Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB6456 Project Name Health Sector Support and Multi-Sectoral Aids Project - Additional Financing Region AFRICA Sector Health (70%);Other social services (30%) Project ID P125285 Borrower(s) GOVERNMENT OF BURKINA FASO Implementing Agency Ministry of Health Telephone No.: (226) 50 30 88 46 ; Permanent Secretariat of the National AIDS Council National AIDS Council (SP-CNLS) Ouagadougou Burkina Faso Tel: (226) 5032-4188 Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared March 9, 2011 Date of Appraisal Authorization March 30, 2011 Date of Board Approval July 5, 2011 1. Country and Sector Background In 2008, the Bank and UNICEF joined forces to support the strong leadership in the MOH to scale up the implementation of the nutrition policy. In 2010, as a result of political recognition of the problem and concerted action, underweight malnutrition had come down to 26% (from 35% in 2003) and acute malnutrition dropped to 11% (from 21%). Despite these recent improvements, Burkina Faso is not on track to reach the MDG1c (halving the non-income side of poverty as measured by the prevalence of underweight malnutrition). Moreover, the multiplier effect of under- nutrition on morbidity and mortality affects Burkina Faso’s potential of progressing on MDGs 4 and 5, which concern child survival and maternal health. Over the past 15-20 years, under-five mortality has improved only marginally; it is estimated at 169 per 1,000 live births in 2009 down from 203 in 1990. The MDG target is 69 under-five deaths per 1,000 live births. In absolute numbers, this translates into 123,000 children who die each year before reaching their fifth birthday, 65,000 of them due to the effects of malnutrition. The Government has made nutrition a priority in the PRSP to ensure that more resources will be available to accelerate the implementation of essential activities in the worst affected districts, and scale up the nutrition program in the whole country. On January 13, 2010, the Council of Ministers adopted the Strategic Plan for Nutrition 2010-2015 with a cost of US$81 million. At present, there is insufficient funding to cover the whole population at risk and, together with resources mobilized by UNICEF, the proposed additional financing will help close the funding gap in the implementation of the government’s Strategic Plan and expand proven nutrition interventions to all the 13 regions of the country, with particular emphasis on the worst affected Page 2 districts. Expanding these interventions to cover the remaining regions will significantly improve the project’s development impact and effectiveness. The first case of HIV infection in Burkina Faso, was identified in 1986, after which the MOH undertook important organizational and institutional reforms and introduced innovative strategic plans to reverse the epidemic with significant results, lowering the prevalence from 7,2% in 1997 (WHO estimates) to 1,2% in 2009 (WHO/Spectrum estimates) with a higher prevalence in urban areas (3.1%). Strikingly, male circumcision, which lowers the risk of HIV transmission, is near universal at 98%. The people living with HIV/AIDS (PLWHA) are estimated at 110,000 (51% women) and infected children are estimated at 16,000. TB/HIV co-infection is found in 19% of PLWHA. Within the high-risk populations, HIV prevalence rates are alarming and require urgent and focused actions. One out of six sex workers (16%) is HIV-infected (2005). In 2008, HIV prevalence was 19% among men having sex with men in Ouagadougou. In addition to its physical impact on those infected with HIV, the disease has negative socio-economic implications on families and their children, further accentuating the extreme poverty that affects 46% of the population. In addition, sexual transmitted infections (STI) continue to be a significant health problem characterized by limited health care seeking behavior, and the number and prevalence have not changed significantly over the past five years. The HIV/AIDS program received an enormous boost following a Presidential decree that made access to anti-retroviral (ARV) treatment free of charge as of January 2010. As a result, the number of people on ARV has now exceeded 30,000, compared to 8,000 in 2005. The National AIDS Council has presented a new 2011-2015 AIDS Strategy which in the short term requires the government to mobilize additional resources to scale up prevention activities by NGOs, ARV treatment, and the prevention of mother-to-child transmission of HIV. The geographical coverage of services needs to be extended to rural areas as it is now concentrated in large cities. Further awareness-raising, notably in information, education, and communication, needs to be done at the community level, and the quality of services needs to be strengthened. An analysis of the execution of the financing plan between 2006 and 2009 by programmatic areas shows that only 43% of prevention activities were funded as compared to 90% of treatment activities. This is why the additional financing is so important to the government. 2. Objectives The project development objective is reformulated to improve access and quality of priority health, nutrition and HIV/AIDS services. The change is deemed necessary to clarify the intent of the original project development objective. The proposed additional financing will support the subcomponent IV under Component A, i.e., the implementation by the MOH of the National Nutrition Strategic Plan; and Component B, the implementation of the National HIV/AIDS Strategy by the SP/CNLS-IST. 3. Rationale for Bank Involvement The project supports the 2010-12 Country Assistance Strategy objective of promoting shared growth through improved social services delivery. The objective of this strategic theme is to improve both the supply of and demand for effective and quality social services. HSSMAP is a Page 3 key instrument for IDA to help improve the delivery of decentralized basic health services for vulnerable populations. The nutrition and HIV/AIDS programs are two cross-cutting priority programs in the health sector that benefit from high-level political commitment and a vibrant civil society engagement. The borrower requested Additional Financing to expand nutrition activities (sub component IV under Component A: to improve the project’s impact and development effectiveness) and to cover the financing gap for HIV/AIDS activities (Component B) of the HSSMAP. The subcomponents I-III of Component A (health sector support) have largely achieved their development objective. Moreover, on request of the borrower, a new investment project of approximately US$42 million on reproductive health is currently being prepared for delivery in FY12. The task team considered the possibility of preparing a new project but concluded that additional financing to the HSSMAP would be more efficient as the financial, procurement and implementation arrangements are already in place. The overall risk for the preparation and implementation of the additional financing is low and medium-low, respectively. Key risks include the capacity to improve the quality of services and the M&E system. 4. Description Project Support to the National Nutrition Strategic Plan ($15 million): The nutrition subcomponent, introduced to the project through Additional Financing when the project was half way into its implementation, is progressing well following rigorous preparation of the contracting out approach of community health and nutrition services. With the proposed Additional Financing there will be scope to scale up the coverage, consolidate the strategy and improve quality of services. This component will support the following subcomponents: (i) the scaling up of essential direct health and nutrition actions at family and community level to all 13 regions; and (ii) policy and program coordination and monitoring and evaluation of direct nutrition action. Direct nutrition action at community level includes community-based child growth promotion with emphasis on behavior change communication, including care of pregnant women, and case management of severe acute malnutrition. Community-based management of severe acute malnutrition for non-complicated cases is used to complement in-patient care for cases with complications. Community-based activities will be implemented in all 13 regions with emphasis on the worst affected districts. They will be implemented over three years (2012- 2014), reaching 65% of the total population of rural children under five years old. This will be achieved by strengthening the capacity at district level, contracting out implementation to NGOs and CBOs, and strengthening their link with the decentralized system. Project Support to the National HIV/AIDS Strategy ($18 million) : This component will complement the activities currently funded and proposed by the government for funding by the Global Fund – if approved (approximately US$24 million for 2011-2016) – and provide continuity to the activities funded under the initial project, particularly the strategic priorities and objectives focused on prevention and promotion activities. It aims to reduce new infections and control the risk of epidemic rebound among high-risk groups and its effects on vulnerable populations. It will support the following subcomponents: (i) the strengthening of community- based approaches for the prevention of risky behaviors by target populations and increasing the use of voluntary counseling and testing (VCT) and prevention of mother-to-child transmission Page 4 (PMTCT) services (ii) enhancing the quality of early diagnosis and case management of HIV, sexually transmitted infections (STI) and opportunistic infections; (iii) laboratory improvements (to be funded by the Spanish Cooperation Africa Plan); (iv) improving the care of and support to PLWHA and in particular to orphans and vulnerable children (OVC); and (v) improving the capacity to coordinate and monitor the HIV/AIDS strategic plan. The case management of HIV patients with ARV treatment are covered by Global Fund. Moreover, the team is working with the government to introduce a line item in the national budget for ARV treatment. Project activities will include behavioural change communication (BCC) promoting healthier sexual behaviours through condom use and reduction of partners, decentralized VCT for HIV, training of health personnel for better PMTCT management and BCC interventions to increase use of prenatal services, early testing and treatment of STIs, improvement of blood safety, universal precaution measures and management of accidental exposure to HIV, and prevention of sexual violence against women. Implementation will continue to draw on the experience of working with NGO, line ministries and local authorities to develop IEC/BCC and care interventions targeted to miner s, sex workers, uniformed personnel, in school and out of school youth, OVC´s, health workers, local story-teller (“griotes”), religious and traditional authorities and other groups. 5. Financing Source: ($m.) BORROWER/RECIPIENT 0.00 International Development Association (IDA) 30.00 Spanish Program for Africa 3.02 Total 33.02 6. Implementation The implementation arrangements remain the same as the ones currently in place. The project will continue to use the same implementation and coordination mechanisms, namely the Programme d 'appui au De'veloppement Sanitaire (PADS), which is a project management unit, that is well-integrated within the Directorate o f Planning and Research (DEP) of the Ministry of Health, and the Permanent Secretariat of the National AIDS-STI Council. The PADS is overseen by a steering committee chaired by the General Secretary of the MOH, and includes Directors of major departments, representatives of donors participating in the pooled fund and WHO. The technical directorates of the MOH are represented by the Director General for Health but can also directly participate if needed. The steering committee will systematically involve the Directors of Nutrition and Disease Control. Similarly, the steering committee will inform (i) the CNCN for matters that concern nutrition and (ii) the Technical Committee for the Management of Epidemics. Given the immediate focus on essential health and nutrition actions at community level, and therefore, the central role of the Directorate of Nutrition in the preparation, planning and execution process, UNICEF has agreed to strengthen the capacity by providing technical assistance in planning and monitoring to the Directorate of Nutrition. Page 5 The National AIDS-STI Council (CNLS-IST) provides oversight and policy guidance for the National HIV/AIDS program. It is chaired by the President of Faso, with the Ministers of Health and of Social Action serving as First and Second Vice-Chairs, respectively, and includes representatives of civil society (including persons living with HIVIAIDS), donors, private sector, and other key ministries. Program coordination is the responsibility of the Secretariat of the National AIDS-STI Council (SP/CNLS-IST), based in the office of the President. The SP-CNLS- IST was established in 2001. The Department of Planning, Monitoring and Evaluation of the SP- CNLS-IST will be responsible for technical monitoring, including producing semester Financial Monitoring Reports in coordination with the FMU. A steering committee with representatives of government, donors, and civil society will provide financial and technical oversight, with an annual joint program review (involving all major development partners) taking place in second half of each year. 7. Sustainability There is strong ownership for the nutrition, health and HIV/AIDS programs; Nutrition and HIV/AIDS are two cross-cutting priority programs in the health sector that benefit from high- level political commitment and a vibrant civil society engagement; and capacity at central level is well developed. 8. Lessons Learned from Past Operations in the Country/Sector Improving the quality and accessibility of medical treatment - whether for AIDS, malaria, or TB - requires addressing fundamental weaknesses in the health system. These include the quality, distribution, and motivation of health providers, the adequacy of sector financing, sector monitoring and surveillance systems, logistics systems, multisectoral coordination and community mobilization. With this comes the necessity to identify and mobilize non-traditional implementation capacity in the form of civil society organizations. 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, particularly those that require involvement of central ministries (e.g., budget reforms, human resource reforms). But experience suggests that in the medium term, providing harmonized support to a sector program could help ensure reliability of financing for priority activities, particularly at decentralized levels, strengthen ministerial and decentralized capacity, accountability, and performance management, and finance activities at community- level that would be difficult to support through the budget alone. Harmonization of financing arrangements (particularly in social sectors) is an important element in reducing transaction costs and improving development effectiveness. Budget support and pooled funding seem to reduce transaction costs for government in the medium term. Vertical disease programs and multi-sectoral activities also need to be integrated, particularly at decentralized levels and community levels. Increased resources or donor harmonization, while important, will not necessarily lead to improved health outcomes. Resource allocations need to be aligned to disease profiles, and Page 6 performance toward objectives regularly monitored. Although Burkina was among the first countries in the region to develop performance contracting for districts, additional technical support and guidance are needed to ensure that district action plans prioritize the most important actions to achieve sector objectives (e.g., malaria, malnutrition, IMCI). The HIV/AIDS program also needs to shift from a focus on planning and processes to a performance-based , management culture. The multisectoral approach has contributed to significant mobilization at national and local levels, but there is need to improve donor coordination and enhance synergies among various components. In light of the growing importance of AIDS treatment, an integrated approach to financing Ministry of Health care and treatment activities at national and district levels is essential. Strong monitoring, evaluation, and surveillance is essential to move toward a greater results- based focus, but considerable effort is required to make monitoring system fully functional, particularly when a wide range of actors and organization structures are involved. A comprehensive evaluation of various approaches to community/village interventions is necessary to move toward an integrated package of community health, nutrition, and HIV/AIDS activities. The contracting approach with large NGOs has helped reach high-risk and vulnerable groups, but geographic coverage needs to be increased while reducing administrative costs, including through contracting NGOs to support a range of interventions in a given region 9. Safeguard Policies (including public consultation) The Environmental Category for the AF is B, as was the case in the original project. The proposed implementing agencies are the Ministry of Health and the National AIDS/STI Council. During HSSMAP preparation, the Government of Burkina Faso developed a Medical Waste Management Plan (MWMP), in compliance with National and World Bank Safeguard Policies. The MWMP has been updated and re-disclosed in March 2011. The activities of the nutrition component will not trigger any environmental or social safeguard policy issues. Under Component B, the Spanish Program for Africa Grant (US$ 3,029,158) will finance the renovation of, and equipment and furniture for various laboratories, hospitals, and facilities. The project will not support any construction works. The renovation works are limited to painting and fixing windows, doors, floors and frames/panels of the existing structures. These works will be carried out in accordance with national and local laws and regulations. 10. List of Factual Technical Documents 11. Contact point Contact: Haidara Ousmane Diadie Title: Health Specialist Page 7 Tel: 5354+2255 / 223- -2070-2255 Fax: Email: housmanediadie@worldbank.org Location: Ouagadougou, Burkina Faso (IBRD) 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop