Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB1408 Project Name BF 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 Ministry of Health; National AIDS Council (SP-CNLS) Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared April 18, 2005 Estimated Date of Appraisal Authorization May 25, 2005 Estimated Date of Board Approval October 27, 2005 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 440 per 100,000 births in 1999, but this is likely to be an underestimate. Burkina has among the highest HIV prevalence rates in West Africa (estimated at 4.2 percent in 2003), 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. The second objective of the 2003 Country Assistance Strategy (CAS) update is “Ensuring that the poor have access to basic social services.” A new results-based CAS is under preparation, and achieving MDGs for health and HIV/AIDS will figure prominently. 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 five-year HIV/AIDS strategy (2001-2005). 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- Page 2 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 – requires addressing fundamental weaknesses in the health system. Finally, 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 Dutch Cooperation, the Global Fund, UN Agencies (UNICEF, WHO, UNFPA, UNAIDS, WFP), African Development Bank, other bilateral donors (Belgian, French, German, Italian, and Swedish Cooperation) and international NGOs (MSF, Plan International). 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 serve as a project execution unit for multiple partners. 2. Proposed objective(s) The overall objective of the program would be to: (i) contribute to improving the quality and coverage of preventive and curative health services, and strengthen the health system’s capacity to accelerate progress toward the health and nutrition MDGs; (ii) strengthen multi-sector and civil society efforts to reduce HIV/AIDS transmission and to mitigate the socio-economic consequences for those affected by the epidemic; and (iii) strengthen systems for monitoring and evaluating progress toward health sector and HIV/AIDS objectives, including the use of performance-based contracts. 3. Preliminary 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 would eventually manage (pooled) funds of the Bank and other participating partners. Page 3 The Credit would seek to accelerate progress toward the health, nutrition, HIV/AIDS MDGs, including reducing child and maternal mortality, child malnutrition, fertility, and decreased HIV prevalence (particularly among youth). Intermediate program indicators would serve as the basis for annual monitoring of progress, including contraceptive prevalence, 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 ( 50% of funds/US$17.5 million) This component would provide global support for improving sector performance through a multi-donor basket funding mechanism, which would 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 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) would form the basis for program preparation and for dialogue with both MOH and MFB regarding budget priorities for achieving sector objectives and MDGs. Emphasis would 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 would 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 would 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 Multi-sectoral HIV/AIDS response (50 percent, $17.5 million) This component would provide support to the multi-sectoral 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 (BCC) 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, although implementation may be delegated to the CDD mechanism (the PGNT project). As part of the broader social protection strategy, the program would finance non-medical care and support for persons infected and affected, including civil servants, and piloting new approaches and support for policy development with the Ministry of Social Action. More generally, program dialogue would 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 Page 4 non-school youth programs. A performance-based contract will be signed between the MoF and the National AIDS council which will spell out the objectives to be reached. 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 would 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 supplemental grant for the ongoing project would support implementation of the first phase of the medical waste management action plan, with further support to be provided through this project. 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 2 INTERNATIONAL DEVELOPMENT ASSOCIATION 35 Total 37 6. Contact point Contact: Timothy A. Johnston Title: Senior Human Development Specialist Tel: 5354+319 Fax: (226) 50 308649 Email: Tjohnston@worldbank.org Location: Ouagadougou, Burkina Faso (IBRD) Conseil National de Lutte contre le Sida et les IST (SP/CNLS-IST) 03 BP 7030 Ouagadougou 03 - Burkina Faso Tel. (226) 50 32 41 88 Programme d'Appui au Développement Sanitaire 03 BP 7062 Ouagadougou 03 - Burkina Faso Tél. (226) 50 30 88 46