Document of The World Bank ]OI OmCIAL USE ONLY Report Ne. P-4086-BUR - REPORT AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRFCTORS ON A PROPOSED CREDIT OF SDR 26.9 MILLION TO BURKINA FASO FOR A HEALTH SERVICES DEVELOPMENT PROJECT May 14, 1985 ,-- I e cham mM ma olrwse be d_idoaiwlO. WOdd Bu& ihEoD i CURRENCY EQUIVALENTS Currency Unit CFA Franc (CFA!) :`S$1.0 CFA 490 CFA! i = US$0.0020 CFA! i-Million US$2,041 IWEIGETS ANID MEASURES Hetric System FISCAL YEAR January 1 - December 31 GLOSSARY 0F ACRONYNS CSPS Center for Realth and Social Promotion (Centre de Santé et de Promotion Sociale) DEPSS Directorate of Kealth Studies, Planning and Statistics (Direction des Etudes, de la Planification et des Statistiques Sanitaires) DPSP Provincial Directorate of Public Health (Direction Provinciale de la Santé du Ministère die la Santé Publique) FEER Rural Water and Equipment Fund (Fonds de l'Eau et de l'Equipement Rural) FEFS Health Services Equipment Fund (Fonds d'Equipement des Formations Sanitaires) ONAF National Office oie Pharmaceutical Supplies (Office National d'Approvisionnement Pharmaceutique) MOPH Ministry of Public Health PH4U Project Management Unit (Cef Cule de Gestion du Projet) PPF Project Preparation Facility FOI OFFICIÂt USE ONLY BURIINA HEALTH SERVICES DEVEOPEME PROJECT CREDIT AMD PROJECT SUNNARY Borrover: Burkina Faso Beneficiary: N-inistry of Public Health Amount: SDI 26.9 million (US $26.6 million equivealent) Term: Standard :ro ect Objectives: The major objectives of the project are to: (a) Strengthen basic health and f amily planning services, with initial emphasis on the control of communicable dise,ases and the treatment cf malaria; (b) Further formulate national health and population policies and promote their application; and (c) Strengthen the instïtutionnl capabil-ity of the Ninistry of Public Realth ln planning, evaluation and pr'ect inSplementation and monitoring. Benefits: The project vould improve the quality and accessibiity cf health and family planning services for about 4 million persons (over half the total population), vith about 60 percent cf children 0-4 years being effectively protected against major nhildhood communicable fiseases. The skill and performance cf about 1i000 health aorkers iu rural areas vould improve. Essential drugs are expected to be imore videly available throughout the country at lover cost, ahile partial cost recovery vill be introduced more videly into the health system. The mascent f amily planning program vould be strengthened. Improved health policy formulation, plnnning and donor coordination are expected. Risks: Ri.sks include the Coverment's lack of experience in imple- mentBing a nationvide health projqect and the possibility thatps due te Burkina's precarious finpancial situation, the Government may be unable to support fully incremental recur- rent costs at the end cf the project. By relying on and strengthening experienced local agencies,i together with technical assistance vhere appropriate, the risk cf unsatis- factory project itplementation vould be reduced. Cost con-' tainment and cost recovery beasures, to be set in place through the project, as veli as frequent IDA consultation vith the Covermment on-steps to be taken te mobilize addi- tional resources for the health sector, are expected te assist the Goverument to meet recurrent cost requirements. This document bas a o oestrited distibution and fay bc used by recipients only in the performanoe of their officiai duties Ils contents may not otherwise bc disclosed witaout World Bak authori2ation. - il - Estimated ProJect Costs: (Net of taxes and duties from which the project vould be exempt.) Local Fareiïg Total --U S$ million- - 1. Strengthening of Basic Health and Family Planning Services - Development of Immunization and Malaria Programs 0.8 3.1 4.0 - In-Service Training of Eealth Personnel 0.1 0.3 0.5 - Strengthening of Health Infrastructure 4.4 4.9 9.3 2. Development of National Realth and Population Policies and Programs - Policy Development Studies 0.1 0.4 0.5 - Implementation of Sub-projects Resulting From Special Studies, and for Population Activities 1.8 3.2 5.0 3. Strengthening of Ministry of Public Health 1.2 2.2 3.4 b! TOTAL BASE COST 8.4 14.2 22.6 Physical Contingencies 0.5 0.7 1.2 Price Contingencies 2.1 2.1 4.2 TOTAL PROJECT COST 11.0 17.0 28.0 ~= Financing Plan: IDA 9.6 17.0 26.6 Goverxmient 1.4 _ 1.4 TOTAL 11.0 17.0 28.0 a/ Totals may not add up due to rounding. b! Includes a US$0.8 million PPF advance. - iii - Estimated Disbursements: FY86 PY87 FY88 FY89 PY90 FY91 - -US$ mï11ion- AnnUal 2.4 3.7 5.3 5.9 5.6 3.7 Cumulative 2.4 6.1 11.4 17.3 22.9 26.6 Appraisal Report: 5352-BUR Economic Rate of Return: Not Applicable Project Completion Date: January 31, 1991 MSp. No. IBIRD 18565 INTERNATIONAL DEVELOPMENT ASSOCIATION REPORT AND RECOMMENDATION 0F THE PRESIDENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO BURKINA FASO FOR A HEALTE SERVICES DEVELCPMENT PROJECT 1. I submit the fo}lowing report and recommendation on a proposed development credit to Burkina Faso in an amouat of SDR 26.9 million (US$26.6 million equivalent) on standard !DA terms to help finance a Realth Services Development Project. PART I - TRE ECONOMY 1/ 2. A country Economic femorandtm entitled "Upper Volta: Investment in Ruman Resources" (4040-UV) vas distributed to the Executive Directors on September 5, 1983. The following paragraphs are based on this report and on subsequent economic updates by Bank Staff. Background 3. With a GNP per capita of US$180 in 1983, Burkina (population 6.7 million) is one of the poorest countries in the world. As in m»st of the Sahelian region, this poverty is largely the result of a limited resource endowment. Soils are generally shallow, poorly structured, and easily depleted by traditional methods of cultivation. Rainfall is scarce and highly variable both among regions and from year to year. The lack of a permanent vater flow in the couutry's river system severely limits the potential for irrigation and hydroelectric pover. The cost of mining known mineral deposits (e.g. zinc, silver, phosphorus) is relatively high. The country's landlocked position, scarcity of roads, and long distances from seaports further constrain the country's development potential in all sectors. 4. An estimated 80-90 percent of the population depends for its livelihood on the predominantly subsistence-oriented agriculture and livestock sectors. Concentration of over half of the population on the central plateau has resulted in declining fallow periods, rapid deforesta- tion, and deteriorating soil fertility in this region. The impoverishment of the central region has given rise to spontaneous resettlement to the south and west, areas recently freed of riverblindness (onchocerciasis), and to emigration to coastal countries, primarily the Ivory Coast. Approx- imately 0.6 percent of the population emigrates each year and roughly half of the emigrants are working age males. PmiLgration has provided the required safety valve for population pressure and has resulted in an annual 1/ Parts I and II are substantially the same as those in the Primary Education President's Report. -2- inflow of remittances of about 8 percent of GDP. Both demographic move- ments, however, represent only partial and temporary solutions to the challenge of raising the living standard of the population, which is groving at approximately 2 percent annually (adjusted for emigration). Past Economie Performance and Recent Developments 5. The 1970's vere good years for Burkina's economy. Outperforming other Sahelian countries, the country's GDP grev at an annuel 3.9 percent in real terms between 1970 and 1979 and GDP per capita at 2 percent. These favorable trends vere due to relative political stability, increased inflows of foreign aid and workers' remittances (the latter accounting for most of the gains in national income), and the .expanded production of cotton, the country's major export crop. Also, Government economic policies vere generally judicious. The three ruling administrations of the 1970's avoided major errors in the selection of investments, kept the economy free from price distortions, and stayed vell within the conservative financial policy guidelines of the West African Nonetary Union (WAMU), of which Burkina is a member. There vas, however, one area of veakness in Burkina's otherwise creditable economie performance during the 1970's, namely, the inadequate planning of capital and recurrent public expenditure. This led to a neglect of certain sectors such as health and education, and, in the second part of the decade, to budgetary deficits amounting to 1-1.5 percent of GDF. 6. A strine of adverse developments in the 1980-1983 period caused a reversal of the 1970's trends and helped plunge Burkina's economy into a severe recession. A rapid turnover of governments led to a climate of political instability which, in turn, slowed down the inflow of both foreign aid and vorkers' remittances - the two major stimulants of demand in Burkina's modern sector. In addition, because of irregular and below average precipitation, cereal harvests fell steadily from the peak reached in 1981, thus substantially reducing outputs in agriculture, the country's traditional sector. Public economic and financial policies deteriorated as vell in 1980-1983, a period when the Goverument undertook questionable investments and inordinately expanded its debt burden by borroving from local banks and contracting foreign loans on non-concessionary terns. The budget deficits brought about by these policies and by falling custom revenues led to mounting reciprocal arrears between the Treasury and the state enterprises and contributed to further exacerbate demand for bank credits. All told, between 1980 and 1982, investment fell approximately 50 percent, GDP stagnated, and the budget deficit increased to 4.2 per- cent of GDP by 1983. 7. The present Government, which came to poaer in August 1983, initially directed its energies almost exclusively to establishing a solid political base. In mid-1984, however, the country's vorsening economic conditions compelled the Governuent to redirect its attention to the economic front and to delineate a preliminary set of development and - 3- financial stabilization policies. Thus, the new Government announced that it would place increased emphasis on rural and human resources development, tighten budgetary expenditures, and start elaborating a National Develop- ment Plan. 8. A first concrete step to implement these policies vas the launch- ing of a "programme populaire" comprising a "self-help" program of suall investments and operations at the villaga level (construction of small dams, grain storage, health and education facilities). A second important step vas the passing of an "austerity budget" for 1985 calling for cuts in expenditures (other than investment) and increases in revenues. Thus, in a rapid succession of fiscal measures, the Government introduced taxes on land title and on cattle, raised the tax on alcohol, and required employees in both public and private sectors to forego their "13th-month" bonus payment as well as between 1/12 and 1/24 of their basic salaries in favor of the Treasury. Hovever, the Governmenc has also taken steps to suppress rental payments and establish new land tenure arrangements, measures which are likely to prove counterproductive. 9. Although it is difficult to assess the final impact of the foregoing measures on the economy and on public finances, preliminary data indicate that economic growth has not yet revived. This is not surprising given the continuation of drought conditions in Burkina, which caused a 7 percent drop in 1984 cereals output (vis-a-vis the already depressed average of the two precedi-ng years), and theî persistence of an unstable political climate, which has adversely affected both foreign aid and workers' remittances. As for publie finances, the budget deficit appears ta have remained at 4 percent of GDP in 1984 despite the austerity budget, as the economic slowdown caused revenues to drop further. Economic Policy Issues 10. While some of the recent measures are preliminary steps in the right direction and do indicate the Covernment's willingness to undertake reforms, the redressing of the economic and public finance situation requires a range of complementary policy changes in the areas of investment planning, financial management, and public enterprises. Corrective action in these areas could also pave the way for a possible IMF standby arrange- ment. 11. Investment Planning Burkina's public sector has never shown great enthusiasm for planning its investments. Continuing in this tradition, the current Government is proposing to embark on a number of highly visible, large-scale projects vithout having made a serious anAlysis of their economic merits or budgetary implications. The largest and most controversial of the proposed projects, representing a total cost of about US$320 million, is the Tambao project involving the Ouagadougou-Kaya-Dori railroad extension, development of a manganese deposit at Tambao and construction of related infrastructure. Although more appropriate in the Burkinabè context, the recently launched "programme populaire" appears overambitious as vell, when viewed against the rural communities' limited implementation capacity. - 4- 12. Recently, hovever, the nev Government has appeared to be giving increased consideration to economic planning and has asked the Bank Resi- dent Mission to help. Clearly, one of the major goals of any planning process should be the definition of a realistic and vell-conceived invest- ment program, l.e. one vhich vould channel investment resources tovards priority uses, and vould be commensurate vith the country's absorptive capacity. The objective ranking of investment proposals according to clearly defined development priorities, estimated economic impact, and budgetary implications vould undoubtedly lead to a shift of attention from some high-risk propositions (e.g., Tambao) currently contemplated by the Covernment to sounder project proposals, such as exist in the agriculture. transportation and human resources fields. The definition of a sound investment program could serve to rationalize not oaly the use of domestic resources but also that of external aid, which has financed 80-90 percent of Burkina's public investment in recent years. Such a program vould be a valuable instrument for improved aid coordination; it would provide the donor community vith a sounder basis for its decisions and would afford the Burkinabè Governuent the opportunity of taking an increasingly firmer hand in directing external assistance tovards nationa' economic priorities. 13. Financial Management. Burkina's Public Finances are - and will for saome years continue to be - severely strained by the peaking of debt service payments. While this peaking is primarily due to the expiration of grace periods on foreign concessional loans obtained after the 1973-74 drought, it also reflects'`payments due on non-commercial external'.and internal debt incurred in the 1980-1982 period (para. 6). Debt-service payments due in 1984 amounted to CFAP 12 billion, with a further increase projected for subsequent years. 14. Restoring balance to the public finances requires a number of actions - complementary to those recently taken by the Government - on both expenditure and revenue sides. Thus expenditure cutbacks should be extend- ed to defense spending and public transfers, notably student stipends. Non-concessional debt incurred iiQ the 1980-82 period vill probably need to be rescheduled, and new borrowing closely monitored. Despite the limited tax base, some scope exists for increasing budgetary revenues by raising import taxes and/or the indicative prices of imported consumption goods and petroleum products. Improved tax collection could also prove to be an important source of increased revenues. 15. Putting the public finances in order vould also require a strengthening of such essential functions as budgeting, accounting and financial control. particularly in the areas of external debt and public recruitment. The Government has recently proceeded to tighten control of personnel expenditures, procurement, and technical assistance contracts. An important complementary measure vould nov be the establishment of a budgetary and accounting system to monitor the external f inancing of public investment and the associated counterpart and recurrent costs obligations for the Goverument. A close watch also needs to be kept on the evolution 5- of debt service obligations to avoid the recent recurrence of late payments ta foreign creditors. In addition, Burkinabè authorities should consider elaborating annual investment budgets (para. 12) which would allow them to adjust investment levels, from year to year, to the country's changing circumstances and evolving economic parameters. 16. Public Enterprises. Burkina has several major parastatals vhich are managed quite efficiently and, in fact, could serve as models for similar entities in the West Africa region - notably OPT and ONE, the telecommunications and vater utilities, respectively, and SOFITEX, the cotton marketing organization. Hovever, most of the other public enterprises suffer from 3.ax financial accounting and reporting to the central Government, which makes it difficult to assess the impact of their operations en the consolidated public financial situation. The increasing financial troubles of the public enterprise sector in recent years are rooted partly in the liquidity problems of the Treasury and partly in inadequate policies relating to prices and tariffs, employment and internal management. To improve the financial performance of the public enterprise sector, the newly created Ministry of State Enterprises vill need to take prompt action to ensure realistic pricing, curtail excess employment, and strengthen public enterprise finances. Long-Term Development Piospects 17. Barring the dibcovery of major economically exploitaole .mineral deposits, Burkina must continue to rely for its growth on the development of its agricultural and human resource endovments. Therefore the develop- ment of these two assets should constitute the focal point of any long-term strategy to extricate the country from its present conditions of extreme poverty. 18. In agriculture, top priority should be given to reversing the deterioration of renevable resources - ground vater, topsoil and forest cover - which has resulted from the pressure of growing human and livestock populations. The abandonment of traditional shifting cultivation, overcutting of forests and brush to meet fuelwood demand, and unccr-:olled grazing have combined to create nearly irreversible damage to the carrying capacity of parts of the central plateau. To arrest this environmental degradation and eventually raise productivity, requires erosion control and replacement of organic matter in the soil by integrating crop cultivation vith reforestation and livestock husbandry. More and better focused research is needed to overcome the technical and economic constraints co the intensification of crop/forest/livestock production systems. Difficult social and political issues as well need ta be addressed, particularly concerning land tenure and communal responsibility for management of forests and grazing areas. 19. A second major challenge for the country is to accelerate the development of its human resources. Increasing access to primary education and improving health through better primary health services, vater supply and sanitation, and nutrition will be critical to expanding the application -6- of new agricultural technologies and to raising productivity levels. Progress in these areas vill require policy refor aimed at reducing unit costs, redirecting budgetary resources towards primary services, and in- creasing coct recovery. Improved education and health services are also important means of changing attitudes regarding fertility and reducing the rate of population growth, which currently outpaces the expansion of agri- cultural output and makes it difficult to adopt measures to preserve the embattled agricultural resource base. 20. Other elements of a long-term strategy must include exploration and, where economically feasible, development of the country's mineral potential to generate public revenues, diversify exports, and reduce the country's vulnerability to its uncertain'climate. Finally, development of transport infrastructure - with an emphasis on ensuring adequate mainte- nance and rehabilitation of existing assets - is needed to complement actions in the directly productive sectors. Foreign Assistance and Aid Coordination 21. Burkina has received, and continues to receive, a considerable volume of external assistance. The bulk of this assistance is on highly concessional terms. Rovever, the increasing constraints on counterpart contributions and recurrent expenditures due to the tight budgetary situa- tion call for a more selective and coordinated approach in planning foreign assistance, on the part of the Governnent and the donor communfty alike. The country's ability to finance recurrent costs vill remain very re- stricted for some years to come, especially as it undertakes the expansion of agricultural and social services which vill inevitably increase demands on the domestic recurrent budget. Accordingly, local cost financing, recurrent cost financing, and high cost-sharing ratios vill continue to be necessary features of external assistance to the country. PART Il - WORLD BANK GROUP OPERATIONS IN BURKINA 22. The Bank-Group's commitments in Burkina, as of March 31, 1985, amounted to US$250 million for twenty-eight IDA credits. IFC has made one investment. About US$150 million have been disbursed. The IDA credits comprise fourteen projects in agriculture (including one supplementary credit), six projects in transportation (iicluding one supplementary credit), two projects in education, three projects in telecommunications and one project each in industry, mining exploration, and urban develop- ment. The IFC investment vas made for the production of plastic products destined for the local market. Burkina is also one of the major beneficia- ries of the Onchocerciasis Control Progrmme financed by IDA and other donors. Annex II contains a summary statement of IDA credits and IFC commitments. -7- 23. Project implementation has generally been satisfactory over the past fifteen years. Hovever, the recent political turmoil and resulting administrative and personnel changes have slowed the implementation or start-up of many projects, in some cases necessitating the extension of closing or effectiveness dates. Also, project implementation has been hampered by the Covernment's fiscal management problems which have made it difficult to meet promptly counterpart funding obligations. Burkina's disbursement rate, which historically has compared favorably uith that of other countries in the region, has deteriorated in recent months. Dis- bursements are expected to return to normal levels, however, as the politi- cal and administrative environment stabilizes. 24. In the face of uneven progress in different areas of the economic dialogue, Bank lending is being directed towards operations in sectors of certain priority where the dialogue is advancing the best. Also, opera- tions with heavy policy orientation, designed to improve overall sectoral environments, have been given priority over exclusively "hardware" projects. Thus, recent lendir.g operations in mining and rural development have addressed sectoral policy issues such as sector investment priorities, institution-building and financial policies. The Fertilizer Credit, the first project in the fiscal year, seeked to reform the fertilizer subsector by removing subsidies and other distortions. The present Health Services Development Project, the third to be presented this fiscal year, and the Primary Education Project, submitted earlier this year, vill substantially improvc the efficiency of the respective sectors, thus- permitting expansion of rural health care services and primary school enrollment, vithout excessive strain on the public finances. Other projects under active preparation are aimed at improving the delivery of agricultural research and extension services and expanding livestock production. 25. On the other hand, operations in sector; bogged down by major issues, which can only be solved in the context of substantial progress in the economic dialogue, are being held in abeyance. Cases in point are the RAN Rehabilitation and the Ouaga-Kaya-Dori Road Projects, which must avait the resolution of policy issues in the transport sector concerning the econcomic feasibility oi the Tambao project (para. 12) and the currently inadequate maintenance of existing infrastructure. PART III - POPULATION, HEALTH AND NUTRITION SECTORS Background 26. Realth Status. Burkina's underdevelopment is aggravated by its people's poor health and nutritional status combined with rapid population growth. The fclloving parameters give a measure of the magnitude of the problem: life expectancy at birth varies from 32 to 45 years between rural and urban areas (compared vith 47 years in Ethiopia and 48 years in Bangladesh on average); 38 percent of children do not live beyond 5 years of age; 30 to 50 percent of preschool children suffer from various degrees of malnutrition; and, depanding upon the ausumptions, population is ezpect- md ta reach batween 8 and JO million by the year 2000 f rom 6.7 million ini mid-1982. Recurr±ng droughts and food ahortagmu are key factors, outaide the contrai of the Burkinabè health system. vhich contribute ta the poor health status of the country's rural armas. 27. Health System. Betveen independeuce snd the 1970's, Burkina uaintained a hmalth delivery system baued on a netvorlc of curative facili- ties in urban armas and major population centers and on mobile teamu for the controi of major endemic and epidemic diseases. This dual system achieved major Bucceus in elim±nating amallpox, in reducing sleeping sickness and...yellov f ever toasporadic cases, and in .decreasing leprosy levels faster than elseehere in Africa. 28. As a result of these successes, nev diseases einerged as health priorities (i.e., tuberculosiB, dïarrheal. diseases, malaria). At the same time, improved medical technology, socio-economic changes, and a better avarenesas of health benefits increased demands for health services beyond that which the health system vas designed ta meet. In the mid-1970's3 the urban and rural health services vere integrated In an attempt ta meet this nov demand. This resulted iu a larger Bhare of health resources being channelled ta curative and mainly urban facilities vhere expressed demand vas greatost, vhile health services in rural areas vere neglected. Kortality of adults (the productiv-e population) dïd not decrease signif 1-- cantly afte? 'integration of the rural and urban health -ervices, indicating that curative servïces alone had a very limited impact on the health * ~~status. 29. The health care system comp-rises a pyraumid of services lu each cf * ~~Burkina's thïrty provinces. At its base are village-level prlmary health care co-nittees, voluntary organizations ta imprave health and nutrition through village self -help. The activities cf several af these caimnittees are supervised by a center for health and social promotion (CSPS) * an upgraded form of existing rural maternities and dispensaries established in rural tovus. The CSPS is managed by~ a cors team cf four (a head nurse, an auxiliary nurse, a mLidvif e and an itinerant health vorker), and it is the base f rom vhich health education,' techuical suipport and key services, such as immunization, move out tovards the villages. It is also the first entry point into the health systenL for vïllagers and townspeople iu need cf cars. Bach province is administered by a provincial Directorate of Public Realth (DPSP) headed by a physician who coordinates health activities and supervises CSPS. Sa far, facilities for DPSP exïst only in tventy-four of Burkina's provinces. Surgery can be performed in nlne ref erral centers located in major- tovns. The Government intends te increase the surgical coverage by building six additional referral centers. This coverage vould provide access te emergency care and surgery to over half of Burkina's population through fifteen strategically placed ref erral conters - (oee ref erral conter for tva provinces on average). Existing medical. centers, regional hospitals and tva national hospitals complete the national system cf referral services. Issues and Problems 30. Restructuring the health system is necessary to make it more responsive to present needs of rural populations. Poor performance to date has led to a lack of confidence on the part of the rural population in a system whïch has not been capable of reaching out to them and which has lacked the drugs to treat them. Alternative approaches must be f ound to extend health benefits to geographically remote populations, and financial resources need to be reallocated from curative urban-centered activities tovards the rural population. 31. Health System Performance. The deterioration of medical health services is due to the poor condition of buildings and technical equipment in existing facilities, the poor quality of medical services, and the unavailability of drugs. Furthermore, easy access to these facilities is liaited to about half of the population living within a 10 km radius. Personnel is adequate in number but often dispirited and deprofessionalized and neither supervised nor trained on a regular basis. Drugs are poorly chosen, inadequately distributed, and often prescribed inappropriately. Expensive drug proecurement practices and insufficient supply result from the lack of coordination among the principal sources of procurement, i.e., the Ministry of Public Realth, the National Office of Pharmaceutical Sup- plies (ONAP), the private sector, and foreign aid. ONAP, a public commer- cial agency, with a monopoly in drug supply t:o the public sector, cannot be relied upon for adequate drug supply: it lacks financial resources to Lmport drugs due to non-payments of ONAP's bills by public agencies and local authorities and due to huge deficits incurred by its sales outlets. This inefficient procurement system, combined vith lack of revenue due to free drug distribution practices by the Ministry of Public Health, has severely constrained the distribution of low cost drugs to rural areas where the public health services are the sole distributor of drugs. The private sector, essentially urban, has extended into rural areas, but its coverage is. limited to communities large enough to ensure a profitable drug distribution. 32. Alternative Approaches to Rural Realth. Since about 50 percent of the population does not have ready access to health centers due to geographical dispersion, approaches which are financially and operationally viable must be found te improve basic health and nutrition self-reliance- Such approaches would emphasize preventive measures, detection of diseases which require the intervention of qualified personnel and simple curative techniques which could be handled by the communities themselves. The design and implementation of such a program requires a better understanding on the part of health officials of the villagers' demand for health ser- vices and their acceptance of preventive health measures. It also requires convincing villagers that adequately equipped and staffed health facilities exist to which they can be referred in case of need. - 10 - 33. Financial Rasources. Insufficient f inancial resoureao for rural health stemned from: Wi) a reduction of the health shars ln the national budget; and tii) allocation of much of the hcalth budget to urban areas and personnel. The share of health in the national operating budget decresased from 12 percent in 1960 to 6 percent In 1978. While its ohare has picked up over the last fev years, it 8till stood at 9 percent in 1984. Within that share, the tvo major towvEs in Burkina, Ouagadougou and Bobo-Dioulasso, received about 50 percent of the recurrent health budget. Salaries repre- sent 80 percent of the budget. Cost recovery has been practically non-existent es Government has been under strong political pressure to provide health services free of charge. If the basic health needs of rural areas are to be met, a continuing effort vill be needed to make the most efficient use of available budgetary resources, to channel greater re- sources to rural areas, and to recover a larger percentage of costs wher- ever possible. Realth Program Implications 34. Whatever health policy measures are designed for the medium and long term to address the above issues, current rural health services must and can be rehabilitated immediately. Without increasing the number of facilities, existing buildings need to be renovated and properly equipped. CSPS (para. 29) staff need to be trained in the areas of: (i) organization and management of primary health care; (ii) immunization; (iii) maternal child health and family planning; (iv) sanitanion; (v) detection and treat- ment of malnutrition and control of infections and parasitic diseases; and (vi) prescription of essential drugs. Training programs need to be devel- oped to retrain existing staff, and immunization programs need to be extended immediately to cover the entire target population, using amended immunization schedules and complementing services delivered in fixed facilities vith those of mobile teams. Furthermore. malaria can be easily controlled by supplying chloroquine to village communities for treating outbreaks of fever. Publie opinion can be sensitized on population issues; and family planning services can be introduced into maternal and child health clinies. 35. Although the foregoing immediate measures alone cannot be expect- ed to solve all health problems, they are essential to a viable rural health system and would restore the system's credibility vith the rural population. Further improvements will be needed to complement immediate actions. For example new strategies need to be developed for communicable diseases to prevent the recurrence of major endemic diseases successfully controlled in the past and to control nev priority diseases (e.g., tubercu- losis, diarrheal diseases). Simple preventive and curative measures for common diseases should be introduced to rural communities through village health workers. Drugs should be made available to the rural population. This vill require giving priority to essential drugs, reforming procure- ment, and finding efficient and cost effective distribution channels. New sources of revenues for the health sector must be identified since budgetary allocations are unlikely to increase. All consumers of health services must share a greater portion of recurrent health costs with - il - Government. Finally, strengthening the planning and evaluation capacity of the Ministry of Public Health is required to implement measures derived from these policies and to coordinate future investments in the health sector. Recent Gov=,,.ment and Donor Actions 36. Over the past few yearb, successive Governments have again begun to emphasize rural health. A series of policies have been adopted that aim at rehabilitating bealth services in rural areas, improving the procurement and distribution of drugs, enforcing existing and introducing new cost recovery measures, and starting family planning activities. Increased donor coordination is being pursued by the Government, and foreign assistance totalling US$20 million (1982) has been channelled into the health sector. (Major donors include the African Development Bank, Canada, People's Republic of China, EEC, France, Federal Republic of Cermany, Italy, Netherlands, UNICEF, USAID and various NGO's). With donors' sup- port, Government has begun the rehabilitation of health facilities and the expansion of vaccination campaigns. 37. The Government has begun a national program to upgrade about 400 existing maternity and dispensary facilities to CSPS (para. 29) by 1995. About 200 facilities already have been renovated or reconstructed vith assistance from the African Development Bank, the EEC and the Federal Republic of Germany. MedicaL staff has already been redeployed from urban to rural facilities. The Goverument administered àbout 5 million doses of vaccines against measles, yellow fever, and meningitis during a "commando operation" at the end of 1984 -- a unique feat in Africa. A comprehensive immunization campaign in the Kaya region, supported by the Netherlands, has resulted in a 90 percent coverage of the target child population and vill soon be extended to two new provinces. Italy is supporting research necessary for anti-malaria programs. 38. The Government has decided to give priority to increasing the availability and affordability of essential drugs, i.e. drugs recomended by WHO, and nov adopted by the Ministry of Public Health. Only essential drugs would be authorized for distribution in Burkina to ensure that only effective quality medications are provided to consumers. To reduce costs. essential drugs would be procured in bulk quantities at reduced import prices by only one importer of drugs, the SONAPHARM, created recently by the Governuent vith the support of the private sector to replace the debt-ridden ONAP (para. 31). SONAPHARM, a mixed corporation (51% State, 49% private), will supply drugs to both private and public distributors on a strictly commercial basis. In order to gain the confidence of international pharmaceutical suUpliers, the Government has already begun to reimburse most of ONAP's debt through the sale of drug stocks and retail sales outlets. To reduce risks of conflicts with the private sector and to make it financially viable, the Ministry of Public Health vould limit the new entity to wholesale of drugs and keep it out of the retail drug distribution business. With lower importation costs, the private sector is expected to earn adequate profit margins on sales. The Government vill - 12 - also rely on private shareholding and management practices to ensure efficLency. The Government has requested Bank technical assistance in the launching of SONAPEAIM. The new entity, if successful, could simplify drug procurement and 'emuDre an adequate supply of essential drugs needed for rural health. However, its de facto monopoly might detract from the enterprise's ecotnomic and management performance in the long term. The Governnent is avare of that risk, and in order to safeguard efficiency in the long run, wïll assess jointly vith IDA on an annual basis its operations, its impact on drug supply and the opportunenesu of allowing competition in proeurement (Supplemental letter in Annex IV). 39. The Ministry of Public Health has recently undertaken a series of cost recovery measures. Evacuees are now asked to share the cost of medical evacuaticn abroad. Better enforcement of medical fees for services is being introduced in the two national hospitals. With Italian assis- tance, the Governnent is seeking means to extend user fees to lover levels of the health system. Employers are nov required to use public health facilities in the provision of medical benefits which are mandatory in Burkina (Workman's compensation). These measures vill yield an annual increment of US$0.6 million equivalent, representing an annual increase of about 8 percent over the 1985 budgetary resources. Rovever, these cost recovery measures alone vill have only a limited impact on the channelling of resources into the health sector. Better availability of drugs, improved medical_ services, and better coverage of health services will offer opportunities to increase revenues vhich vill need to be fully exploited. Finally, the Governient is considering creating a Realth Services Equipment Fund (FEFS), financed by 75 percent of all fees collected through cost recovery measures at health facilities as vell as from proceeds from the sale of vaccination cards. 40. The Government, becoming aware of the consequences of rapid population growth, has introduced family planning services in urban areas vhich, in turn, could have a demonstration effect on rural provincial capitals. Birth spacing is promoted by the media. Recently, the Govern- ment repealed the ban on artificial contraception, a colonial lav dating back to 1920. _There is not yet a national population program, but the Government, vith the assistance of USAID, has prepared a population planning assistance project, which in three years, through demographic analysis, information and training, and improvement of family planning services, vould lay the groundwork for a population program. 41. The Ministry of Public Health established in 1982 a Directorate of Health Studies, Planning and Statistics vhich vas responsible for preparing the proposed project. The Directorate also prepared the 1986-87 biennial investment program and is involved in the preparation of the 1986-1990 Bealth Sector Plan. The Directorate receives the technical assistance of a five-member team of USAID to strengthen the planning function in the Ministry. However, in addition to planning, the Ministry still needs to strengthen its epidemiological surveillance capability to avoid the spread of communicable diseases, to complete its network of - 13 - Provincial Directorates of Public Health (8 provinces out of 30 still need to be covered) and to strengthen the staff of these Directorates. Bank's Role in the Health Sector 42. Through its 10-year involvement in Burkina vith the Riverblindness Program, the Bank has become increasingly avare of the importance of developing primary health care systems for the rural areas. The Bank's strategy for Burkina emphasizes development of human resources. Economic and health sector missions in 1981 (Health Sector Report No. 3926-UV, November 12, 1982) initiated a dialogue with the Government on health policies, emphasizing priority on rural health, and vere the origin of the Bank's direct involvement in the Health Sector. The policy framework recommended by IDA vas subsequently approved by the Gover,ment in October 1982 and vas not modified later despite changes in the Government. The preparation of the proposed project has given momentum to the dialogue with the new Government. The project itself would provide the framework for continuing the policy dialogue on major sector issues and on the financial and budgetary implications of improving Burkina's health system. 43. The first IDA-assisted project in the health sector would comple- ment activities already undertaken by other donors to rehabilitate the existing system. In addition, it would address policy issues, for which detailed measures still need to be found, before these policies can be implemented to imrprove Burkina's health system. Preparatibu of the pro- posed project had a catalytic effect on donor coordination in the health sector and resulted in common objectives for action, sharing and adoption of design standards for construction, iumunization programs and measures to be taken in pharmaceuticals. There is an increased common understanding on policy issues among donors, particularly UNICEF, Italy and the World Bank. PART IV - TEE PROJECT Project Preparation 44. The proposed project preparation followed adoption by the Govern- ment in 1982 of policies and approaches recommended by the 1981 economic and health sector missions. Two advances under the Project Preparation Facility (approved in November 1982 and November 1984) totalling US$820,0000 equivalent helped establish a Directorate of Health Studies, Planning and Statistics in the Ministry of Public Health. The proposed project vas appraised in May 1984; negotiations vere held in Washington in April 1985 and the Burkinabè delegation vas led by Mr. André Fayama, Directeur de Cabinet in the Ministry of Financial Resources. The Staff Appraisal Report (No. 5352-BUR) is being distributed separately to the Executive Directors. A Supplementary Project Data Sheet is given in Annex III. - 14 - Project Objectives 45. The project is designed as the firet in a series of interventions in the health sector by IDA and other donors in support of the Governmnt's strategy in health and population. It plans to rehabilitate and increase the efficiency of the existing rural health infrastructure and institu- tions, while simultaneously devising cost recovery and budgetary policies that will enable Government in the long run to finance a broad-based rural health care system. It supporta the Government's efforts to reorder priorities vithin the existing health care system from the urban to the rural population through efficiency improvements and the reallocation of financïal and human resources. Moreover, the project provides the frame- work for a continuing dialogue vith the Coverument on the development of the sector. 46. The proposed project would: (a) strengthen existing basic health and family plarning services, vith initial emphasis on the control of communicable diseases and the treatuent of malaria; (b) further formulate national health and population policies; and (c) strengthen the MOPH's institutional capability in planning, evaluation, and project implementa- tion and monitoring. Detailed Features A. Strengthening of Basic Health 47. The project would upgrade 142 existing health dispensarïes into CSPS (para. 29) in 15 provinces, foUowving a low cost approach. To complete the caverage of surgical care foreseen by the Goverument and to ensure adequate referral of emergency cases requiring surgery, the project would upgrade six existing medical centers to serve as surgical referral centers (para. 29). Cost estimates of civil works for health facilities are based on simple but functionally appropriate design standards developed by the Ninistry of Public Health and successfully being used elsewhere in the CSPS progran in Burkina. The average building cost per square meter compares favorably vith costs for simnilar facilities in the region. Moreover, the project foresees mobilizing rural communities to manufacture bricks and to provide unskilled labor during the construction period. Each CSPS vould be provided with year-round vater supply, and equipped vith a refrigerator, motorbicycle or bicycle. 48. Through the project, each CSPS staff, either already in place or to be made available through reallocation of the existlng pool of health providers, would receive training and supervision provided by the Provincial Directorate of Public Realth in each of the 30 provinces. A minimum of two training cycles would be completed in each province. 49. For about 50 percent of the rural population who, largely due to geographic dispersion, do not have ready access to a CSPS. the project would finance tests and studies to find appropriate village-level - 15 - approaches that would be operational and financially viable on a national scale. Limited tests have already started with assistance from a variety of sources including the British "Save the Children Fund", the Federal Republic of Germany and the United Nations Fund for Population Activities. 50. The project would provide vaccination coverage in 15 provinces and major urban centers to children under age four against measles, pertussis, poliomyelitis, diptheria, tetanus and tuberculosis. The 1-15 age group vould also be inoculated against yellow fever and meningitis. Chloroquine would be provided and sold throughout the country in support of a nationa'l malaria program. The credit would finance adequate amounts of chloroquine for an initial two-year period. Replenishment of chloroquine stocks vould be secured through a revolving fund financed by the sale of the initial stock. The proceeds from the sale of chloroquine would be placed in an account in its Treasury which would operate as a revolving fund on conditions satisfactory to the Association, to support primary health care services. including the replenishment of chloroquine for the anti-malarial program (Section 3.06 of DCA). In addition, as a condition of disbursement, no credit withdrawals vould be authorized for chloroquine until the Association is satisfied that adequate arrangements have been made for bulk procurement, packaging, distribution and recovering costs through sales (Schedule 1, para. 3 (c) of DCA). B. Development of National Health and Population Policies and Programs 51. Realth Policies. To ensure that the Government, the Association and other donors are coordinating efforts around a commonly understood sector policy, the Government has submitted an updated statement of its health policy (included in Annex IV). This policy may be modified as a result of further studies, including inter alia, the studies and experi- ments to be carried out under the Project. However, if these studies and analyses would indicate the need for a reorientation of the national health policy, the Government would consult about it with IDA as is reflected in a supplemental letter attached in Annex IV. Furthermore, to maintain an effective policy dialogue, the Government will: (i) organize annually a meeting of all aid agencies participating in the financing of the Primary Health Care Progran in arder to review progress made in its execution anci to coordinate further assistance; and (ii) review in detail annually vith the Association all expenditures t.ade in the health sector during the previous year and proposed to be made during the upcoming year, regardless of the source of financing of such investments. (Section 3.03 of DCA). 52. The proposed project provides for studies aimed at determining detailed measures needed to implement effectively health and popula- tion programs and at adjusting national policies accordingly. These studies vould cover the following four areas: (i) users' fees for health services, (ii) drug distribution, (iii) extension of basic health services to villagers, and (iv) development of a population program. All these studies require operational field testing, most of which would be undertaken in one specifically designated province. The Government vould present the results of the studies to the Association by March 31, 1988, - 16 - for it. review and comment; prenant specific proposals for sub-projectt in application of measures emanating from these atudies, by September 30, 1988; and start implementation of an agreed program by April 1, 1989, (Schedule 3, para. 14 of DCA). Funds would be provided under the project to finance these sub-projects. The Government vill follow agreed criteria and procedures for the use of fundt for the implementation of 8uch sub- project proposals (Schedule 3, para. 16 of DCA). 53. Usera' fees. To strengthen the system of fees for services (para. 39), the project would finance studies and teste to extend cost recovery from the national hospitals to the provincial hospitals (para. 29) and to the CSPS with a view to determining how various payment schemes affect the quality of services and people's willingness to make use of such services. Parts of these studies will be undertaken by experts provided by the Government of Italy, following terms of reference which have been found satisfactory to the Association. 54. Drug distribution. The prolect would provide about 24 man-months of technical assistance to strengthen central drug procurement, to improve prescription practices and to launch a public information campaign on the benefits of generic drugs. To improve drug distribution from the provincial capitals to the village level, the project would include a field research component to test how the private and public sectors and village pharmacies could function most efficiently. The Covernient vill: (i) by December 31, 1985, present tc the Association for its review and comments: `.. (a) a plan for strengthening national drug procurement and distribution; and (b) an official list of pharmaceutical products authorized foQr importation and distribution, in conformity with the World Bealth Organization's essential drug guidelines; (ii) subsequently adopt, and periodically review, such a list; (iii) by June 30, 1986, publish a national drug formulary based on this list, and create a pharmaceutical information service; (iv) carry out a program to inform the public about its essential drug policy (Schedule 3, para. 15 of DCA); and (v) carry out, jointly with IDA, an aanual assessment of the performance of SONAPHARM (Supplemental letter in Annex IV). 55. Extenision of Basic Heal1Jh Services to Villagers. For outlying villages, the project vould study and test the kinds of health and nutrition services that could appropriately be provided by villagers theIselves vith the support of CSPS. Simultaneously, it would test the organizational and managerial requirements of the CSPS with regard to out- reach, supervision and referral. 56. To support current efforts to establish a national Population Program, the project would provide technical assistance for the preparation of a feasibility study to upgrade 8 of 15 maternal and child health and maternity facilities in Burkina's two major cities. Funds are also provid- ed under the IDA credit to implement the recommended improvements in these facilities. In addition, the project would be co-ordinated with a national Population Assistance Program vhich has been identified and prepared vith assistance from USAID. This program would strengthen the Government's - 17 - capabilities to undertake demographic analysis and surveys related to family planning attitudes and practices. It would develop and diffuse messages on family planning; train doctors, nurses and midwives in contra- ceptive technology; and test various avenues, including the private sector, for providing family planning services. USAID is currently funding some priority activities under this program; USAID approval of funds for the entire program is expected in mid-1986. C. Strengthening the Ministry of Public Realth 57. At the national level, the project vould, through participation of MOPH staff_ in managing its implementation, continue to support the strengthening of the MOPR's health planning and coordinating capability begun during project preparation. It would complement a separate USAID project providing 5 years of -technical assistance in health planning, economics, epidemiology and data collection. To support efforts to monitor communicable diseases, to limit chances of epidemics, and to screen and treat sleeping sickness, the project would provide two mobile epidemio- logical surveillance units. The project would also provide office facili- ties for eight Provincial Directorates of Public Health (para. 29). Project Costs and Financing 58. Total project costs are estimated at US$28 million equivalent. Foreign exchàhge costs are estimated at US$17 million e'juivalent (about 60 percent). Base costs are in April 1985 prices. Price contingencies have been applied as follows: inflation rates for foreign costs have been estimated at 5 percent for 1985; 7.5 percent for 1986; and 8 percent for 1987-90. An annual inflation rate of 10 percent has been estimated for all local costs during the period 1985-90. Physical contingencies of 10 percent have been added to the base cost for civil works, equipment and architectural services. Cost estimates of civil works for health facili- ties are based upon simple but functional designs prepared by the NOPR and used on ongoing health programs in Burkina. 59. The proposed IDA Credit of SDR 26.9 million (US$26.6 million equivalent) would finance the foreign exchange component and about 87 percent of local costs, representing about 95 percent of total project costs net of taxes. The Government and beneficiaries vould meet the remaining local costs of US$1.4 million equivalent. Affordability and Cost Recovery 60. The project is expected to generate an increment in annual operating costs of US$0.9 million equivalent. Vaccination campaign vould amount to about US$0.4 million equivalent and chloroquine needed for the anti-malaria caz.paign to about US$0.2 million equivalent. The remaining US$0.3 million equivalent include vehicle and equipment maintenance for health facilities (para.47) and training (para. 48). At the end of the project, it is assumed that the donor community vould continue to finance - 18 - US$0.4 million equivalent in support of vaccination campaigna. Domestlc resources would be required to finance about US$0.5 izdilion equivalent, all of which would readily be met if cost recovery measures discussed in para. 39 above are implemented. 61. Studies and tests ta be financed under the project are expected to identify additional cost recovery achemes which could increase substan- tially the financial resources available for rural health care. Cost requirements and financing of this and other donor-financed program activities vould be closely monitored-through annual consultations vith the Government (Section 3.03 of DCA). During project implementation, incremental recurrent costs vould be met by IDA on a declining scale (para. 67). 62. Coverage and Replicability. The project vould complete a nation- wide health facilities network in rural areas and strengthen the health delivery system which vill serve about 50 percent of the rural population. Extending the health facilities network to provide health coverage to the reinaining 50 percent population is not feasible due to the geographical dispersion of this population in outlying villages; and so a different ap- proach is needed to serve these areas. The project's operational research component would seek viable, low-cost approaches to promoting self- help in nutritional improvement* simple preventive measures, health education and first-aid in outlying villages. If the project does not prove successful in identifying such measuzes, these villages eould have to continue%to rely on traditional healers and midwives and a distant CSPS for health care until a vay could be found to provide them vith improved health services at an affordable cost. - 19 - Procurement and Disbursements 63. Procurement arrangements are summarized in the table below, vith the figures in parentheses showing amounts financed by IDA: Procurement Nethod Project Element ICB LCB Other N/A -/ Total Cost -US$ Million-- Civil Works 7.7 3.4 b/ - 11.1 (7.7) (3.4) 11.1 Furniture, Office Equipment, 0.6 0.2 0.1 - 0.9 Material, Supplies (0.6) (0.2) (0.1) (0.9) Medical Equipment, Drugs 4.6 - - - 4.6 (4.6) (4.6) Vehicles 0.8 0.2 - - 1.0 (0.8) (0.2) (1.0) Technical Assistance - 1.3 - 1.3 's (1.3) (1.3) Professional Fees - 0.2 - - 0.2 (0.2) (0.2) Training - 0.1 - 0.1 (0. 1) (0.1) Project Preparation Facility - - - 0.8 0.8 (0.8) (0.8) Preinvestment Studies - - - 0.3 0.3 (0.3) (0.3) Funds for Implementation of - - - 5.0 5.0 Studies (5.0) (5.0) Recurrent Costs - - - 2.7 2.7 (1.3) (1.3) TOTAL 6.0 8.3 4.9 8.8 28.0 (6.0) (8.3) (4.9) (7.4) (26.6) a/ Not applicable bi Fonds de l'Eau et de l'Equipement Rural. - 20 - 64. Contracte for equipmont, furniture, vehicles, materials and drugs amounting to US$5.3 million equivalent, including contingencies, vould be procured in accordance vith IDA's procurement guidelines for international competitive bidding procedures (ICB). Exceptions to ICB include: '1) contracte with a value of les8 than US$75,000 equivalent each (for a total of US$400,000 equivalent) which would be avarded through locally advertised competitive bidding procedures acceptable to the Association; and (ii) small value items costing less than US$10,000 equivalent per contract (for a total of US$100,000 equivalent) which would follow prudent local shopping procedures acceptable to the Association (Schedule 4 (C) of draft DCA). Purchases of medical equipment and drugs using UNICEF's international procurement procedures vould be permitted where feasible as a recognized means of limiting costs. 65. Civil works contracts for the Provincial Directorates of Public Health (DPSP) (US$0.9 million equivalent including contingencies), referral centers (US$2.2 million equivalent), and for the supply of construction materials for about 142 CSPS (US$4.6 million equivalent), which are unlike- ly to interest foreign contractors (due to size and dispersion), would be awarded following locally advertised competitive bidding acceptable to the Association. CSPS construction materials costing less than US$10,000 equivalent per contract may be procured on the basis of prudent local shopping procedures acceptable to the Association. Architectural designs, draft tender documents and master lists of furniture, equipment and vehicles would be reyieved by IDA. 66. Because the Government is unable to pre-finance expenditures to be reimbursed under the IDA Credit, an IDA-financed Special Account of US$1 million equivalent would be established (Section 2.02 (b) of DCA). The Government would also establish a Local Advance Account for its own local revolving fund for counterpart financing. The opening of this account and the initial deposit of CFAF 25 million would a condition of effectiveness (Section 5.01 (b) of DCA). 67. Proceeds from the proposed Credit would be disbursed as follows: (i) 100 percent of total expenditures for civil works (US$9.6 million equivalent); equipment, furniture, vehicles, materials and drugs exrept chloroquine (US$5.6 million equivalent); chloroquine (US$0.2 million equivalent); technical assistance and training (US$1.8 million equivalent); implementation of sub-projects (US$5.0 million equivalent); refunding of project preparation advance (US$0.8 million equivalent); (il) 95 percent of operating costs (US$0.9 million equivalent), excluding salaries except for Project Management Unit staff, until disbursement reaches US$0.48 million equivalenr, 60 percent thereafter until aggregate disbursement reaches US$0.7 million equivalent and 30 percent thereafter; and (iii) an amount of US$2.7 million equivalent would be unallocated. - 21 - Accounts and Audits 68. The project provides for services of independent accountants to audit the Special Account, the Local Advance Account and all other accounts in respect of the Project for each fiscal year; audited statements would be submitted to IDA no later than six months after the end of each fiscal year (Section 4.01 (b) of DCA). Organization and Management 69. The office of the Secretary General of Realth in the Ministry of Public Health vill be strengthened by the creation of a Project Management Unit (PMU) which vould coordinate project implementation. It vould monitor project costs, keep project accounts, and authorize all project expendi- tures. The setting up of an appropriate PMU project accounting system would be a condition of Credit effectiveness (Section 5.01 (a) of DCA). Key staff of the PMU include a director, an administrator and an accountant. The establishment and staffing of the PMU would be a condition of Credit effectiveness (Section 5.01 (a) of-DCA). 70. Construction Program. Construction of the referral centers and DPSP wvuld be undertaken by the private contractors under the supervision of the Ministry of Equipment. Rehabilitation of the CSPS vould be undertaken through village self-help by concerned villagers themselves, under the supervision of the Rural Water and Equipment Fund (FEER), an independent public body under the Ministry of Water, which has a proven capability in coordinating rural small works such as CSPS construction. The conclusion of an agreement between the Ministry of Public Health and the Ministry of Financial Resources, on the one hand, and the FEER on the other. would be a condition of disbursement of the civil vorks component of the project (Schedule 1, para. 3 of DCA). The appointment of an engineer, accountant and site supervisors to the FEER, to assist in coordinating the CSPS building program, would also be a condition of disbursement on the civil vorks component (Schedule 1, para. 3 of DCA). 71. Technical Assistance. In addition to available Burkinabè expertise, the project would provide 100 man-months (mlm) for technical assistance to be utilized as follows: in-service training, 21 m/m; economist, 24 m/m; drug specialists, 30 m/m; maintenance specialist, 4 m/m; maternal andr child health and family planning specialist, 4 m/m; financial specialist, 3 m/m; auditors,-14 m/m. Project Benefits and Risks 72. The project vill yield the folloving benefits: First, it would principally improve the quality and accessibility of health services available to more than half the total population of Burkina. Second, it would improve the quality of preventive and curative services by increasing the skills and performance capability of rural health staff, by improving the supply of essential drugs, and by promoting village-level health and - 22 - nutrition prograus. Thïrd, due to improved procurement and distribution practices, essential drugs vould be available to the population at reduced costs. In addition, the gradual introduction of cost recovery measures vould provide additional revenue required for more efficient functioning of health services at all levels of the system. Pourth, the project would help lay the basis for a national integrated program of maternal and child health and family planning services in both urban and rural areas. Fifth, the project would help strengthen institutional mechanisms thus allowing for improved health sector planning, policy implementation tnd donor coordination. 73. There are two primary risks. The first risk is that institutions and measures needed to mobilize resources for the health sector and to enforce cost recovery may not meet expectations. This risk would be mitigated by an ongoing consultative process in the form of regular super- vision missions, quarterly reports and annual meetings among Government, IDA and other donors. A second risk stems from the Government's lack of experience in implementing projects on a national scale in the population and health sectors in Burkina. It is already implementing localized projects in the primary health care sector wn h the help of other donors and seems to be capable of mobilizing the limited resources necessary to carry out the projects. Moreover, the project vould strengthen insti- -tutions, create a rqrong Project Management Unit, and draw on ,5he support and experience of other donors through the consultative process indicated in para. 51, above. The largest and mcst costly component (infrastructure) is entrusted to an experienced organizatien, the FEER, with demonstrated achievements in rural areas of Burkina. The strengthening of the MOPK's Secretary General's office and the Directorate of Studies and Planning will contribute to a better coordination of the various inputs required to improve health services through the project. PART V - LEGAL INSTRUMENTS AND AUTHORITY 74. The draft Development Credit Agreement between Burkina Faso and the Association and the Recommendation of the Committee provided for in Article V, Section 1 (d) of the Articles of Agreement of the Association are being distributed to the Executive Directors separately. 75. Annex IV contains a Health Policy Statement prepared by the Government and a Supplemental Letter reflecting agreement to: (i) consult vith IDA prior to modifying the policy; and (ii) assess annually vith IDA the performance of the newly created drug importation enterprise. Special conditions of the project are listed in Section III of Annex III. Conditions of effectiveness vould be the establishment of: (i) a Local Advance Account (para. 66); and (ii) the Project Management Unit (including appointment of the required full-time staff and establishment of its accounting system). - 23 - 76. I am satisfied that the proposed Credit would comply vith the Articles of Agreement of the Association. PART VI - RECOMMENDATION 77. I recomend that the Executive Directors approve the proposed Credit. A.W. Clausen President Attachments Washington, D.C._ May 14, 1985 -24- . ANNEXI TAULE a Page b f 5 B~~~~T a *_ot O M ens swm~~~~uw omaom c~~ uzwua aànus.>C p am t~~~~~~~~~ nLWU RIA UM oua~~~ 3.0 9.0 O2.0 6La 53.0 POPKEMOU.HID-TIA (TUOUUSIDI 4164.0 5071.0 14530. M POPUATION (Z Or TOTAL) 4.7 6.8 10.9 19.2 29.7 vomanos moelo PoLATE RN ZAR 2000 (NLL) - 10.0 SATIAna mKILr - 34.7 POPULTION Ilf l 1.7 PoPIImoU DEmN PIE SQ. I. 15.2 18.5 23.1 32.5 55.0 P sq. . JIC.LAID 36.7 41.4 50.1 119.2 111.5 POPULATII AuI ShUDCTUhE (1> 0-14 rvs 42.8 *3.9 U.7 45.6 45.4 15-64 TUs 54.3 53.2 51.9 51.5 51.7 ISU AUlIt 29 2.9 2.8 2.9 2.9 POPUATIOI mou1a RATE (Z> TOTAL 1.9 le 2.0/e 2.1 le 2.8 2 L URUS 5.7 5.7 6.0 6.2 5.2 Cur *m RATE (PU uTus) 486 40.o 47.9 48.6 47.0 CRi OUIR RaI tP TlOtM) 26.8 23.8 21.3 17.7 15.2 eae EEFUIXT[O RTE 3.2 3.2 3.2 3.Z 3_2 FAltLIT PLAJUINS ' ACCEPTMS. UAL ( 101.0 102.0 95.0 85.q 91.6 pS CAPTA SUFIS WF CALORIESCt or OFEQUIRDIEN) 92.0 89.0 95.0 96.4 98.2 PmIann (mCRa ER DAr) 71.0 69.0 72.0 49.9 56.7 OF 11CR AND" AND PULSE 19.0 19.0 19.0 Id 18.1 17.0 CID (CAES 1-4) DLEINI RAI 71.0 *9.0 36.0 23.8 11.7 LIT EXPCr. AT 5119 ) 21.2 . 14.7 10.7 7.2 5.3 PUIL-T -CNE "na PRIIUS 47.0 44.0 54.0 46.1 38.6 SECNlARY 20.0 23.0 20.0 la 25.9 24.3 ADU1S LITERACT RATE (Z) 1.5 & 5.0 il 8.8l/ 44.3 35.6 PAsslt t CAUstIoUSA vo 0.4 1.3 2.0 L 3. 20.7 RADIO RECEIVERSITUOUSAIID POP 0.7 17.2 17.9 *:.9 100.8 TV EECEIEUITDUUSAUD POl 0.1 1.2 1.6 2.0 11.5 NsrPE (rUIIt CEILBA IllISESm) CIIICMATION . L. pRu IOUISAI POPULAITOS .. 0.3 0.2 nk - 5 17.2 CE?VIA AMUA ATrENODAMCCAPITA .. 0.2 0.7 T7 1.4 0.3 TOTAL LABO FORCE <1110153 2380.0 2779.0 3320.0 *fLE PERCENT> 47.1 46.8 46.1 36.3 33.8 AGRICULTU (PERCENT) 92.0 87.0 82.0 77.4 37.1 ]NUS=ET (PERCENT) 5.0 8.0 13.0 9.8 17.4 PARTlClPATION RAE (PERCENT) TOTL 57.2 54.8 51.1 41.0 36.3 nALE 60.8 5118 55.3 52.1 47.6 FEKALE 53.5 50.9 47.0 30.2 25.1 ECeONRIC DEPEHDENCI RATIO 0.8 0.9 0.9 1.2 1.4 uom anstRrune PERCET F rPRIVATE I[CORtE REcELE B MIGIEST t5 OF MIU5EHOLOS .. HIGISr 202 OF HOUSEROLDS .. LUJEST 202 OF HOUSEHOIDS .... LOWIST 42.OF IOUSENOS .. norum s Crs ESTINATEO ARSOLUII POVEI INCQIE IfEt () CRam - . 164.0 /k 168.3 525.3 RURAL .. .. 105.0 90.8 249.0 ESTIMATED RELATIVE POVER 1SIEE LEVEL .USI PER CAPITA) CR .- - *- 107.7 4771. RURAL ,. .. 53.0 Ik 65.0 186.0 ESTMTEO POP. 1SD ABSOLLTE POIVE ICOE LEVEL URB.W .A * .. 34.7 RUgAL ' , ,, 6 b5.4 . Tr AVAILALE EUT APPLICABLE la Thear' avPatear for aaeb Ladicaror ara populatiou-v4ghted arttbartc _a.. Ceueraue of cocrter nouS tha ludicator. deped- on avalbility of data ad la ont unifor. lb uJes. otherbvia oted. -Data for 1960 refer EC ay year batau_ 1959 ad 1961; -Data for 1970- batueen 1969 *nd 1971; sud data for HMut Raceat E.c:t_at between 1980 snd 1982. le D. te engratLon population growst rate tL Lower tcan rata cf matural iereae.; Id 1977; le 1975: tF 1963; 1 1962; lh 1964; IL 1972; 1 978; lk 1979. 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CONDAIRESIUAG 1640 OUTES tISO V \.) _,_ ~~~~~~~~~~~U14PAVIDRoO-AvOltSIRtIMMW AI4INDAJbFVI-ICNT!RIPtStINTfPIrfH '* - INtERAONALDONoeBAUIE -« C O A S T \ \* * rxlssrs@NcrS |~~~~~~~ RP FERRAL. CEIÇERS t_ e ? ~~~~ ~ ~~~~~*_* TO BE PINNC~EOf EAPMOJECO T_. . t*-W 40rmri""* ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~AlREFNACS A L ROE