Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB2141 Project Name Health System Strengthening & Multisector HIV/AIDS Program Region AFRICA Sector Health (75%);Other social services (25%) Project ID P093987 Borrower(s) GOVERNMENT OF BURKINA FASO Implementing Agency Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD Date PID Prepared February 2, 2006 Date of Appraisal Authorization December 16, 2005 Date of Board Approval March 30, 2006 1. Key development issues and rationale for Bank involvement Despite promising trends in some health service and outcome indicators, Burkina Faso has among the highest rates of child and adult mortality in the world. Most key indicators for child health and nutrition worsened during the 1990s, but in the past five years, infant mortality has declined and coverage of preventive health services improved. But Burkina remains significantly “off-track” to achieving the millennium Development Goals (MDGs) for health: juvenile mortality (ages 1-5) has remained unchanged for the past decade – due to limited progress in combating malaria, increased AIDS mortality, worsening child malnutrition, and high fertility rates. Maternal mortality was estimated to be 484 per 100,000 births in 1999, but this is likely to be an underestimate. HIV prevalence rates appear to be stabilizing (estimated at 2.3 percent in 2004), but malaria remains the major cause of mortality among children and morbidity among adults. Consistency with Bank and Borrower strategy: One of the four key objectives of the Burkina Faso PRSP is to improve access to social services for the poor. A new results-based Country Assistance Strategy (CAS) for the World Bank’s Burkina Faso program was discussed by the Board in July 2005, which supports the pillars of the revised CSLP. The proposed health and HIV/AIDS Program will support two of the four major objectives of the CAS: improved access to basic social services, as well as better governance with greater decentralization. The government has demonstrated its commitment to combating HIV/AIDS through the establishment of a National AIDS Council (SP-CNLS), chaired by the President, and the adoption of a new five-year HIV/AIDS strategy (2006-2010). In the health sector, the national 10-year Health Sector Strategy (PNDS) was approved in 2001, which provides the framework for government and partners. Lessons from current operations and ESW: In 2001, the Bank discontinued direct project lending for the health sector in favor of budget support through the PRSC. The PRSCs have proven effective instruments for pursuing policy and structural reforms, but would be more effective if complemented by flexible sector support for implementing the PNDS. The Burkina Faso MAP project (PA-PMLS) was launched in 2002, to further scale up the national multi-sectoral response to HIV/AIDS. The MAP has disbursed rapidly and is fully committed. The mid-term review in June 2004 noted significant progress in scaling up multi-sectoral activities, but recommended reorienting and mainstreaming prevention activities of non- health ministries, strengthening program coordination (including merging the project unit into the national AIDS council), and further enhancing monitoring and evaluation. Moreover, experience suggests that improving the quality and accessibility of medical treatment – whether for AIDS, malaria, or TB – Page 2 requires addressing fundamental weaknesses in the health system. Finally, experience in Burkina and other countries in the region has shown that harmonization of financing arrangements (particularly in social sectors) is essential to reduce transaction costs and improve development effectiveness. Partners and sector-wide approach. Other key partners supporting HIV/AIDS and health programs in Burkina Faso include bilateral donors, UN Agencies, regional development banks, the Global Fund, and international NGOs. Relations and consultation among donors are strong, although joint annual program reviews need to be further formalized. WHO plays a lead role for coordination activities in the health sector, including convening meetings for all health partners every two months, and hosts technical for HIV/AIDS, in collaboration with UNAIDS. With the rapid growth in the number of partners and programs in recent years, both the National AIDS Council and the Ministry of Health have asked donors to harmonize procedures and move to sector-wide support and pooled funding if possible. A pooled funding mechanism is already in place for the health sector. For multi-sectoral HIV/AIDS activities, the MAP project unit has been transferred to National AIDS Council so that it can form the basis for the development of a project execution unit for multiple partners. 2. Proposed objective(s) The objective of the Project is to support the implementation of the Recipient’s health sector and multisectoral HIV/AIDS strategies. In particular, the project will support the government’s programs to: (i) improve the quality and utilization of maternal and child health services; (ii) improve quality and coverage of treatment for HIV/AIDS and sexually transmissible infections; (iii) expand the national response to malaria prevention and treatment, at both community and health facility levels; (iv) improve knowledge of HIV prevention and encouragement of the adoption of lower risk behaviors, among high- risk groups as well as the general population; and (v) mitigate of the socio-economic consequences of the AIDS epidemic through improved coverage of social safety nets for orphans and vulnerable children, and improved coverage of community care and support. 3. Project description Several alternative approaches have been considered, and it was agreed that a separate health and HIV/AIDS sector operation was needed to address health system weaknesses, increase use of services by the poor, and to consolidate and mainstream HIV/AIDS prevention activities. The approach also offers the advantage of reducing the transaction costs of preparing two separate operations. Support to the health sector would be provided under a pooled financing mechanism (already in place) in the context of a health sector medium term expenditure framework (MTEF), with priority expenditures to be integrated into the government budget. Program financing would thus complement rather than substitute for budget support through the PRSC. Similarly, HIV/AIDS activities would be coordinated by the SP-CNLS, through a multi-donor project management unit, which will manage pooled funds of the Bank and other participating partners. Intermediate program indicators will serve as the basis for annual monitoring of progress, including trained birth attendance, coverage of mosquito nets, condom use at high risk sex. Proposed program components are organized according to the flow of funds: (a) Strengthening the health sector response ($26 million) This component would provide global support for improving sector performance through a multi-donor basket funding mechanism, which will finance district, regional, hospital, and central action plans based on performance contracts with agreed monitoring indicators and targets. The Ministry of Health’s 10-year Page 3 health sector development strategy (2001-2010) provides the overall strategic framework for the sector and for the PRSP. The Medium Term Expenditure Framework (CDMT/santé) will form the basis for program preparation and for dialogue with both the Ministry of Health and the Ministry of Finance and Budget regarding budget priorities for achieving sector objectives and MDGs. Emphasis will be placed on monitoring progress toward agreed objectives rather than earmarking funds for specific activities, including strengthening performance contracting between the health ministry and both public and private service providers, and strengthening monitoring and evaluation. Program resources will be distributed among central, regional, and district levels of the health system according to a transparent allocation formula (including population, poverty, services delivered). The program will seek to ensure continuity of AIDS treatments programs initiated under the HIV/AIDS Disaster Response Project (MAP) (850 persons under treatment) and the Treatment Acceleration Program (TAP), and place strong emphasis on significantly scaling up malaria prevention and treatment activities (including insecticide treated bednets). (b) Support for Multisectoral HIV/AIDS response ($21 million) This component would provide support to the multisectoral HIV prevention and non-medical care and support program, coordinated by the National AIDS Council. This includes continued financing for targeted HIV/AIDS interventions for high-risk vulnerable groups (sex workers, miners, youth); targeted support for action plans of non-health ministries; voluntary counseling and testing; behavior change communications campaigns; and support for prevention and care activities within civil society and the private sector. This component would also support provincial AIDS committees and village micro- project. As part of the broader social protection strategy, the program will finance non-medical care and support for persons infected and affected, including civil servants. More generally, program dialogue will encourage the integration of HIV/AIDS activities into ongoing programs and the national budgets, to the extent possible. For example, school-based HIV/AIDS and reproductive health programs would be integrated into the basic education project support, with targeted support for non-school youth programs. 4. Safeguard policies that might apply The main environmental and social issues relates to medical waste management. While activities financed through the current project and the proposed supplemental will generate relatively little medical waste directly, proper management and disposal of medical waste is clearly an important issue for avoiding accidental exposure to HIV and other blood-related illnesses by health workers and by persons in surrounding communities. The project is therefore classified as "B." An environmental assessment was completed in November 2002 during implementation of the current HIV/AIDS Disaster Response Project, but not fully costed during project design. A medical waste management action plan was approved in November 2005, and implementation will be supported through this project. Aside from treated bednets, no expenditures are currently foreseen for insecticides. 5. Financing Source: ($m.) BORROWER/RECIPIENT 3 INTERNATIONAL DEVELOPMENT ASSOCIATION 47 Total 50 6. Contact point Contact: Timothy A. Johnston Title: Senior Human Development Specialist Tel: 5354+319 Fax: (226) 50 308649 Email: Tjohnston@worldbank.org Page 4 Location: Ouagadougou, Burkina Faso (IBRD)