs. It has also assumed responsibility for maintaining the achievements of OCP in conjunction with control of other diseases (devolution). The new Ministry structure is more appropriate than the previous organization in supporting decentralized and integrated health services. An organigram of the current MSASF is provided in AM 2.2. 2.11 The District Health System. The MSASF is reorganizing basic health services through the establishment of health districts, the new basic operational unit for health care delivery. The districts will consist of a medical center (CM) upgraded to provide emergency operations (Centre m&dical avec antenne chirurgicale - CMA), serving a population of about 180,000, and all health centers (CSPS), usually 15-20, within its zone of responsibility. The health district does not always correspond to an existing political-administrative structure (province). There are 30 provinces throughout the country, and some larger provinces will have two or even three districts.  4 Fifty-three districts have been identified to cover the entire country. Five CMs have so far been upgraded (Bogande, Diapaga, Nouna, Tougan and Zabrd) with the construction of a surgical unit, three of them under the IDA-supported first health project (FHP) which is scheduled to conclude in June 1994. An additional nine CMs are being upgraded (Boulsa, Boromo, Kongoussi, Hounde, Diebougou, Kossodo, Orodara, Paul VI, and Pissy) under the FHP and are expected to be completed by mid-1994. 2.12 'Me ptivate health sector is expanding. A recent survey indicated that there were 140 private doctors' offices or clinics in the country, mainly in Ouagadougou and Bobo-Dioulasso. Traditional practitioners exist in virtually every village and town in Burkina Faso. The Government occasionally sponsors training activities to upgrade the knowledge and practices of these practitioners. In addition, the Directorate of Pharmaceutical Services (DSPH) has an office dealing with the identificaton and promotion of effective traditional pharmacopoeia. Based upon data from only one province, it is estimated that about 60% of out-of-pocket expenses on health care are spent on traditional medicine (para. 2.14). 2.13 The pharmaceutical secto is divided into a growing private sector and a stagnant and inefficient public sector. These two sectors are responsible for all phases of drug distribution. Pharmaceutical production is characterized by: (i) production of perfusion solutions by the M6dicamenes du Faso (MEDIFA) laboratories which were established with the cooperation of Italy; (ii) production of 100mg chloroquine tablets, 500 mg paracetamol tablets, and 500 mg units of acetyl salicylic acid at the Research Institute of Natural Substances (U. Parma/IRSN) which was established through the cooperation of the Belgian government and with assistance from the United Nations Office of Industrial Development; and (iii) production of pharmaceutical alcohol by the mixed capital company Socdte de Production d'Alcool (SOPAL) located in Banfora. Bulk distribution is guaranteed by: (i) SONAPHARM (Soc&te Nadonale dApprovislonnement Phanwaceutqe) a mixed capital company wbich has undergone privatization during which the Government's holding was reduced from 51 % to 5%; (ii) COPHADIS (Cooperatve Phia maceutque de Dltrlbutlon), an entirely private wholesaler which began operations in early February 1994; (1ii) ABOREX Burkina a private wholesaler which has recently obtained its operations permit; and (iv) la CAMEG (Centrale dApprovisionnement en Medicaments essentias Mndrlques) which was created in 1992 to ensure the supply of essential, generic drugs to public health centers and private non-profit health centers according to the recommendations of the Bamako Initiave. Retail distribution of pharmaceutical products takes place through two main channels: (i) free distribution at the public health centers constituting a minimum supply level of emergency medicines in order to assure emergency health care; and (ii) distributton to 60 paying pharmaceutical officies most of which are located in the urban zones (36 in Ouagadougou and 13 in Bobo-Dioulasso). 'Me remaining gap is more or less filed by 460 pharmaceutical outlets which are not managed by pharmacists, and which have received legislative exemption in order to improve drug availability in the rural zones. There is a total of 176 private outlets and 284 communitylvillage-owned outlets in Burkina Paso. The majority of these outlets operate under a cost-recovery system and the funds received from the sale of drugs are used for the resupply of drugs and to cover other village priority needs. Drugs from donors and NGOs represent a non- negligible, but unquantifiable, share of the total supply.  s~~~~~~~~~~~~~~~~~~~ C. Health Sector Flnandug and StaMng 2.14 No comprehensive analysis of private health expenditures has so far been undertaken in Burkina Faso. Studies carried out as part of the cost recovery pilot operation undertaken under the FHP in the province of Boulgou show that, on average, individuals in the study area spent about CFAF 2,800 (US$10 at the pre-devaluation rate of US$1 =270 CFAF) per year on health care. Of this, about CFAF 1,000 (about US$3.70) was for modern treatment and drugs, the rest for traditional medicine. Extrapolation from these studies to the national level suggests that total private expenditures for health might be as high as CFAF 25 billion (US$93 million). That is more than twice the total national health budget (CFAF 9.9 billion or US$37 million in 1992). Public sector expenditure sources include the central budget (60%) and foreign aid (40%). NGOs provided about CFAF 1.3 billion (US$4.8 million) to the health sector in 1991. 2.15 Imports of drugs bave increased considerably in the past few years, growing from about CFAF 3 billion in 1986 to CFAF 9 billion in 1991, equivalent to 1.6% of the GDP. The private sector accounts for the bulk of drug purchases as government purchases have stagnated around CFAF 200 million oust over 2% of total drug imports) in the past few years due to budgetary constaints. To the general public, this situation has meant significant increases in the cost of health care, growing inaccessibility of drugs, as most drugs handled by the private sector are brand names which on average are about six times the cost of their generic equivalents (para. 2.25), and a concomitant declining confidence in public health facilities. As a result of the recent devaluation of the CFA franc, Burkina Faso cannot continue to spend the same US dollar amount to import drugs. Furthermore, the private sector cannot remain viable by maintaining a policy of importing expensive, specialty drugs which are becoming increasingly inaccessible to a large portion of the population. In order to ensure its survival, the private sector must move into the generic drug market, and the Government needs to take measures to ease the introduction of an active generic drug market by adopting a national pharmaceutical policy conducive to such a market in cooperation with the representatives of the private sector. 2.16 Public spending within the MSASF (not including aid-financed projects) rose modestly as a share of total Government budgetary expenditures from less than 7% in the mid-1980s to around 8% in the early 1990s. However, spending on critical commodities, such as drugs, medical supplies, and in-patient feeding, has stagnated in the last three years. Lack of growth in nominal public expenditures for drugs is a particular cause for concern given inflation rates of 7-11% per annum in international drug prices-a situation which will be exacerbated by the recent devaluation of the CFA franc. 2.17 Investment spending by the MSASF has varied considerably from year to year, approaching nearly CFAF 200 million per annum in budgetary expenditures and CFAF 4 billion per annum in aid-financed spending since 1987. These amounts represent 1-4% of total public investment spending and 3-10% of foreign aid disbursements, respectively. Recent survey results indicate that 68% of 1991 aid disbursements in the health sector was investment, of which 29% financed technical assistance, and the remainder was split evenly between facilities construction/rehabilitation and equipment purchases. Seventeen percent covered operating expenditures-mostly goods and services-including 3% for drugs and 5% for medical supplies. Nine percent of aid disbursements supported training activities, and another 3% funded locally hired personnel. 2.18 Burkina Faso has past experience in cost-recovery in some of its health facilities. In the 1970s, fees were introduced in hospitals, urban maternities and medical centers for consultations,  6 laboratory tests, and hospitalization. However, CSPS and other primary health facilities were not allowed to charge for services. And, although drugs have been recently distributed free throughout the entire health system, they have represented only a small portion of total drug consumption throughout the country (para 2.15). Starting in 1984 all locally-generated funds were sent to the Treasury, which takes 25% to be used as general government revenue, and sends 75% to a specW account, the Caisse Maladie, which is managed by the. MSASF. Current legislation provides that the provinces' share be held by the Caisse until the end of the year, at which time each provincial Directorate is notified that the province has a credit in its name at the Catsse Maladie. In practice, the MSASF distributes this year-end credit as it wishes, frequently returing these revemnes to the Ministry's general budget. 2.19 In 1991, in connection with the provision of foreign assistance to national hospitals, the Government adopted a policy calling for self-financing (excepting salaries) of regional and nationl hospitals. This has reduced the health revenues flowing to the Treasury and hence the portion flowing to the Caisse Maladle. This loss of revenue for the MSASF has reduced the Ministry's ability to redistribute resources from the tertiary level to the primary and secondary levels. Thus, it has become imperative that primary and secondary health facilities also be allowed to retain revenues from fees and sales of drugs for the purchase of drugs and medical supplies. In January 1993, legislation was approved allowing the peripheral health facilities (CMAs and CSPS), in principle, to retain the funds they collect. 2.20 In 1991, MSASF employed 5,861 staff members, representing approximately 17% of the towal civil service. Population per physician is about 38,900, while population per nurse and tained midwifelbirth attendant is 4,528 and 22,700, respectively. These numbers indicate an adequate number of nurses, but a considerable shortage of doctors relative to WHO recommended minirmum rates for the Sahelian countries of 1 per 10,000, and, for midwives, 1 per 5,000. The vast majority of health personnel is employed by the public sector. There is a great disparity in staffing availability between urban and rural areas, with nearly half of Ministry personnel being based in the two main cities of Ouagadougou and Bobo-Dioulasso. There is also a considerable disparity in staff availability among provinces, with the greatest shortages occurring in the northern provinces which are generally poorer and have the highest rates of malnutrition and infectious diseases. D. Sector DeeopmletIsu 1. lasues with regard to Health Services 2.21 A study entitled Quolaive Survey of Utilwation of Health Servces, undertaken in May- June I992 as part of the preparation of the proposed project, provides a rather dismal picture of the population's perception of public health facilities. Ihere were six main weaknesses identified under this Survey: (a) underutilization of functioning health services; (b) health workers' negative attitudes; (c) closure of a significant number of health services due to staff shortages; (d) lack of affbrdable drugs; (e) a poorly functioning referral system; and (f) deficient equipment and non- existent maintenance. Solutions are complex given the interdependence of these weaknesses. 2.22 Underutilization of Functioning Health Services. The utilization rate of public health facilities is very low and generally decreasing, particularly in rural areas. Today, utilization of health facilities is estimated to be below 30% of full capacity. Particularly worrisome are the low levels of prenaa examinations and the unsatisfactory vaccination coverage of infants-39% and 23% respectively in 1991. IThis underutilization results from a perception of poor quality of  services. The 1992 Survey showvs that perceived quality of services is one of the most important determins of level of utilization and willingness to pay. Perception of poor quality stems largely from the unavailability of affordable drugs and health workers' attitudes which are often perceived as arrogant. In addition, important and expensive vertical programs, established in the early 1980s (vaccination, famfly planning, MCH care, diarrhea management, etc.), which depend on donor support have declined in quality due to donor budgetary cutbacks. 2.23 Health Workers Attitudes. According to the Survey, health workers' attitdes depend on: Qt) the population's understanding of health problems and solutions; (ii) community participation in health center management; (iii) health workers' knowledge of the areas under their responsibility; and pQv) supervision and monitoring of health workers. Thera is little sense of "ownership" vis-l-vis the health facility among the communities of the health zone. Health workers seldom visit the surrounding village communities to sensitize the population as to health problems and the benefits of modern medicine. The lack of supervision of CSPS personnel by provincial/district authorities induces feelings of isolation and demotivation among health providers. 2.24 Staff Shorta. As the need for a larger, more effective health care delivery system increases, Burkina is also experiencing serious staff shortages. About 30 rural CSPS were recently estimated to be closed, largely due to lack of personnel. One important factor has been the overconcentration of staff in the two provinces containing Burkina Faso's two major urban centers. Although they account for only 15% of the total population, these two provinces have almost half of the MSASF's personnel. This includes 67% of the midwives, 33% of the trained birth adants, 40% of the nurses, and 60% of the doctors, pharmacists and medical technicians. Two underlying factors for the shortage in many rural areas have been imflated staff norms and the strong attraction of the two cities. 2.25 Lack of Affordable Dng. The absence of an effective drug policy has affected the entire health system. Essential generic drugs have been almost nonexistent, and hospitals and other public health facilities have relied upon specialty drugs which, based upon a sampling study in February 1993, have been shown to be approximately six times more expensive than their generic equivalent and unaffordable to the majority of the population. The Government's parastatal SONAPHARM was catering to the interests of local pharmacists and to its own profit margins by focusing on imports of high cost brand-name drugs while showing little interest in generic drugs. Progress has been made since 1992 towards the establishment of an essential drug policy. The Government legally established, in May 1992, the Centrale d'Approvisionnement des M!i canerns Essentels wiques (CAMEG), and this new organization is currently being set up. Legislation allowing peripheral health facilities to retain the funds they collect from the sale of drugs and provision of medical services, which was a condition for appraisal of the proposed project, was approved and signed in January 1993. Nevertheless, it must still be implemented. Successful cost recovery in the health sector under the proposed project, will depend largely on the Govemment's ability to keep the cost of drugs down through reliance on generic drugs. Full cost recovery on drugs alone would be a major step forward for the public health system as it would altiost certainly increase utilization of health services by enhancing drug availability. 2.26 Weakefeal System. There is an insufficient distinction between first line and referal levels, in terms of finctions and resources. In particular, the CMs without surgical activities and laboratories do not play their role of first referral. Refrral where surgical activities are first offered is at the level of the regional hospitals (CHR) and the national hospitals (CHN). Ihere are nine regional hospitals and two national hospitals-too few for first level referral. Moreover,  there is a related issue in the functioning of the two national hospitals in Ouagadougou and Bobo- Diouasso. The establishment of self-financing (excepting salaries) for the hospitals in 1991 (para. 2.19) has had the untoward effect of weakening the health pyramid, in particular its tertiary level. National hospital data indicate that, probably for financial reasons, there has been a shift within hospitals toward less costly primary and secondary care (for malaria, infectious respiratory diseases, diarrhea, hernias, etc.) and away from complicated, expensive procedures which few people can afford. As a result, the occupation rates for the national hospitals have declined from 96% and 90% in 1986 to 45% and 53% in 1991, for Bobo-Dioulasso and Ouagadougou, respectively. Furthermore, 20% of income from the national hospitals has been used to increase hospital personnel salaries. 2.27 Poor Equipment and Lack of Maintenance. Budgetary constraints have caused many of the nation's health facilities to become non-functional because of a lack of equipment, and a long list of equipment and vehicles awaiting repair. Regarding maintenance, there is also a serious lack of instittional capacity. There is only one team for hospital equipment maintenance, located in the Ouagadougou hospital; this team is poorly equipped, overloaded with work, and cannot maintain other health facilities. 2. Ik;ues with reard to Nutrition and Control of Certain Endeic Diseases 2.28 Nutrition. An assessment of the extent and severity of micronutrient deficiency in the country is incomplete, although studies which have been undertaken suggest that deficiencies are severe particularly in the outlying northern and eastern provinces (Anne 2.3). With regard to iodine and vitamin A deficiencies, however, a number of provinces have never been surveyed. Hence, there is the need for rapid surveys to better define areas suspected of suffering from severe deficiencies. Existing donor programs to provide supplementation in iodine and vitamin A (identified in the World Bank's World Development Report, 1993, as one of the most cost- effective health intervendons to reduce child mortality) remain patchy at best. Food fortification, likely to be more sustainable and cost-effective than supplementation, has not yet been introduced in Burkina Faso. Nutrition activities, including nutrition education, child growth monitoring and promotion, and micronutrient supplementation are given low priority by health workers. 2.29 Sustaining Endemic Disease Control. It is imperative that the gains achieved through the successful elimination of onchocerciasis be maintained (paras. 2.6-2.7). The prevention of recurrence of onchocerciasis as a public health problem requires: (i) both active and passive epidemiological surveillance to detect any instances of recrudescence; and (ii) immediate treatment of any new cases, especially within the migrant population. Given the technical constraints of active epidemiological surveillance of the disease, it is infeasible for the peripheral health centers to assume responsibility for it. Nevertheless, their role is important in the detection of new cases (passive surveillance), in case containment, and in sensitization of the population, since many people remain unnecessarily worried about the return of non-infective flies following the cessation of larvicide spraying. 2.30 The control of trypanosomiasis depends on: (i) both active and passive epidemiological suveillance to detect and treat new cases in high risk areas, and (ii) informing populations on ways to control the vector. While increasing awareness among populations can be undertaken by trained CSPS health workers, diagnosis of the disease requires skilled technicians, specific medical equipment, and active campaigns of detection followed by treatment of cases once a year in high risk areas.  9 2.31 In the absence of an effective meam for treating dracunculiasis, eradication must be based upon: (i) public awareness campaigns about the dise3se; (ii) education on ways to avoid its transmission, particularly with cloth drinking water filters; (iii) case containment and case reporting by village health workers (VHW). The plan relies on strong and sustainable supervision of the VHW by CSPS health workers who, in turn, should be trained and supervised by the District health team. 2.32 Epidemiological services within Burkina, particularly at the central level, are extremely weak. Such services are essential to maintining control of endemic diseases. The Department of Preventive Medicine (DMP), which includes the Service of Epidemiology, is scattered around Ouagadougou over seven facilities which are institutionally weak and without proper computer equipment. The resurgence of various diseases such as malaria, schistosomiasis, trypanosomiasis, and, foremost, the emergence of AIDS, have highlighted the need for strong epidemiological surveillance and control services. Moreover, the organizational structure of the DMP has been based on a range of national "vertical" disease programs with little coordination or integration of activities. E. Government's Strawe 2.33 Health Seices. The key objectives of the Government's current health services strategy as set out in the Govermnent's "Letter of Sector Policy' (Annex 2.4), which was finalized during negotiations and submitted to IDA as a condition for Board presentation, are: (a) strengthening the health care pyramid by promoting decentralization, integrating vertical programs, and improving capacity at the central and regional levels to enhance management of human, material and financial resources; (b) improving the supply and minimizing the cost of essential drugs; and (c) encouraging increased accountability and cost recovery mechanisms throughout the health system in line with the UNICEF/WHO-sponsored Bamako Initative which has been endorsed by the Government. 2.34 A key element of the Government's health services strategy is the strengthening of health services at the peripheral level through creating "Health Districts" centered around CMAs (Details are in An=e 3.1). District health authorities will supervise and control primary health care activities-through the CSPS-at the community level and through surgical referral facilities (CMA) at the district level. 2.35 The CSPS are supposed to follow a "Minimum Package" approach, i.e. curative consultations, immunizations, recommendations about appropriate food intake, pre-natal consultation, dealing with chronic sicknesses, family planning, etc. The CMAs are expected to deal with cases requiring hospitalization, referral consultations, and urgent medical/surgical cases. In addition to the basic surgical cases, the CMAs are also expected to handle complicated births and simpler laboratory tests. 2.36 Under the second Five Year Plan (1991-95), the Government set out the following objectives: (J) establishing health districts throughout the country with an average population density of approximately 200,000; (ii) providing all districts without a regional hospital (CHR) with an upgraded CMA; (iii) involving locally elected community members in decision making and management of the CSPS and CMAs; Civ) establishing primary care facilities in urban centers to draw primary care out of the hospitals; and (v) improving the supply of essential drugs and establishing local cost-recovery.  10 2.37 In line with its objective of improving the supply and minimizing the cost of essential drugs, the MSASF has taken a number of initiatives during 1992-1993. It has: (i) revised the pharmaceutical legislation to facilitate the importation of essential generic drugs; (ii) established an initial list of about 60 essential drugs (ED) to be imported exclusively in generic form, which is presently in the process of being expanded to a list of 120 EDs; (iii) created an essential drug purchasing agency, the Centrale d'approvisionnement des mddicaments essentiels gendrlques (CAMEG), modeled on the one established under a BankIUNICEF-supported project in Benin; (iv) given the authorization to donors and donor-supported projects to import directly the drugs included on the Essential Drug List, in generic form; and (v) approved legislation that would allow peripheral health facilities (CMAs and CSPS) to retain the funds they collect from the sale of drugs and provision of medical services in order to establish revolving funds for essential generic drugs. 2.38 To lessen the impact of the recent CFA devaluation on the population, the Government of Burkina Faso has planned the following steps: (i) accelerating the implementation of a community management system for the primary and secondary level (CSPS and CMAs) health centers; (ii) establishing fixed prices for a national list of essential drugs for all public service health centers; (ii) accelerating training relating to generic drugs for drug prescribers; and (iv) informing the population about generic drugs. Under a special action program, the Government has agreed as a condition to the IDA Economic Recovery Credit to finance a one-time initial stock of essential drugs (US$3 million) for the CSPS and CMAs of the districts that do not yet have in place a functioning cost recovery system. Tis stock will provide the initial capital for commencing cost- recovery under a revolving fund scheme. Training for key staff within primary and secondary level health centers would focus on health services management with special attention to drug management, establishment of an accounting system, and organization of essential generic drug distribution. The Government has agreed as a condition to the IIDA Economic Recovery Credit to finance this training component (US$1.8 million) and UNICEF will act as the implementing agency. 2.39 Within the framework of this national pharmaceutical policy which inter alia promotes the availability of inexpensive essential drugs in cooperation with the private sector, the Government intends to take the following actions: (i) abolish the ad valorem margins on drugs; (ii) authorize pharmacists to substitute generic drugs for name-brand, specialty drugs; and (iii) authorize pharmacists who already own a pharmacy to open one or more additional pharmacies. 2.40 Nutrition. Malnutrition is a serious problem (para 2.5) and lack of integration of mntrition activities into the PHC system has been identified as a weakness under a study of the sector undertaken in 1991 (Ouddraogo Andrd, Analyse de la siuation: Secteur de la Nutition) The Govenment's commitment to controlling the problem has increased substantially in the past few years. Ihe "Naftonal Action Plan for Child Survival, Protection, and Development in Burkina Faso," adopted in 1992, specifies the following targets for the year 2000: (i) reduce by 50% moderate and severe malnutrition in children under five; (ii) virtally eliminate iodine deficiency disorders; (iii) virtually eliminate vitamin A deficiency and its consequences, including blindness. The MSASF participated in the Montreal global policy conference "Ending Hidden Hunger' in 1991, which specifically addressed micronutrient deficiencies. The Government prepared a national program on nutrition which was presented at the International Conference on Nutrition in Rome, in December 1992; a large proportion of this document was devoted to micronutrients. 2.41 Endemic Parasitic Diseases. The Government's strategy to secure sustained control of onchocerciasis and trypanosomiasis is based on its Devolution Plan, which was first prepared in  11 1988. It consists of (i) active epidemiological surveillance of both diseases by four trained mobile teams, and (ii) passive surveillance, treatment of cases, and increasing awareness of the characteristics of these diseases among populations by CSPS health workers who will be trained and supervised by District Health Workers. 2.42 Regarding dracunculiasis, the Government has stated its intention to eradicate this disease before 1996. The eradication program entaUils: (i) establishment of epidemiological surveillance through case reports by village health workers; (ii) information and education campaigns; (iii) provision of water-filters to all households in endemic villages; (hv) treatment of detected cases; and (v) supply of endemic villages with safe water. F. The Bank Group's Role 2.43 The Bank's first involvement in the health sector in Burkina Faso was through the successful region4 Onchocerciasis Control Program (OCP), launched in 1974, of which Burkina is one of the principal beneficiaries (Annex 2.1). The Bank's Country Economic Memorandum and Health and Nutrition Sector Review set the stage in 1982 for a strategy of Bank assistance in health to Burkina beyond the OCP interventions. Based upon the findings and recommendations of these reports, and further preparatory work, IDA approved Credit 1607-BUR with an amount of US$26.6 million in 1985 for the First Health Project. 2.44 The FHP was designed to assist the Government in: (i) strengthening basic health and family planning services, with initdal emphasis on the control of communicable diseases; (ii) fwther formulating national health and population policies and promoting their application; and (iii) strengthening the MSASF's institutional capability in planning, evaluation, project implementation and monitoring. 2.45 During the mid-term review of the project in October 1988, it was recognized that the investment components of the project had made progress, but that the required changes in the national health policy had not been forthcoming. As a result, many health facilities were non- functioning or underutilized. ITe mid-term review led to a refocusing of the project towards policy reforms in three main areas. First, it was concluded that the vertical nature of the health system required reform. It was found that the different health services-meant to tackle only specific health/disease problems-led to duplication of efforts, a waste of scarce personnel resources, and high cost, resulting in the need for reorganization and integration of services. Second, Bank efforts were directed at helping make the peripheral health facilities more autonomous, both administratively and financially, to enhance community wownership" and commitment. It was concluded that financial autonomy would ultimately depend, to a large extent, on the availability of essential generic drugs. Third, the short supply of drugs at CSPS level and the high cost of the few available drugs were seen to be an important factor in the extremely low utilization rates. To address this issue, the CAMEG (para. 2.25) was established as a legal entity in 1992 through legislation approved by the Government. 2.46 With regard to the physical accomplishments of the FHP, it has established 142 CSPS in the rural and urban areas and three surgical CMAs. In the area of population/family planning, it extended family planning services to six provinces of the country which had not been covered by other donors. To prepare doctors at the district level for their new managerial and tecnicWa responsibilities, two training programs are underway. One is to train generalist doctors to perform emergency operations. The other program provides supplementary training to district medical officers in management, planning, technical supervision, statstics and epidemiology. A  12 training team formed by a nucleus of national doctors and an expatriate public health specialist has been established under the responsibility of the MSASF's Centre de formation pour le dveIloppement sankaire (CFDS), under the aegis of the National School of Public Health (ENSP). 2.47 The 1992 Food Security and Nutrition Project (Credit 2414-BUR) aims, among other things, at improving food security programs to target low income groups in drought-prone provinces and also at improving efficient use of available household food to achieve better nutritional status for children below the age of three and nursing mothers. Emphasis is being placed on basic nutrients such as energy rich staples, improved weaning practices and nutrition education. That project, however, does not specifically address problems of micronutrient deficiencies. 2.48 The FHP has also provided initial support for Burkina's effort to strengthen national capacity to control three endemic parasitic diseases ("devolution"). Activities under the Devolution Plan (totaling US$900,000) have been supported through the ongoing FHP since early 1992. The FHP has supported the creation of four mobile teams, to conduct epidemiological surveillance-one central team in Ouagadougou, and three local teams in Bobo-Dioulasso, Banfora, Koudougou. The operations are being overseen bv the National Devolution Coordinator with the technical advice of OCP. 2.49 Parallel to preparation of the proposed project, the Government of Burkina Faso and the Bank have prepared a 'Population and AIDS Prevention Project" whose objectives are: (a) to support the implementation of the Government's Population Policy; and (b) to strengthen the national capacity to contain the spread of HIV/AlDS/STDs. The support of the implementation of the Government's population policy will be achieved by: (i) improving the quality of, and access to, family planning (FP) and matemal and child health (MCH) services; (ii) increasing public knowledge of, and demand for, modem contraception methods; (iii) strengthening the institutions in charge of implementing the national population policy and of planning, managing and evaluating PP programs; and (iv) establishing a fund to provide grant financing for projects in the area of population, FP, women in development (WID) and HIV/AIDS/STDs prevention. Strengthening the national capacity to contain the spread of HIV/AIDSISTDs will be achieved by: (1) raising public awareness of HIV/AIDS and STDs to promote safer health practices and behavioral changes; (ii) promoting social marketing of condoms; (iii) strengthening capabilities for HIVIAIDS and STID prevention and control; and (iv) strengthening clinical manement and community care. These two projects are mutually reinforcing because the Population and AIDS project will be implemented through the new health service structures established by the PDSN. Moreover, the success of the implementation of the Population and AIDS prevention project is essential to the sustainability of PDSN because: (i) without AIDS prevention, the health services will be overburdened and health expenses will be shifted to AIDS patients at the expense of other public heath interventions; and (ii) a continuing rapid population growth will seriously undermine efforts to bring about improvements in maternal and child health.  13 G. LessM LaMl 2.50 The design of the proposed project corrects two weaknesses identified in Operations Evaluation Department audits of World Bank health projects. These weaknesses have also hampered implementation of the First Health Project (FHP) in Burkina Faso. They are: (1) lack of decentralization, and (2) lack of improvement in the quality of care. PDSN emphasizes decentralization coupled with training and supervision through district management teams designed to improve the quality of care, and priority is given to improving the quality of services of existing structures. There are three other lessons to be learned from the implementation of the FHP. First, emphasis on providing buildings and other infrastructure will accomplish little if complementary changes in health care policy are not forthcoming. It became clear by 1988 that decentralization of health care services would be essential to project success but virtually all project activities were concentrated on the implementation of the investment component. Dialogue on the need to give the peripheral health facilities more autonomy and discussions on the drug supply/distribution/importation did not start until after the 1988 mid-term review of the FHP-too late to achieve timely adoption of the necessary complementary policy reforms. Under the proposed project these policy issues have been addressed during preparations and most necessary actions have been taken prior to negotiations. Second, despite a sizable project/Governmert input for training under the FHP, the impact of the training on improved health care is unknown. To avoid such a recurrence in the proposed project, IDA will review and approve the content of trainig programs prior to their implemeniation, and the Government will introduce a monitoring system under which supervisors will-at regular intervals-report on the accomplishments/shortcomings of former trainees. Third, introduction of the necessary policy reforms took too long under the FHP because agreement on these reforms was sought through policy dialogue during project implementation rather than earlier during the processing of the project. Under the proposed project virtually all policy reforms have been addressed up front, prior to negotiations. M. TH PROJECT A. Projct Rationale 3.1 Low life expectancy and high infant and maternal mortality rates partly reflect the low quality, unavailability, and underutilization of Burkina's health services. The second Five Year Development Plan calls for an ambitious program of construction and upgrading of health facilities during the 1991-95 period. To reach the rural and urban poor, improvements in, and expansion of, basic health facilities receive highest priority. Budgetary constraints preclude financing the basic health program without donor assistance. System-wide reforms such as those proposed by this project involving the organizational structure of the health delivery system, redeployment of staff, basic financing mechanisms, and the reform of the pharmaceutical system go beyond most donors' scope of intervention because of the extensive analytical work and policy dialogue required to get these reforms accepted and ensure that they are implemented. Health problems caused by micronutrient deficiencies such as blindness, cretinism, anemia, etc., could be corrected through relatively low-cost remedial action. The country's tight financial situation would make it difficult to continue the activities necessary for surveillance of the areas cleared from onchocerciasis and to prevent recrudescence of the disease. Integrating trypanosomiasis control and dracunculiasis eradication activities with control maintenance of onchocerciasis (aDevolution Plan") would be a cost-effective approach to eliminating these endemic diseases and  14 would make a significant contribution to rendering oncho-freed areas safer for resettlement. Burkina has sought bilateral sources of financing for its Devolution Plan since 1989 without result. Supporting Burkina's Devolution Plan would safeguard a major donor investment of US$500 million in the eleven countries covered by the Onchocerciasis Control Program-including US$50 million in grant financing from the Bank-to successfully rid the region of this endemic disease which has been a major constraint to development. Finally, successful implementation of the proposed Population and AIDS Prevention project (para. 2.49) will depend importantly upon actions taken to strengthen the health system and improve the quality of health services under this project. B. Proiec Objectives 3.2 The project would assist the Govermment in its efforts to: (a) improve significandy the quality, coverage, and utilization of basic health services for the Burkinabe population, (b) enhance the nutritional status of the population by decreasing micronutrient deficiencies, and (c) develop a national capacity for achieving sustainable control of endemic parasitic diseases. Progress in achieving these objectives will be assessed against monitoring indicators, developed and agreed upon with the Government, and reflected in the Letter of Health Sector Policy (para. 2.33, AM 2.) which was finalized during negotiations and submitted to IDA as a condition for Board presentation. C. Pro ect mm ; 3.3 To achieve these objectives, the project would support the four components summarized below, through policy reforms and investments. Table 1: Proiect Comoonents 1. Improve quality, coverage, and utilization of basic healt services by: (a) strengthening the health system pyramnd, (b) rationalizing staff use, and promoting staff developrment, (c) dnralizing the public health system, and (d) increasing availability of essential drugs. 2. Reduce micrnutuient defckncies by: (a) supporing niucronutrient supplementation, and (b) developing a longer-term, durable natonal strategy for retucing micronutrient deficiencies. 3. Achieve and maint control of endemic parasitic deass by: (a) strengthening the capacities of the health system to cay out epidmiological sureillance and treat detected cases of onchooeriasis, trypanosomiasis, and dra