Document of The World Bank FOR OFFICIAL USE ONLY Report No: 60634-BF PROJECT PAPER ON A PROPOSED ADDITIONAL GRANT IN THE AMOUNT OF SDR 22.8 MILLION (US$ 36 MILLION EQUIVALENT) TO BURKINA FASO FOR THE HEALTH SECTOR SUPPORT AND MULTISECTORAL HIV/AIDS PROJECT 6 June 2011 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ii CURRENCY EQUIVALENTS Exchange Rate Effective March 31, 2011 Currency Unit = Franc CFA (FCFA) FCFA 462.4 = US$1 US$1.58550 = SDR 1 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AF1 First Additional Financing AIDS Acquired Immune Deficiency Syndrome ARV Anti Retroviral BCC Behavior Change Communication BCEAO Banque Centrale des Etats de l’Afrique de l’Ouest (Central Bank of West African States) CAS Country Assistance Strategy CBO Community-Based Organization CFA Communauté Financière Africaine (Africa Financial Community) CGAC Country Governance and Anti Corruption CHR Centre Hospitalier Régional (Regional Hospital) CIFE Circuit Intégré des Financements Extérieurs (Integrated External Financing System) CMA Centre Medical avec antenne chirurgicale (District Health Center) CMAM Community Management of Acute Malnutrition CNCN Conseil National de Concertation en Nutrition (National Consultative Nutrition Council) CNLS Conseil National de Lutte contre le SIDA (National AIDS Council) CPIA Country Policy and Institutional Assessment CRLS Centre Régional de Lutte contre le SIDA (Regional AIDS Center) DA Designated Account ECHO European Commission Humanitarian Aid Department EOI Expression of Interest EOP End of Project EU European Union FBS Fixed Budget Selection FM Financial Management FMU Financial Management Unit FY Fiscal Year GPN General Procurement Notice HIV Human Immune Deficiency Virus HSS Health Sector Support HSSMAP Health Sector Support and Multisectoral AIDS Project ICB International Competitive Bidding IDA International Development Association IFAC International Federation of Accountants IEC Information, Education and Communication IFR Interim Financial Report IFMIS Integrated Financial Management Information System IMCI Integrated Management of Childhood Illnesses IP Implementation Progress iii ISR Implementation Status Report IST Infection Sexuellement Transmissible (Sexually Transmitted Infection) LCS Least Cost Selection M&E Monitoring and Evaluation MAP Multisectoral AIDS Project MDG Millennium Development Goal MEF Ministère de l’Economie et des Finances (Ministry of Economy and Finance) MOH Ministry of Health MSM Men having Sex with Men MTEF Medium Term Expenditure Framework MWMP Medical Waste Management Plan NCB National Competitive Bidding NGO Non-Governmental Organization ORAF Operational Risk Assessment Framework OVC Orphans and Vulnerable Children PAD Project Appraisal Document PADS Programme d’Appui au Développement Sanitaire (Health Development Support Program) PDO Project Development Objective PEFA Public Expenditure and Financial Accountability PFM Public Financial Management PLWHA People Living With HIV/AIDS PMTCT Prevention of Maternal-To-Child Transmission PRGED Programme de Renforcement de la Gestion de l'Economie et du Développement (Program for the Strengthening of Economic and Development Management) PRSP Poverty Reduction Strategy Paper QCBS Quality and Cost-Based Selection SBD Standard Bidding Document SCADD Stratégie de Croissance Accélérée et de Développement Durable (Accelerated Growth and Sustainable Development Strategy) SDR Special Drawing Rights SP/CNLS-IST Secrétariat Permanent/Conseil National de Lutte contre le SIDA et les IST (Permanent Secretariat/National AIDS/STI Council) SRFP Stratégie de Renforcement des Finances Publiques (Strategy for the Strengthening of Public Finance) SS Single Source Selection STI Sexually Transmitted Infection SUN Scaling up Nutrition TAP Treatment Acceleration Program TB Tuberculosis TF Trust Funds TOR Terms of Reference UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDB United Nations Development Business UNDP United Nations Development Agency UNICEF United Nations Children’s Fund UOM Unit of Measurement VCT Voluntary Counseling and Testing WHO World Health Organization iv Vice President: Obiageli Katryn Ezekwesili Country Director: Madani M. Tall Country Manager Galina Sotirova Sector Manager: Eva Jarawan Task Team Leader: Haidara Ousmane Diadié v BURKINA FASO ADDITIONAL FINANCING II HEALTH SECTOR STRENGTHENING AND MULTISECTORAL AIDS PROJECT CONTENTS Project Paper Data Sheet ....................................................................................................... vi I. Introduction .................................................................................................................1 II. Background and Rationale for Additional Financing .................................................1 III. Proposed Changes .......................................................................................................4 IV. Appraisal Summary ....................................................................................................8 Annex 1: Revised Results Framework and Monitoring Indicators .......................................12 Annex 2: Operational Risk Assessment Framework (ORAF) .............................................18 Annex 3: Detailed Description Project Activities .................................................................29 Annex 4: Financial Management and Disbursement Arrangements ....................................35 Annex 5: Procurement Arrangements ...................................................................................43   vi BURKINA FASO HEALTH SECTOR SUPPORT AND MULTISECTORAL AIDS PROJECT ADDITIONAL FINANCING II DATA SHEET Basic Information – Second Additional Financing (AF) Country Director: Madani M. Tall Sectors: Health (70%); Other social services Sector Manager: Eva Jarawan (30%) Team Leader: Haidara Ousmane Diadié Themes: Nutrition and food security (40%); Project ID: P125285 HIV/AIDS (40%); Child health (10%); Expected Effectiveness Date: September 30, 2011 Health system performance (10%) Expected Closing Date: December 31, 2014 Date: June 6, 2011 Additional Financing Type: Scale up, Financing Gap Environmental category: B – Partial and Restructuring assessment Basic Information - Original Project Project ID: P093987 and P110815 (First Additional Environmental category: B – Partial Financing) assessment Project Name: Health Sector Strengthening and Expected Closing Date: December 31, 2014 Multisectoral HIV/AIDS Project Lending Instrument: SIM Second AF Project Financing Data [ ] Loan [ ] Credit [ ] Grant [ ] Guarantee [ ] Other: Proposed terms: Standard IDA Grant Second AF Financing Plan (US$m) Source Total Amount (US $) Total Project Cost: 74,449,158 Cofinancing (Denmark, UNDP, UNICEF, UNAIDS): 33,420,000 Recipient: 2,000,000 IDA (new) 30,000,000 IDA (recommitted) 6,000,000 The Spanish Program for Africa 3,029,158 Recipient: Burkina Faso Responsible Agency: Component B: Permanent Secretariat, National Component A: Ministry of Health AIDS-STI Council Contact Person: Pr. Adama Troaré, Minister Contact Person: Dr. Joseph André Tiendrebeogo, Tel: (226) 50 32 61 68; Fax: (226) Secrétaire Permanent Email: Tel: (226) 50 32 41 88; Fax: (226) 50 31 40 01 Email : spcnls@fasonet.bf AF Estimated Disbursements (Bank FY/US$m) FY 2012 2013 2014 2015 Annual 4.2 15.3 13.2 6.3 Cumulative 4.2 19.5 32.7 39.0 Project Implementation period: July 2011 – December 2014 Expected effectiveness date: September 30, 2011 Expeced closing date: December 31, 2014 Does the project require any exceptions from Bank policies? []Yes [ ] No (Exception to OP 13.20 on Additional Financing to allow Closing Date to exceed the 3 year limit by 18 months) Have these been endorsed by Bank management? []Yes [ ] No Does the project include any critical risks rated “substantial” or “high”? [ ]Yes [] No vii Original project development objective: The project development objective is to support the implementation of the Recipient’s health sector and multi-sectoral HIV/AIDS strategies, in order to accelerate progress toward the MDGs for health, nutrition, and HIV/AIDS Revised project development objective: The revised project development objective is to improve access and quality of priority health, nutrition and HIV/AIDS services1. Project description – second Additional Financing: The proposed second Additional Financing will support the implementation of the government’s health sector program, in particular the Nutrition Strategic Plan and the National HIV/AIDS Strategic Framework, to: i) scale up of a basic package of essential direct nutrition actions at family and community level included in the Government’s Nutrition Strategic Plan to all 13 of its regions; and ii) scale up of community-based approaches to reduce new HIV infections and control the risk of epidemic rebound among high-risk groups as the drivers of the epidemic; iii) refurbish of, and equipment and furniture for 10 laboratories and three Regional Antennas of the Permanent Secretariat of the National AIDS/STI Council (SP/CNLS-IST; this component will be co-financed by the Bank-administered Spanish Program for Africa Trust Fund); and iv) coordinate and monitor the nutrition and HIV/AIDS strategic plans. Safeguard policies: Environmental Assessment (OP/BP 4.01)  Yes ○ No Natural Habitats (OP/BP 4.04) ○ Yes  No Forests (OP/BP 4.36) ○ Yes  No Pest Management (OP 4.09) ○ Yes  No Physical Cultural Resources (OP/BP 4.11) ○ Yes  No Indigenous Peoples (OP/BP 4.10) ○ Yes  No Involuntary Resettlement (OP/BP 4.12) ○ Yes  No Safety of Dams (OP/BP 4.37) ○ Yes  No Projects on International Waters (OP/BP 7.50) ○ Yes  No Projects in Disputed Areas (OP/BP 7.60) ○ Yes  No Conditions and Legal Covenants: IDA Financing Agreement Description of Date Due (FA) Condition/Covenant Spanish Program for Africa TF Grant Agreement (GA) Reference Condition of Effectiveness: FA & GA, Article IV Cross effectiveness between FA Effectiveness date and GA: compliance with all conditions of effectiveness of the other agreement (other than the effectiveness of this agreement). 1 The PDO for the Spanish Program for Africa Trust Fund is a subset of this PDO, i.e., to improve access and quality of priority HIV/AIDS services. viii Covenants: FA Schedule 2, Section I.A. Maintain the CNCN (and Ongoing Steering Committee) for the nutrition component and CNLS for the HIV component Recruit and appoint to the Not later than 3 months after the PADS, (i) an additional Effective Date accountant, for a total of 5 accountants at the central level; and (ii) an internal auditor. FA & GA Schedule 2, Section Appoint to the CNLS Secretariat Not later than 3 months after the I.A. (i) an internal auditor; and (ii) a Effective Date financial controller FA & GA Schedule 2, Section Implement the Project in Ongoing I.B accordance with the Project Implementation Manual FA & GA Schedule 2, Section Implement the Project in Ongoing I.D accordance with the Medical Waste Management Plan FA & GA Schedule 2, Section Prepare and furnish to IDA and Not later than 15 December of I.E Co-financiers, an annual each year program of activities proposed for inclusion in the Project (and related financing plan); thereafter adopt and carry out the agreed annual work program; IDA to confirm the disbursement % for that year based on such program for the IDA financed HIV component.   1 I. Introduction 1. This Project Paper seeks the approval of the Executive Directors for a second Additional Financing to Burkina Faso Health Sector Support and Multisectoral AIDS Project (HSSMAP; P093987 and P110815; CR 4165-BUF and H400-BF) through an IDA grant in an amount of 22.8 SDR million (US$36 million equivalent; US$30 million new IDA and US$6 million recommitted IDA). The proposed Additional Financing would help finance the costs associated with the expansion of nutrition activities (to improve the project’s impact and development effectiveness) and cover the financing gap for HIV/AIDS activities of the HSSMAP. The IDA Grant would be co-financed by a trust fund grant of US$3,029,158 from the Spanish Program for Africa, administered by IDA. 2. The development objective is reformulated from the original objective 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. Most outcome indicators remain the same but some have been dropped or replaced with more precise or more relevant indicators. The indicator targets have been revised upwards, as appropriate, in line with the extension of the Project closing date. 3. The nutrition and HIV/AIDS activities, in addition to the pooled funding arrangements for HIV/AIDS, are closely coordinated with other development partners, notably UNICEF, the Dutch Cooperation and the Global Fund, that provide support to the health sector. UNICEF is the lead agency for nutrition under the UN Development Assistance Framework; the Dutch Cooperation leads the donor group in the pooled funding for the health sector. WHO plays a lead role for coordination activities in the health sector, including convening bimonthly meetings for all health partners, and hosts technical meetings for HIV/AIDS, in collaboration with UNAIDS. II. Background and Rationale for Additional Financing ($39,029,158) 4. 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 key instrument for IDA to help improve the delivery of decentralized basic health services for vulnerable populations. 5. The HSSMAP is being financed through a Sector Investment and Maintenance Credit. The original Credit in the amount of SDR 33 million (US$47.7 million equivalent) was approved on April 27, 2006 and became effective on November 14, 2006 with a closing date of June 30, 2010. An Additional Financing in the form of a Grant (P110815; H400-BF) of SDR 9.2 million (US$15 million equivalent) was approved on June 5, 2008 and the project closing date was extended to January 31, 2013. The original project has two components. Component (A) provides support for the national health strategy for the following subcomponents for: (i) improved quality and utilization of maternal and child health services; (ii) malaria prevention and treatment; and (iii) treatment for HIV/AIDS and sexually transmissible infections. Component (B) supports the HIV/AIDS Strategic Framework through a pooled fund at the Permanent Secretariat of the National AIDS/STI Council (SP/CNLS-IST) for the following 2 subcomponents to: (i) improve knowledge of HIV prevention and encourage the adoption of lower-risk behaviors, principally among high-risk groups; and (ii) mitigate the socio-economic consequences of the HIV/AIDS epidemic through improved coverage of social safety nets. 6. As part of the first Additional Financing, the project was restructured in FY08 by adding a new subcomponent IV under Component A to implement essential nutrition activities at the community level in five of the country’s 13 regions reaching at least 10% of the total population of rural children under five years old. The Additional Financing paid for: (i) the implementation of essential nutrition actions at community level; (ii) the development of a community health and nutrition strategy focused on decentralization, contracting out to civil society, consolidating implementing agencies, and capacity building; and (iii) the prevention and control of the meningitis outbreak. 7. The original project, as restructured under the first Additional Financing (AF1) has performed well. The ISR ratings for Implementation Progress (IP) and Development Objective (PDO) have been consistently rated as moderately satisfactory and satisfactory. Good progress on the outcome indicators have been reported; however, the moderately satisfactory rating between mid-2009 and mid-2010 was due to a weak monitoring and evaluation framework, and weaknesses in financial management and procurement. The IP was upgraded to Satisfactory in June 2010 and the PDO returned back to Satisfactory in February 2011. The utilization of maternal and child health services has increased and close to half of the outcome indicators have already exceeded the end-of-project (EOP) target. For example, vitamin A supplementation coverage of children aged 6-59 months is systematically being reported at more than 100% compared to the EOP target of 50% (original project) and 80% (AF1); immunization coverage for pentavalent vaccine 3 is reported at 100% compared to the EOP target of 91% (original project and AF1); prenatal care coverage of at least two visits has reached 82% compared to the EOP target of 70% (original project) and 75% (AF1); and skilled birth attendance reached 75% compared to the EOP target of 38% (original project) and 65% (AF1). 8. The Ministry of Health (MOH) continues to make progress in the implementation of both components. The coordination between departments has been strengthened. Two consultants have been hired to improve the quality of the M&E system. All covenants have been complied with. Finally, the Medical Waste Management Plan has been updated, disclosed in-country on March 3, 2011 and is being implemented satisfactorily. There are no other environmental concerns. The original credit is 93% disbursed. The HIV/AIDS component is now 99.4% disbursed. The additional financing is 43% disbursed, and is expected to reach 75% by December 2011. All covenants have been complied with. There are no unresolved issues with fiduciary and social safeguards. Audit compliance has been satisfactory. Finally, the procurement arrangements under the proposed Additional Financing would be the same as the arrangements under the ongoing project. However, in the case of the activities funded under the proposed Additional Financing, the Bank’s Procurement and Consultant Guidelines of January 2011 would apply. 9. 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 Recipient has requested a second Additional Financing to expand nutrition 3 activities (subcomponent IV under Component A added under the first Additional Financing: 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 Recipient, a new investment project of approximately US$42 million on reproductive health is currently being prepared for delivery in FY12. 10. 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. 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 MDG target is 69 under-five deaths per 1,000 live births. 11. The Government has made nutrition a priority in the Poverty Reduction Strategy Paper (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 Nutrition Strategic Plan 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 districts. Expanding these interventions to cover the remaining regions will significantly improve the project’s development impact and effectiveness. 12. 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 (MSM) 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. 4 13. 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 reached 30,148 in 2010, compared to 8,000 in 2005. The National AIDS Council (CNLS) has presented a new 2011-2015 HIV/AIDS Strategic Framework 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 at the community level is needed 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. 14. 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-likelihood, respectively. Key risks include the capacity to improve the quality of services and the M&E system. III. Proposed Changes 15. 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 and focus the formulation on the outcomes to be achieved. The proposed additional financing will support the subcomponent IV under Component A, i.e., the implementation by the MOH of the Nutrition Strategic Plan; and Component B, the implementation of the HIV/AIDS Strategic Framework by the Permanent Secretariat of the National AIDS-STI Council (SP/CNLS-IST). The proposed additional financing would require an extension of the closing date of the Original Financing Agreement and first Additional Financing Agreement to December 31, 2014. In addition, the project performance indicators for the Original Financing Agreement and first Additional Financing Agreement will require some modification as indicated below. 16. Component A (subcomponent IV of the original project): Nutrition Strategic Plan (IDA $18 million): The nutrition component, introduced to the project under the first Additional Financing when the project was half way into its implementation, is progressing well following rigorous preparation of the community health and nutrition services contracting out approach. In this approach, a limited number of NGOs with good capacity are contracted by the Recipient, following Bank’s procurement guidelines, as service providers to strengthen capacity of and subcontract with a larger number of Community Based Organizations (CBO) for implementation. With the proposed Additional Financing there will be scope to scale up the coverage, consolidate the strategy and improve quality of services. 17. This component will support the following activities: (i) the scaling up of a basic package of essential direct nutrition actions at family and community level as defined in the National 5 Health Development Plan to all 13 regions through support to the annual outsourcing to NGOs and CBOs and of regional and district health plans; and (ii) coordination, monitoring and evaluation of nutrition actions. Direct nutrition action at community level includes community- based child growth promotion with emphasis on behavior change communication (BCC), 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. This component will finance technical assistance services (e.g., consultants, training and workshops), goods and equipment, and incremental operating costs (e.g., contribution to the PADS operating costs). 18. Component B: National HIV/AIDS Strategic Framework (IDA $18 million; TF $3,029,158; pooled fund $35.42 million2): This component will complement the activities currently funded by the Global Fund and the Government and provide continuity to the activities funded under the original project, particularly the strategic priorities and objectives focused on prevention and promotion activities. Specifically, this component aims to reduce new infections and control the risk of epidemic rebound among high-risk groups as the drivers of the epidemic, and its effects on vulnerable populations. It will support the following activities: (i) community- based approaches for the prevention of risky behaviors by target populations, notably commercial sex workers, MSM and detainees, and increasing the use of voluntary counseling and testing (VCT) and prevention of mother-to-child transmission (PMTCT) services (ii) early diagnosis and case management of HIV, STI and opportunistic infections through the dissemination and training on updated guidelines, early voluntary testing and improved case management; (iii) refurbishment of, and equipment and furniture for 10 laboratories and three Regional Antennas of the SP/CNLS-IST (to be funded under the Spanish Program for Africa TF Grant); (iv) care of and support to PLWHA and in particular to orphans and vulnerable children (OVC) through training and social mobilization; and (v) capacity building through training and supportive supervision to coordinate and monitor the HIV/AIDS Strategic Framework. These activities are implemented through the public sector (i.e., health, social welfare and other ministries), the private and commercial sector, civil society organizations, and national and decentralized coordination mechanisms. The Project will not support ARV treatment which is covered by Global Fund. The Bank team is also working with the government to introduce a line item in the national budget for ARV treatment. 19. Project activities for the prevention of risky behaviours (subcomponent 1) will include BCC promoting healthier sexual behaviours through condom use and reduction of partners targeted specifically to high risk groups as well as decentralized VCT for HIV, training of health personnel for better PMTCT management and BCC interventions to increase use of prenatal services. Similarly, BCC will be needed for earI’ly testing and treatment of STIs, universal precaution measures and management of accidental exposure to HIV, and prevention of sexual violence against women (subcomponent 2). The project will support the provision of socio- 2 Other pooled fund contributors in addition to the Government are Denmark, UNDP, UNICEF, and UNAIDS. 6 economic assistance, through NGOs but also through the Ministry of Social Affairs, in order to help mitigate the psychological, social and economic impact of the epidemic on PLWHA, orphans and other vulnerable children and their families (subcomponent 4). Implementation will continue to draw on the experience of working with NGO, line ministries and local authorities to develop Information, Education, Communication (IEC) / BCC and care interventions targeted to miners, sex workers, MSM, uniformed personnel, in school and out of school youth, OVC´s, health workers, local story-teller (“griotes”), religious and traditional authorities and other groups. This component will finance technical assistance, training and workshops, goods and equipment, and incremental operating costs. The pooled fund will finance certain critical commodities, including medicines for PMTCT and STIs, and complementary incinerators for medical waste management where needed, as well as the implementation of the medical waste management plan. 20. The Spanish Program for Africa TF Grant (US$3,029,158) will finance subcomponent 3 including the refurbishing of, and equipment and furniture for the: (i) HIV/AIDS and STIs national reference laboratory; (ii) laboratories of two regional hospitals (CHR), three district hospitals (CMA), and four NGO-run laboratories involved that support PLWHA (those that previously operated under the ARV treatment acceleration program (TAP) funded by World Bank from 2002 to 2007); and (iii) facilities of three Regional Antennas of the SP/CNLS-IST, which were all damaged by the floods of September 1, 2009. 21. Financing plan: The total cost of the Nutrition Component is US$18 million. The cost of the HIV/AIDS Strategic Framework is $56,449 million to which the second Additional Financing IDA Grant will contribute US$18 million and the co-financing Spanish Program for Africa TF will contribute US$3,029,158. Total donor commitments are estimates only as for most sources, exact contribution amounts are not known until the year in question, and will vary throughout the life of the project. The annual disbursement percentage of the IDA Grant for the pooled HIV/AIDS component will be determined by the Association on the basis of annual joint program reviews (in April/May) and work programs finalized by December 15 each year for agreement with IDA. The costs and financing plan (in US$) for this project are presented below. Table 1: Project components and financing Proposed Project Pooling Spanish cofinanciers Recommitted Program for and Activity New IDA IDA Africa TF Government Total Nutrition component 15,000,000 3,000,000 - - 18,000,000 HIV/AIDS component 15,000,000 3,000,000 3,029,158 35,420,000 56,449,158 Total additional financing 30,000,000 6,000,000 3,029,158 35,420,000 74,449,158 22. Project Implementation Arrangements. The implementation arrangements remain the same as the ones currently in place. The nutrition component will be implemented by the Nutrition Directorate through a Project management unit within the Ministry of Health, known as the Programme d'appui au Développement Sanitaire (PADS). The PADS is overseen by a steering committee chaired by the General Secretary of the Ministry of Health, and includes Directors of all major departments, donors and WHO. The technical directorates of the MOH are 7 represented by the Director General for Health but can directly participate if needed. Although PADS was established to manage a pooled fund, IDA has not joined in pooling its resources with that fund and will continue to finance the nutrition activities outside the pooled fund. 23. In light of the Additional Financing for nutrition, the steering committee will involve the Director of Nutrition when necessary and inform the National Consultative Nutrition Council (CNCN) for matters that concern nutrition. The CNCN is a consultative body, chaired by the Minister of Health, and composed of relevant sectors and actors, to coordinate, monitor and advise on the implementation of the National Nutrition Policy (2007). The CNCN is supported by a Technical Secretariat chaired by the Director of Nutrition. 24. The HIV/AIDS component will continue to be implemented by the SP/CNLS-IST. The Permanent Secretary is the technical body of the CNLS-IST which is chaired by the Recipient’s President. The ministers responsible for health and social action serve as vice-chairs. The CNLS- IST is comprised of representatives of ministries involved in this component, representatives of civil society, private sector and development partners involved in the fight against HIV/AIDS.3 25. The IDA Grant proceeds allocated to the HIV/AIDS component (except for the laboratory refurbishing which will be financed separately out of the TF Grant) will be pooled with counterpart funds provided by the Government of Burkina Faso, and co-financing provided by Denmark, UNDP, UNICEF and UNAIDS. The disbursement from the IDA Grant of amounts allocated to the HIV/AIDS component will be made on the basis of annual joint program reviews (in April/May) and work programs (in December) for the coming year (which will also require Bank approval) which will take into account the pace of implementation of the project and the project’s needs. Disbursements will continue to be made on the basis of Interim un-audited Financial Report (IFR), including tables detailing: (i) the use of resources from the pooled funding that shows the funds from the proposed additional financing; (ii) the use of resources by sector (e.g., nutrition, malaria, HIV/AIDS, etc); and (iii) commercial bank accounts. 26. Project Outcome Indicators: The performance indicators listed in Table 2 are proposed to measure the outcomes of the second additional financing, as well as the Original Financing and the first Additional Financing. These are a selection of the same outcome indicators of the first additional financing plus a new performance indicator on nutrition and HIV/AIDS replacing indicators that were difficult to monitor (those are dropped from the results framework that was adopted with the first Additional Financing) and/or do not reflect the scope of the second Additional Financing. Similarly, several new intermediate outcome indicators have been added to replace and complement the initial results framework. These changes are proposed as a result of the enhanced experience in nutrition programming and monitoring in the past three years, and the selected focus in support of the HIV/AIDS Strategic Framework. 3 IDA is not a member of the CNLS-IST. 8 Table 2: Proposed project development indicators EOP target EOP target Progress EOP target Indicator Baseline PAD 2006 1st AF 2008 Nov 2010 2nd AF 2011 OP: Births assisted by trained health 33% 38% 65% 75% 65%1 personnel (percentage) OP: Women making two or more pre- natal consultation during pregnancy 62% 70% 75% 82% 75%1 (proportion) AF2 (new, core indicator): Pregnant women receiving antenatal care during NA NA NA 616,971 682,000 a visit to a health provider (number) AF1: Infants under six months in the 7% intervention areas exclusively breastfed NA 12% 8% 15%2 2008 in the past 24 hrs (proportion) AF2 (new): Children under five with severe acute malnutrition being treated NA NA NA 30% 50% according to the new protocol (proportion) OP: Reported condom use rate at last sexual contact among commercial sex 97 98 NA 98% 90%1 workers with paying client (percentage) AF2 (new): Pregnant women tested for NA NA NA 172,452 300,000 HIV (number) AF2 (new, core indicator): Direct Project Beneficiaries (number), of NA NA NA 2,231,560 2,467,005 which female (%) 1 Targets signify maintaining levels at a minimum sufficiently high level 2 Target will be reviewed upon availability of the 2010 DHS data IV. Appraisal Summary 27. Economic and technical analysis: The economic analysis does not change as a result of the proposed Additional Financing. Malnutrition slows economic growth and perpetuates poverty through three routes: direct loss in productivity from poor physical status; indirect loss from poor cognitive function and deficits in schooling; and losses owing to increased health care costs. The activities proposed by the Government have favorable cost-effectiveness ratios as documented in the Bank’s “Repositioning nutrition as central to development” report (2006) and “Scaling up Nutrition: What does it cost” (2010). 28. The AIDS epidemic seems to have reached a plateau in the general population but high levels of prevalence in specific groups such as sex workers and their clients, MSM, truck drivers, prisoners and youth pose a risk for a rebound of the epidemic. Associated to this and to poverty levels, poor knowledge of preventive measures, delayed diagnosis and treatment of STI and non- consistent use of condoms are still very frequent. The government and civil society organizations have made significant strides in the control of the epidemic, and the HIV/AIDS strategic framework (2011-2015) continues to provide a sound framework to continue to curb and reduce the impact of the epidemic. The proposed Additional Financing will provide resources that will help sustain action in key areas of promotion, prevention and impact reduction. 9 29. To allow sufficient time for implementation of the activities under the Second Additional Financing, and completion of the activities financed under the Original Financing and First Additional Financing, an extension of the closing date to December 31, 2014 would be required. Paragraph 2 of the Bank’s OP13.20 on Additional Financing for Investment Lending provides that “when providing Additional Financing, the Bank also confirms that the additional loan is expected to close within three years after the current closing date for the original loan”. In the case of multiple additional loans to an operation this has been interpreted under OPCS Guidance as requiring that the closing date of the proposed additional financing not exceed 3 years beyond the closing date that was in effect when the first Additional Financing was approved. The proposed second Additional Financing of the HSSMAP would exceed the three-year closing date limit specified in the OPCS Guidance by 18 months. For this reason, a waiver of OP13.20 for the proposed additional financing has been requested and endorsed by the Managing Director for subsequent approval by the Executive Directors. 30. Fiduciary arrangements: In accordance with the new Financial Management Principles issued in March 2010, and AFTFM ORAF guidelines, the Financial Management (FM) arrangements of the implementing agencies, i.e., the coordination unit of the MOH (Programme d’Appui au Dévéloppement Sanitaire; PADS), and the Financial Management Unit (FMU) of the SP/CNLS-IST, have been reviewed to determine whether these are acceptable to the Bank. The proposed second Additional Financing will use the same FM and disbursement arrangements that are currently in place under the original Project and first Additional Financing and managed by the two above mentioned implementing entities (see schema below and Annex 4 for more detail). The FM performance of the implementing entities project is rated moderately satisfactory4 following the supervision carried out in December 2010. No audit report is overdue. The country project FM system will be used according to the modalities described in the Bank Economic Sector Work on Burkina PFM system5. It provides flexibility to use a standalone Project Implementation Unit or a fully integrated unit within a Ministry. The conclusion of the Financial Management Assessment is that the overall project arrangements are adequate and satisfy the Bank’s requirements under OP/BP10.02 to provide, with reasonable assurance, accurate and timely information on the status of the execution of the project. 4 This performance rating was explained as follows: For PADS the rating is the result of the inefficiencies in the segregations of duties as a result of the increasing number of projects managed that might pose fiduciary risks. For the SP/CNLS-IST the rating is affected by the departure of two key staff in the internal audit unit that could weaken the control environment. For both entities, required steps have been taken to recruit more FM staff and develop a delegation of authorities’ matrix. 5 Burkina Faso: Country Systems review for project Financial Management, Next Steps and Ways to move forward, April 2010. 10 IDA Grant IFR IFR Donors and Govt funds PADS SP/CNLS-IST Designated Account A in SGBB Designated Account B in BCEAO (basket funds) Order of Transfer CNLS Transaction Account in Commercial Bank Foreign & Local services providers TF IFR SP/CNLS-IST Order of Transfer Designated Account C in BCEAO SP/CNLS-IST Transaction Account in Commercial Bank Foreign & Local services providers Legend: Transfers of funds Flow of documents (invoices, good receipt notes, purchase order, contract, IFR) Payment to suppliers 31. PADS and FMU/SP/CNLS-IST have well-established organizational structures, financial and administrative procedures, and computerized financial management system. To reinforce the control environment, two actions have been identified. These actions include (i) the amendment of the Terms of Reference of the external auditors to take into account the second Additional Financing (at negotiations); and (ii) the recruitment of one more accountant at the central level (for a total of 5 accountants) and one internal auditor at PADS (3 months after effectiveness); and (iii) the appointment of an Internal Auditor as well as a Financial Controller at SP/CNLS- 11 IST (3 months after effectiveness). The overall control risk has been assessed as Medium-L (Low impact/High likelihood). 32. The procurement arrangements under the proposed Additional Financing would be the same as the arrangements under the first Additional Financing. However, in the case of the activities funded under the proposed second Additional Financing, the Bank’s Procurement and Consultant Guidelines published in January 2011 would apply. More specifically, procurement of goods and non consulting services required for the project and to be financed out of the proceeds of the second Additional Financing and the TF Grant shall be governed by the "Guidelines Procurement of Goods, Works and Non-Consulting Services under IBRD Loans and IDA Credit and Grants by World Bank Borrowers " published by the Bank in January 2011. Procurement of consultants' services shall be governed by the "Guidelines Selection and Employment of Consultants under IBRD Loans and IDA Credit and Grants by World Bank Borrowers" published by the Bank in January 2011. For each contract to be financed by the second Additional Financing or the TF Grant, the different procurement methods or consultant selection methods, estimated costs, prior review requirements, and time frame will be outlined in the Procurement Plan. As in the original arrangements, UNICEF will continue to provide procurement and supply services to the MOH to facilitate timely procurement of items required for the implementation of the nutrition program. Hence, items like therapeutic food, and nutrition relevant drugs may be procured from the UNICEF warehouse. To ensure the successful implementation of the proposed Additional Financing at SP/CNLS level, a new procurement specialist has been recruited, who will be trained on Bank procedures, and the Bank will conduct a procurement supervision mission every six months. Moreover, the ratio of post review is at least 1 out of 5 contracts. The Bank’s Anti-Corruption Guidelines apply to the implementation of the project as outlined in the “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants” dated October 15, 2006 and revised in January 2011. 33. Procurement plans for each component for the next 18 months have been reviewed during negotiations. An additional General Procurement Notice (GPN) would be advertised in the United Nations Development Business (UNDB) and the Client connection in addition to local newspapers of wide national circulation after this Second Additional Financing is approved. Specific Procurement Notice for all goods and non-consulting services to be procured under International Competitive Bidding (ICB) and Expressions of Interest (EOI) for all consulting services costing the equivalent of US$200,000 and above would be published in the UNDB and in national press. 34. Safeguard policies: The environmental and safeguards category for the requested additional funding remains B. An Environmental Assessment Report including a Medical Waste Management Plan has been updated, disclosed in-country on March 3, 2011 and sent to InfoShop on March 12, 2011, and is being implemented. There will be no works under this Additional Financing, although there will be minor refurbishing of damaged offices, such as painting and window replacements, none of which would trigger a safeguard policy. 35. Conditions: The second Additional Financing Agreement and TF Grant Agreement will have cross-effectiveness conditions, so that both will be declared effective at the same time. 12 ANNEX 1: REVISED RESULTS FRAMEWORK AND MONITORING INDICATORS BURKINA FASO HEALTH SYSTEM STRENGTHENING AND MULTISECTORAL AIDS PROJECT ADDITIONAL FINANCING II PDO Current (PAD) Proposed Comments/Rationale for change The objective of the HSSMAP was to To improve access and quality PDO is reformulated to clarify the support implementation of the of priority health, nutrition and original intent of the project Beneficiary's health sector and multi- HIV/AIDS services development objective and focus the sectoral HIV/AIDS strategies, in formulation on the outcomes to be order to accelerate progress toward achieved. the Millennium Development Goals (MDGs) for health, nutrition, and combating HIV/AIDS. PDO indicators Current (PAD) Proposed change* Children under five sleeping under Indicator to be dropped The project has had little leverage on insecticide-treated bed nets this indicator as most of the nets were (percentage) provided through the Global Fund. Births assisted by trained health No change The EOP target of 65% has been personnel (percentage) achieved and will be maintained Women making two or more pre- No change The EOP target of 75% has been natal consultation during pregnancy achieved and will be maintained. (percentage) Pregnant women receiving antenatal New Core indicator added: This will be care during a visit to a health measured by the number of pregnant provider (number) women receiving a second dose of tetanus toxoid. Infants under six months exclusively EOP target moved to 2014 but Progress (2010) and project targets will breastfed in the past 24 hours may be revised upon be updated with the new data from the (proportion) availability of the new DHS DHS (2010) expected in April 2011 (2010) data. Children under five with severe acute New This is an important indicator under the malnutrition being treated according Nutrition Strategic Plan to the new protocol (proportion) Young people (age 15- 24) reporting Indicator to be dropped Use rate is relatively high and has to have used a condom during their shown no improvement over the last 7 previous sexual intercourse with a years. As the project will focus on high non-regular partner (percentage) risk groups, this indicator will be replaced by an indicator covering behavior change among commercial sex workers (see below). STI patients who are diagnosed, Indicator to be dropped As the number of STI goes down this counseled and treated (percentage) indicator will be a poor reflection of project performance Reported condom use rate at last New This indicator will replace the one on sexual contact among commercial condom use in young people. sex workers with paying client (percentage) Pregnant women tested for HIV1 New This indicator reflects the emphasis on (number) PMTCT under the proposed Additional 13 Financing Direct Project Beneficiaries New Core indicator added: This will be (number), of which female (%) measured by number of children receiving vitamin A, beneficiary women of community services (PADS), MSM and commercial sex workers Intermediate Results indicators Current (PAD) Proposed change Children under one year of age No change receiving a third dose of the pentavalent vaccine (percentage) Children immunized (number) New Core indicator added: This will be measured by the number of children 12-23 months fully immunized Children under two in the Target revised The EOP target of 36% has been intervention areas with diarrhea surpassed and is raised 50%. receiving oral rehydration therapy conform the IMCI protocol (proportion) Children aged 6-59 months receiving No change a vitamin A supplements in the past six months (percentage) Children receiving a dose of vitamin New Core Indicator added: This will be A (number) measured by number of children aged 6-59 months who received a vitamin A supplement in the past six months Post-partum women receiving a New Since free donation for this target group vitamin A supplement within the 8 by Canada has stopped, the project has weeks of delivery (proportion) started to purchase capsules for post- partum women Rural children under two reached To be revised: Rural children Change necessary due to information through the subprojects of under five who participate in availability. The EOP target is set community-based growth promotion community-based according to current progress level. activities (proportion) health/nutrition activities (proportion) People with access to a basic package New Core indicator: this indicator is of health, nutrition or population limited to a subgroup composed of services (percent increase based on children under five and is based on number of people (number) above indicator Newborns put to the breast within the New Exclusive breastfeeding rates being one first hour of birth (proportion) of two top priorities under the Nutrition Strategic Plan, this is an important intermediate indicator for the PDO. Meningitis case fatality rate at three To be dropped Too difficult to measure; no months of the onset of a meningitis information available outbreak Health personnel receiving training New Core indicator added: This will be (number) measured as number of community health workers trained HIV positive persons receiving Indicator has been moved from ARV was provided under the original antiretroviral treatment (number) PDO level to the intermediate project; hence, indicator is replaced by results level and is to be applicable core indicator. The target of replaced by: 18,000 has been surpassed and will be 14 Number of adults and children maintained at 20,000. with HIV receiving anti- retroviral combination therapy Persons receiving voluntary HIV No change The EOP target of 215,000 has been testing and counseling (number) surpassed and is raised to 425,000. Villages and community-based Reformulated to: Implementing The EOP target is raised to 8,500. organizations implementing and coordinating institutions HIV/AIDS activities (number) actively engaged in the fight against HIV/AIDS (number) Orphans and vulnerable children To be dropped As the number of orphans goes down receiving care and support (number) this indicator will be a poor reflection of project performance Men having sex with men reached New With the emphasis on targeted with preventive interventions prevention, this indicator reflects better (number) the support provided by the proposed Additional Financing Commercial sex workers reached New With the emphasis on targeted with targeted interventions (number) prevention, this indicator reflects better the support provided by the proposed Additional Financing 15 Revised Project Results Framework Project Development Objective (PDO): The objective of the HSSMAP is to improve access and quality of priority health, nutrition and HIV/AIDS services. Baseline Cumulative Target Values Original Project Progress Responsibility Core Start To Date Data Source/ for Data PDO Level Results Indicators UOM (2003) (2010) 2011 2012 2013 2014 Frequency Methodology Collection Comments Target of 65% has been 1. Births assisted by trained National % 33 75 - 65 - 65 Biannual MOH, INSD achieved and will be health personnel surveys maintained 2. Women making two or more Target of 75% has been 62 MOH, INSD, pre-natal consultation during % (2008) 82 - 75 - 75 Biannual Survey CBIO achieved and will be pregnancy maintained Number of pregnant 3. Pregnant women receiving Survey women receiving a antenatal care during a visit to a Number N.A. 632,715 616,971 637,948 659,638 682,066 Annual HMIS DSF/MOH second dose of tetanus health provider (number) toxoid Targets will be adjusted 4. Infants under six months MOH, INSD, based on the new DHS exclusively breastfed in the past % 7 8 - 10 - 15 Biannual Survey CBIO (2010) data once 24 hours available 5. Children under five with severe acute malnutrition being Activity DS/ONG % 0 30 35% 40% 45% 50% Annual treated according to the new reports DN/DGIS protocol 6. Reported condom use rate at Progress has been good last sexual contact among but has to be maintained % N.A. 98 - 90 - 90 Biannual Survey SP/CNLS-IST commercial sex workers with at a level of 90% or paying client higher 7. Pregnant women tested for Routine MOH, Number N.A. 172,452 175,000 200,000 250,000 300,000 Annual HIV monitoring SP/CNLS-IST Total of children receiving vitamin A, 8. Direct Project Beneficiaries 7,649,0 7,910,04 8,179,8 8,458,23 Routine MOH, beneficiary women of Number 0 7,641,651 Annual (number), of which female (%) 51 8 75 2 monitoring SP/CNLS-IST community services (PADS), MSM and commercial sex workers 16 Intermediate Results and Indicators Baseline Target Values Original Project Progress Responsibility Core Start To Date Data Source/ for Data Intermediate Results Indicators UOM (2006) (2010) 2011 2012 2013 2014 Frequency Methodology Collection Comments Intermediate Result 1: Enhanced health sector performance 1. Children under one year of age Progress has been 6 good but has to be receiving a third dose of the % 57 100 91 91 91 91 Annual HMIS PEV/MOH maintained at a level pentavalent vaccine of 91% or higher Number of children 2. Children immunized Number NA 647,614 589,329 609,366 630,084 651,507 Annual HMIS PEV/MOH completely immunized 3. Children under two with diarrhea receiving oral % 13 42 42 45 48 50 Annual HMIS DSF/MOH rehydration therapy conform the IMCI protocol 4. Children 6-59 months receiving vitamin A supplements in past six % 33 1137 80 80 80 80 Annual HMIS DN/MOH months Number of children aged 6-59 months who 5. Children receiving a dose of 4,756, 4,904, 5,056, 5,212, 5,374, Number N.A. Annual HMIS DN/MOH received a vitamin A vitamin A 733 021 213 955 556 supplement in the past six months 6. Post-partum women receiving a vitamin A supplement within the % N.A 50 50 55 60 70 Annual HMIS DN/MOH 8 weeks of delivery 7. Children under five who Activity DS/ONG/ participate in community-based % 0 54 55 60 65 65 Annual reports DN/PADS health / nutrition activities 8. People with access to a basic This indicator is 1,614, 1,644, 1,793, 1,943, 1,943, Activity DS/ONG/ limited to children package of health, nutrition or Number 0 589 489 988 487 487 Annual reports DN/PADS under five as a population services (percent subgroup of the total 6 There are two reasons why coverage may reach 100% or higher. These include error in: (i) age determination; and (ii) the estimated number of children within the age range. 7 Coverage is estimated as a function of the number of capsules distributed and the estimated number of children aged 6-59 months. There are various reasons why the estimated coverage surpasses the 100%. This happens when: doses are (accidentally) distributed to children outside the target age range; target children receive a double dose (e.g., from two different rally points); the actual number of children aged 6- 59 months is higher than estimated from the census data 17 increase based on number of population people (number) 9. Newborns put to the breast % N.A. 24% - 25% - 30% Biannual Survey DN within the first hour of birth Training of 10. Health personnel receiving Activity DN/PADS/ Number 0 8,405 - 9,000 9,500 Biannual community workers is training reports ONG done biannually. Intermediate Result 2: Enhanced fight against HIV/AIDS 11. Adults and children with HIV receiving antiretroviral Number 8,136 30,148 20,000 20,000 20,000 20,000 Annual HMIS CNLS, MOH combination therapy (number) CNLS-IST, 12. Persons receiving voluntary 264,660 Routine Number 38,000 310,000 350,000 390,000 425,000 Annual MOH, HIV testing and counseling (2008) monitoring PROMOCO 13. Implementing and CNLS-IST, coordinating institutions actively Routine Number 3,400 7,500 7,500 8,000 8,250 8,500 Annual CPLS, CRLS engaged in the fight against monitoring MOH, MASSN HIV/AIDS 14. Men having sex with men Routine SP/CNLS-IST, reached with preventive Number 0 0 400 700 1,000 1,200 Annual monitoring MOH interventions 15. Commercial sex workers Routine SP/CNLS-IST, reached with targeted Number 3,500 10,000 10,500 11,500 12,500 13,000 Annual monitoring MOH interventions 18 ANNEX 2 OPERATIONAL RISK ASSESSMENT FRAMEWORK (ORAF) Project Development Objective(s)      The objective of the HSSMAP is to improve access and quality of priority health, nutrition and HIV/AIDS services       PDO Level Results  1. Births assisted by trained health personnel (percentage) Indicators:  2. Women making two or more pre-natal consultation during pregnancy (percentage) 3. Pregnant women receiving antenatal care during a visit to a health provider (number) 4. Infants under six months in the intervention areas exclusively breastfed in the past 24 hours (proportion) 5. Children under five with severe acute malnutrition being treated according to the new protocol (proportion) 6. Reported condom use rate at last sexual contact among commercial sex workers with paying client (percentage) 7. Pregnant women tested for HIV (number)    Risk Category Risk Rating Risk Description Proposed Mitigation Measures Project Stakeholder Risks M-L Multiple NGOs as well as donors in health, The project objectives are closely aligned with the nutrition and HIV/AIDS may fragment the program Government’s forthcoming PRSP, the National Health field Sector Development Plan, the Nutrition Strategic Plan, and the HIV/AIDS Strategic Framework. The project will support policy monitoring and coordination in the two areas of interest for the proposed Additional Financing. Implementing Agency Risks M-L Implementation and administrative capacity The project builds on the considerable experience it relatively well developed at the central level, but has accumulated. Moreover, emphasis will be on less so at sub-national. quality. The issue of sustainability in maintaining the high The case management of HIV patients with ARV level of treatment and care is a major operational, treatment are covered under a separate project by economic and ethical problem if the flow of funds Global Fund. Moreover, the team is working with the is not kept constantly growing as new treatment government to introduce a line item in the national cases and new cases in need of 2nd and 3rd lines of budget for ARV treatment. 19 treatment are cared for. PADS and SP/CNLS-IST are well performing. Nonetheless, from experience of the ongoing project, the modest and non homogenous capacity at the sub national level might hamper the implementation. Project Risks  Design M-L Coordination between the Health Sector Support The CNLS-IST and MOH in Burkina Faso have (HSS) and Multisectoral AIDS Project (MAP) adopted the principle of outsourcing the implementing agencies has been weak but implementation of community health and nutrition following measures taken in 2009-2010, interventions to civil society organizations and coordination has dramatically improved. capacity building to competent non-governmental organizations. This arrangement has shown to work MOH is poorly equipped to get involved in well and ensure adequate management of the funding community mobilization. of community-based activities. Moreover, the additional financing will follow a simple design by focusing on supporting a limited set of essential interventions. The additional financing for the two components will strengthen community-based interventions, and improve targeting, monitoring and evaluation of behavior change interventions.  Social and Environmental M-I Main risk lies in the production and disposal of The MOH has revised the existing Medical Waste medical waste. Management Plan (MWMP) to adapt it to the needs of the proposed additional financing. The new MWMP Resistance to behavior change. includes measures for capacity building needs, training, and awareness building to ensure its proper and effective implementation. The proposed additional financing will strengthen community-based interventions, and improve targeting, monitoring and evaluation of behavior change interventions.  Program and Donor M-L Although there are a sizeable number of donors The implementing agencies and donors have effective involved in the sector, the implementing agencies coordination mechanisms in place in support of the and donors have established and accumulated pooled funding for health and HIV/AIDS. experience in coordinating the sector effectively.  Delivery Quality M-L Although funding is a permanent concern, the The MOH has recruited two local consultants to 20 quality of services is also determined by strong improve the M&E system and database management sectoral ownership. The MOH and CNLS-IST are not merely implementing a Bank-supported project but rather their national programs. The M&E system is weak and has affected the management of the program. Overall Risk Rating at  Overall Risk Rating During  Comments  Preparation  Implementation  Apart from some technical preparations, the financial, L  M‐L  procurement and implementation arrangements are already in place for implementation  21 ANNEX 3: DETAILED DESCRIPTION OF PROJECT ACTIVITIES BURKINA FASO HEALTH SECTOR SUPPORT AND MULTISECTORAL AIDS PROJECT ADDITIONAL FINANCING II 1. The proposed Additional Financing will help finance the costs associated with the expansion of nutrition activities (to improve the project’s impact and development effectiveness) according to the Nutrition Strategic Plan (2010-2015) and cover the financing gap for HIV/AIDS activities of the HSSMAP in line with the HIV/AIDS Strategic Framework (2011-2015). 2. Nutrition Strategic Plan: The proposed Additional Financing for Nutrition under Component A of the HSSMAP will be implemented using the same implementation arrangements as under the first additional financing. The proposed additional financing will support the following subcomponents: (i) the scaling up of essential direct nutrition actions at family and community level through support to the annual contracting out to NGOs and CBOs and financing of regional and district health plans; 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, improved infant and young child caring and feeding practices, and community-based management of acute malnutrition (CMAM). 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 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. 3. The scaling up of essential direct nutrition actions at family and community level will be achieved through: (i) the contribution to the contracting out of community-based nutrition interventions to NGOs and CBOs; (ii) support to regional and district health plans for training and supervision for maternal and child nutrition; and (iii) support to nutrition-relevant interventions by other sectors. 4. Community-based nutrition: The first Additional Financing for Nutrition and Meningitis (US$15m) contributes about US$1.0 million per year to the contracting out of community health and nutrition interventions to NGOs and CBOs, which is approximately one third of the total budget for the contracting out. A total of 20 NGOs and 151 CBOs have been hired to provide community-based health and nutrition services which cover approximately 35% of women and 54% of children under five. The proposed second Additional Financing for Nutrition will continue to support the community-based nutrition services through NGOs and CBOs with approximately US$1 million per year for 2012-2014. 5. Regional and District health plans: The proposed second Additional Financing will provide financial support to nutrition activities in regional and district health plans related to 22 training and supervision of vitamin and mineral deficiency control activities, nutrition monitoring and education during prenatal care, growth monitoring and promotion of infants and young children, the promotion of infant and young child caring and feeding practices, and screening for and management of acute malnutrition. It is estimated that this support will increase to approximately US$1 million a year for 2012-2014 from US$0.6 million in 2011. 6. Support to other sectors: The support of nutrition-relevant or nutrition-sensitive interventions by other sectors aims to strengthen the multisectoral approach in the fight against malnutrition. The two ministries that are most likely to be targeted first include the Ministry of Women Promotion and the Ministry of Social Affairs, which have their own mechanisms and structures for community mobilization and education. The PADS can directly finance these multisectoral activities by other ministries through an implementation agreement based on submitted and approved annual plans of action and budgets accompanied with an implementation manual. 7. Coordination and Monitoring by central level: The support to the policy and program coordination and monitoring and evaluation of direct nutrition action refers to capacity enhancing activities including:  specialized training for members of the Nutrition Directorate;  support to the implementation of the communication plan;  technical assistance on nutrition to the contracted NGOs and CBOs;  material and equipment to the Nutrition Directorate;  supervision and M&E of program activities;  support to the nutrition information system; and  contribution to the implementation of the MWMP. 8. Goods and services: This set of activities includes the procurement of goods (i.e., bicycles for community workers; ready-to-use therapeutic food for severe acute malnutrition, anthropometric equipment) and services (reproduction of communication tools; surveys). Tentative allocation of funds (in US$ million) to above nutrition activities by calendar year 2011 2012 2013 2014 Community-based nutrition (NGO/CBO) 0 1.20 1.20 1.20 Regional and District Health Plans 0 0.60 1.50 1.50 Policy coordination, M&E at central level 0 0.57 0.40 0.40 Goods and services 1.01 2.55 2.05 3.11 Support to other sectors 0 0.31 0.20 0.20 Total 1.01 5.23 5.35 6.41 23 Disbursement on community-based services by NGO and CBOs: 2010 2011 No. of No. No. children of of in the Budget Budget Cost / Region NGO CBO program Total budget Nutrition Total budget Nutrition child BdM 2 12 171,134 226,874,574 97,647,661 129,172,177 48,794,344 755 Cascade 1 5 53,757 85,558,177 36,658,772 50,216,041 10,355,920 934 Centre 2 20 344,400 246,785,999 105,289,440 161,242,575 59,280,720 468 C Est 2 14 177,411 237,561,295 84,149,010 160,289,220 43,254,090 903 C Nord 2 20 85,036 279,943,003 119,435,633 211,560,485 55,851,344 2,488 C Ouest 2 13 210,129 200,755,466 83,623,730 131,424,120 48,934,260 625 C Sud 1 7 95,544 132,000,495 54.486,870 95,406,035 26,825,550 1,009 Est 1 4 99,573 88,545,822 41,617,211 - - - H Bass 2 15 24,920 141,942,513 60,558,734 86,224,965 21,653,530 3,460 Nord 2 15 181,057 211,791,432 85,651,313 162,318,539 44,561,577 897 Plat C 1 7 91,331 126,197,602 55,121,211 95,924,063 27,163,480 1,050 Sahel 1 10 10,667 110,449,140 42,843,300 111,215,370 ,29,618,440 10,426 Sud O 1 9 70,630 167,803,029 69,015,385 117,076,618 30,685,400 1,658 Total 20 151 1,614,589 2,256,208,546 936,098,270 1,512,070,208 446,978,655 937 9. HIV/AIDS Strategic Framework: The strategy defined by the government intends to: (i) contribute to reduce the HIV transmission with regards to the risk of a rebound of the epidemic and existing STI prevalence; (ii) strengthen the case management at clinical and community levels for people tested by improving the quality of care and treatment; (iii) improve the protection and social care of PLWHA and people affected and infected by increasing the access to quality support services; (iv) strengthen the multisectoral coordination and resource mobilization; and (v) improve the strategic information management system, including research, monitoring and evaluation. The second Additional Funding will provide continuity to the activities funded under the initial project, particularly to the strategic priorities and objectives that are focused on prevention and promotion activities. It will support the following subcomponents: (i) community-based approaches for the prevention of risky behaviors by target populations, notably commercial sex workers, MSM and detainees, and increasing the use of VCT and PMTCT services (ii) early diagnosis and case management of HIV, STI and opportunistic infections; (iii) refurbishment of, and equipment and furniture for 10 laboratories and three Regional Antennas of the SP/CNLS-IST (to be funded by the Spanish Program for Africa TF); (iv) care of and support to PLWHA and in particular to OVC including the implementation of a pilot approach for the integration of gender and sexuality with interventions for the fight against HIV, AIDS and STI; and (v) capacity building through training and supportive supervision to coordinate and monitor the HIV/AIDS strategic framework. The case management of HIV patients with ARV treatment is not included in this Project as this is covered by Global Fund project. Moreover, the team is working with the government to introduce a line item in the national budget for ARV treatment.   10. Community-based prevention and VCT: The experience of the ongoing project to contract with a great number of NGOs made the overall management cumbersome and led to inefficiencies. With the proposed Additional Financing, the SP/CNLS-IST will take greater caution to involve fewer but more qualified NGOs in the process of delivering services to improve and expand preventive activities to reduce the HIV/AIDS transmission especially 24 among high risk groups. To enhance the early diagnosis of STI and HIV, the proposed Additional Financing will continue to provide support to counseling and testing, training of new health professionals, and refresher training for the ones already in place in VCT on STI diagnosis and case management, and interpersonal communication skills. The training initially targets 30 districts, and is prepared with the support of the central level and of Bobo Dioulasso. 11. The strategy for the different interventions targeting risk groups is based on the experience using: (i) an integrated approach with direct services to high risk groups such as sexual workers or miners; and (ii) capacity building of NGOs and CBOs, Community Health Management Committees, and decentralized SP/CNLS-IST teams that work with these groups. This approach of “adapted services” requires well targeted behavior change interventions as well as case management of STI´s, and access to VCT and psychosocial support. All these groups will receive appropriate training on IEC/BCC, interpersonal communication skills, VCT, community based management of HIV and STIs. The approach relies on: (i) contracting appropriate NGOs that are already involved in the first phase of the project; (ii) significant participation of the beneficiaries; (iii) quality of the health services; and (iv) regular financing to ensure continuity of interventions. The feminization of the epidemic in Burkina Faso is seen in the numbers of women infected. For that reason the proposed Additional Funding will provide support to women’s organizations at all levels to strengthen their capacity to program and implement activities focused on HIV prevention, negotiation capacity in sexual relationships and sexual violence including the problems related to female mutilation. 12. The project will continue to support the design and implementation of Annual Action Plans of some of the more important public sector ministries that may have increased impact in some of the high risk groups namely youth, young adolescent girls, commercial sex workers, MSM, detainees, truck drivers, and miners. For the next three years, the pooled fund will particularly support the plan of action and implementing activities of the Ministries of Youth, Health, Social Affairs, National Solidarity, Defense, Security, Women Promotion, Primary, Secondary and Higher Education. As for the MOH, the proposed Additional Financing will support the control of STI with the revision and update of the guidelines and algorithms for syndrome diagnosis and case management. Meanwhile, the CNLS-IST will develop the training and dissemination of the revised guidelines during the three years of the project in all regions. Moreover, the project will support the acquisition of STI drugs according to the national STI case management guidelines. 13. The proposed Additional Financing will also support the training of professionals from the mass media, such as journalists from the main daily and weekly journals, national and local radios and television. They will be trained to understand the issues related to HIV infection and prevention, as well as the determinants and dynamics of the epidemic, role of gender and gender violence issues, and special needs of PLWHA and OVCs. This information will help the media professionals to be clearer in the information they pass in their services. Similarly, the project proposes to train more than 100 local artists (“griotes” local theater actors and singers) in all regions to support their role as behavior change communicators. This training will be done by seminars in each region. 25 14. Early diagnosis and laboratory improvements: The Project will include the refurbishing of the National HIV/AIDS and STI reference laboratory and nine decentralized laboratories, damaged by flooding in September 2009 to strengthen the capacity of epidemiological surveillance and research related to HIV, specifically the follow-up of patients on ARV treatment, or those treated for opportunistic infections and STIs, and PLWHA that need to control and know their immunological situation. Most of the renovation works but also the furniture, reagents, laboratory supplies and equipment needed to make the laboratories functional and improve the quality of HIV/AIDS and STI case management and epidemiological surveillance will be supported by the Spanish Program for Africa TF Grant. 15. More specifically, the TF Grant will support the refurbishing and equipments for: (i) the HIV / AIDS and STIs national reference laboratory damaged by flooding in September, 2009; (ii) two regional hospital laboratories (CHR) and three health center laboratories (CMA); (iii) facilities of three regional offices of the SP/CNLS-IST; (iv) four laboratories of NGOs/Associations involved in PLWHA support, precisely those that support ARV treatment acceleration program (TAP) funded by World Bank from 2002 to 2007. The TF Grant falls within the framework of health system strengthening, which aims to support PLWHA with the collaboration of both the public sector (MOH) and NGOs/Associations involved in HIV/AIDS and STIs control. The Grant allocation is shown in the table below and the proposed closing date for the TF Grant Agreement is set for December 31, 2012 given the donor’s disbursement deadline of July 2013 for the Trust Fund itself. Spanish Program for Africa Grant Allocation (rounded): US$ (million) Renovation of the HIV national reference laboratory 0.70 Renovation of regional and local laboratories of MOH and NGOs/Associations 0.80 Equipment of laboratories of the MOH and NGO/Associations 0.93 Renovation and equipment of facilities of regional SP/CNLS-IST offices 0.60 16. Care and support to PLWHI and OVC: This component intends to create a favorable environment for an adequate community-based continuum of care and support, and will provide socio-economic assistance, through NGO´s and the Ministry of Social Affairs, in order to help mitigate the psychological, social and economic impact of the epidemic on PLWHA, orphans and other vulnerable children and their families. 17. Coordination and monitoring: The operational coordination of the proposed activities under the proposed Additional Financing continues to be executed by the SP/CNLS-STI. Annual multisectoral national and regional plans will be developed by the different stakeholders such as the focal points of the different line ministries, civil society organizations, and coordinating structures at regional, provincial and communal levels. The Project will improve the capacities of central level and 3 regional centers (CRLS) acquiring 4x4 vehicles that will increase the ability to supervise and coordinate the activities at each level of intervention. 26 Tentative and rounded allocation of IDA and TF Grant funds (in US$ million) to above HIV/AIDS activities by calendar year 2011 2012 2013 2014 1. Community-based prevention and VCT 0.80 2.30 2.30 2.30 2. Early diagnosis and case management 0.10 0.35 0.30 0.25 3. Laboratory improvements 0.60 2.10 0.20 0.13 4. Care of and support to PLWHA and OVC 0.25 0.80 0.75 0.70 5. Coordination and monitoring 0.55 2.65 1.75 1.85 Total 2.30 8.20 5.30 5.23 Tentative and rounded allocation of IDA and TF Grant funds (US$ million) to above HIV/AIDS activities by funding source IDA Spanish Program for Africa 1. Community-based prevention and VCT 7.70 - 2. Early diagnosis and case management 1.00 - 3. Laboratory improvements - 3.03 4. Care of and support to PLWHA and OVC 2.50 - 5. Coordination and monitoring 6.80 - Total 18.00 3.03 27 ANNEX 4: FINANCIAL MANAGEMENT AND DISBURSEMENT ARRANGEMENTS BURKINA FASO HEALTH SECTOR SUPPORT AND MULTISECTORAL AIDS PROJECT (HSSMAP) ADDITIONAL FINANCING II Executive Summary 1. In accordance with the new Financial Assessment Principles and AFTFM ORAF guidelines, the Financial Management (FM) arrangements of the coordination unit of the MOH (Programme d’Appui au Dévéloppement Sanitaire; PADS), and the Financial Management Unit of the Permanent Secretariat of the National AIDS/STI Council (FMU/SP/CNLS-IST), have been reviewed to determine whether it is acceptable to the Bank. The proposed second Additional Financing would use the same financial management and disbursement arrangements that are currently in place under the original Project and first Additional Financing currently managed by the two above mentioned implementing entities. The FM performance the implementing entities project is rated moderately satisfactory8 following the recent supervision carried out in December 2010. The implementing entities have no overdue audit report. The country PFM system will be used as per the modalities described in the Bank Economic Sector Work on Burkina PFM system9 . The conclusion of the Financial Management Assessment is that the overall project arrangements are adequate and satisfy the Bank’s requirements under OP/BP10.02 to provide, with reasonable assurance, accurate and timely information on the status of the execution of the project. Details of the financial management arrangements are described below. 2. PADS and FMU/SP/CNLS-IST have a well-established organizational structure, financial and administrative procedures, and computerized financial management system. To reinforce the control environment, two actions have been identified. They actions include (i) the amendment of the Terms of Reference of the external auditors to take into account the AF funds and (ii) the recruitment of one more accountant and one internal auditor at PADS and (iii) the appointment of an Internal Auditor as well as a Financial Controller at FMU/SP/CNLS-IST. The overall control risk has been assessed as Medium Likelihood. 8 This performance rating was explained as follows: For PADS the rating is the result of the inefficiencies in the segregations of duties as a result of the increasing number of projects managed that might pose fiduciary risks. For the SP/CNLS-IST the rating is affected by the departure of two key staff in the internal audit unit that could weaken the control environment. For both entities, required steps have been taken to recruit more FM staff and develop a delegation of authorities’ matrix.. 9 Burkina Faso: Country Systems review for project Financial Management, Next Steps and Ways to move forward, April 2010. 28 Financial Management and Disbursement Arrangements Overview of Project and implementing entities 5. Under the second Additional Financing of US$39,029,158 (US$36 million IDA Grant and US$3,029,158 Trust Fund Grant) and extension of ongoing project closing date the following components will be financed: (i) Nutrition Strategic Plan ($18 million): This component will be implemented by PADS coordination unit and will support: (i) the scaling up of essential direct health and nutrition actions at family and community level to all 13 regions (from five under the current project); and (ii) policy and program coordination and monitoring and evaluation of direct nutrition action. (ii) HIV/AIDS Strategic Framework ($21,029,158): This component will be implemented by SP/CNLS-IST. It aims at reducing new infections and at controlling the risk of epidemic rebound among high-risk groups and its effects on vulnerable populations. Country Issues 6. Overall, the Bank has judged implementation performance of the PFM reform program (Stratégie de Renforcement des Finances Publiques or SRFP) to date and Government’s commitment to PFM improvements as exemplary. As a result, the Bank is preparing its 11th budget support operation. SRFP is supported by most donors providing budgetary support, and is a core element of the MoU for budget support. To assess progress made so far after 4 years of SRFP implementation, the Government has performed a repeated PEFA. Outcomes from this PEFA, completed on June 2010, have confirmed progress made so far by Burkina Faso in the PFM area. Improvements are noted on budget credibility (indicators 1-4). Confirmation of adequate arrangements has been highlighted for the remaining indicators (comprehensiveness and transparency, policy based budgeting and predictability and control in budget execution). To complement the national PEFA, a sub national PEFA for the Ouagadougou municipality was also completed on June 2010 with major outcomes fairly similar to the National PEFA. Meanwhile, the MEF is working on several initiatives on PFM area. Among them (i) new sectoral strategy (Stratégie Sectorielle du Ministère de l'Economie et des Finance) that will merge both SRFP and PRGED (Programme de Renforcement de la Gestion de l'Economie et du Développement) and include objectives to implement the WAEMU PFM Directives recently issued and (ii) the new Integrated Circuit for Donors-financed Projects (Circuit Intégré des Financements Extérieurs, CIFE).10 10 CIFE was launched on April 1st, 2011 following the final approval by the Council of Ministers held on March 2nd, 2011; is built on a computerized system; and aims at applying the country PFM system at the projects level by involving key players of country system players in project monitoring (Directorate of Budget, Directorate of Finance Control, and Directorate of Public Treasury...). CIFE has six modules; two are already being utilized since 2010. They relate to project identification and financing agreement monitoring. The four remaining cover budget monitoring as well as internal controls and accounting arrangements in line with the national PFM system. All modules are interfaced with the country’s Integrated Financial Management Information Systems (IFMISs). CIFE allows for donor funds after review by the key players above, to be fully integrated into the budget, accounting, reporting and treasury systems, yet remain earmarked for a specific use. It includes flexibility to use a standalone project implementing unit or a fully integrated unit within a Ministry. The proposed additional financing will be 29 Risk Assessment and Mitigation Risk Risk Risk Mitigating Measures Risk after Remarks rating Incorporated into Project mitigation Design measures INHERENT RISK ML ML Country level ML Joint donors and GoBF yearly ML Implementation of the Delay in the implementation of assessment of the 3 years rolling PEFA recommendations the different PFM reforms that action plan resulting from 2007 through the 3 years action might hamper the overall PFM and 2010 PEFA plan is deemed satisfactory environment. recommendations. based on the joint donors’ and GoBF assessment following the September 2010 steering committee meeting of the PFM reforms. Entity level ML ML PADS and SP/CNLS-IST are Pursue the ongoing capacity well performing. Nonetheless, building and coordination Over from experience of the activities carried out by the project ongoing project, the modest PADS and SP/CNLS-IST for the implementa and non homogenous capacity benefit of the sub national tion at the sub national level might structures. hamper the implementation Project level ML ML The involvement of an Pursue the selection on a increasing number of new competitive basis (in accordance NGOs increases the fiduciary with the Bank’s procurement/ risk. consultant guidelines) of the NGOs meant to be used as contractors CONTROL RISK ML ML Budgeting ML ML PADS and SP/CNLS-IST PADS Recruit one more FM staff at 3 months budget formulation are well Work load that might delayed PADS after integrated into national the budget process. effectivene budget preparation. Before Rely on PADS and SP / CNLS ss CIFE implementation, SP/CNLS-IST existing budgeting arrangements. donors-financed project’s No risk identified. budget execution did not follow the national budget procedures. Since the project will be implemented through CIFE, this issue will be addressed. Accounting ML ML As per CIFE procedures, the project’s accounting PADS Recruit one more FM staff at transactions will be Work load that might lead to PADS reflected into the national channeled through CIFE as per the recommendation of the ESW on Burkina PFM system since all Bank’s 10 recommendations identified in the said ESW are met. 30 Risk Risk Risk Mitigating Measures Risk after Remarks rating Incorporated into Project mitigation Design measures delay and inaccuracies in financial statements as financial data. Rely on PADS and SP/CNLS – opposed to the former IST existing accounting situation. This will improve arrangements. reliability of the national SP/CNLS-IST financial statements. No risk identified. Internal Controls and MI Rely on the existing manual of MI Internal Audit procedures at PADS and SP/CNLS-IST PADS Insufficient staff at the Internal Audit Unit Recruit one internal auditor at 3 months PADS. after SP/CNLS-IST effectivene Finalize the appointment process ss Departure of the Internal of an Internal Auditor and a Auditor and the financial Financial Controller at controller. SP/CNLS.-IST Funds Flow MI MI Open at the Central Bank, 2 Over For each DA, a PADS & SP / CNLS Designated Accounts for the implementa Transactions Account will Funds might be diverted with Additional Financing (DA – A tion also be opened in a the other projects funds will finance activities commercial bank to managed by PADS and implemented by PADS under the facilitate payments with the SP/CNLS-IST. IDA Grant, DA – C will finance suppliers and transfer to the activities implemented by sub national entities. SP/CNLS-IST under the Trust Fund) and maintain a third As per CIFE procedures, all designated account (DA – B for withdrawal applications activities under the IDA Grant to will be subject to review by be carried out by SP/CNLS-IST) the Directorate of Public Account before processing Rely on the existing funds flow into the national accounting between PADS and SP/CNLS- books and submitting to the IST and the sub national entities Bank. including NGOs. Financial Reporting ML ML Since the accounting PADS Recruit one more FM staff at 3 months software has a multi project Delay in financial reporting PADS. after and site version, the process effectivene reporting process will be ss eased. Following a satisfied reconciliation between SP/CNLS-IST Rely on PADS and SP/CNLS- financial reporting from No risk identified IST existing reporting system CIFE and the project arrangements. accounting software, decision will be made to shift to national reporting system CIFE. Auditing ML ML In line with the use of PFM 31 Risk Risk Risk Mitigating Measures Risk after Remarks rating Incorporated into Project mitigation Design measures Update the ToR of the current system, the Supreme Audit The ToR of the current auditor external auditor to take into Institution might jointly under recruitment does not account in the audit scope the contribute in the audit field include the second additional new Additional Financing. work with the external financing auditor. In case of new appointment, this Institution will lead the process. OVERAL RISK M ML The overall risk rating is deemed Medium Likelihood. Strengths 7. PADS and SP/CNLS-IST have a track record in managing donor – financed projects (current World Bank, French Development Agency, Netherland, and European Commission projects...) with an adequate control environment which is underway to be reinforced. Action Plan to reinforce the control environment Action Responsible body Completion Recruit one internal auditor and one accountant at PADS 3 months after effectiveness PADS. Finalize the appointment process of the Internal Auditor SP/CNLS-IST 3 months after effectiveness and the Financial Controller at SP/CNLS-IST. Update the ToR of the external auditor currently under PADS; SP/CNLS-IST Done recruitment to take into account in the audit scope the new Additional Financing and the matching grant scheme 8. Staffing and Training: PADS and SP/CNLS-IST are staffed with experienced accountants. However, given the recent moves in the SP/CNLS-IST FM team and the risk of overload at PADS, there is a need (i) at PADS to recruit one more accountant and internal auditor and (ii) at SP/CNLS-IST to complete the appointment process of the Internal Auditor and the financial controller. 9. Budgeting: Reliance will be placed on the PADS and SP/CNLS-IST existing budgeting arrangements which are well aligned with the national budget at formulation stage, not execution. With CIFE implementation, donors-financed projects’ budget execution will be also aligned with the national budget execution process. Then, the project’s entire budget process will be well aligned with the national budget arrangements. 32 10. Accounting Policies and Procedures: PADS and SP/CNLS-IST accounting policies and procedures are documented in their manual of procedures recently updated. The implementing entities will continue to prepare the financial statements by using the multi site version of the accounting software TOMPRO which is already customized to generate IFR. As per CIFE procedures, the project’s accounting transactions will be reflected into the national financial statements as opposed to the former situation. This will improve reliability of the national financial statements. 11. Internal Control and Internal Auditing: The existing manuals of procedures are adequate for the additional financing. One additional internal auditor will be recruited to reinforce PADS internal audit team. To ensure a sound control environment, the appointment process of the internal auditor and the financial controller will need to be completed. 12. Flow of Funds: There will be three (3) designated Accounts for the Additional Financing and TF Grant (DA – A will finance activities under the nutrition component implemented by PADS, out of the proceeds of the IDA Grant; DA – B will finance activities under the HIV/AIDS component to be carried out by SP/CNLS-IST and to be financed out of the proceeds of the IDA Grant; DA – C will finance activities under the HIV/AIDS component, implemented by SP/CNLS-IST to be financed out of the proceeds of the Trust Fund. DA – A will not be part of the existing pooled funding operating at PADS since the Bank has not signed a MoU to participate in this basket arrangement. DA – B will be disbursed into the pooled funding arrangement operating at SP CNLS. Given the specifics related the Trust Funds to be disbursed under DA – C by SP/CNLS, the pooled funding arrangements will not be applied. For each DA, a Transactions Account will also be opened in a commercial bank to facilitate payments with the suppliers and transfer to the sub national entities. Direct payments will be made to service providers if needed. IDA Grant IFR IFR Donors and Govt funds PADS SP/CNLS-IST Designated Account A in SGBB Designated Account B in BCEAO (basket funds) Order of Transfer CNLS Transaction Account in Commercial Bank Foreign & Local services providers 33 TF IFR SP / CNLS-IST Order of Transfer Designated Account C in BCEAO PADS Transaction Account in Commercial Bank Foreign & Local services providers Legend: Transfers of funds Flow of documents (invoices, good receipt notes, purchase order, contract, IFR) Payment to suppliers 13. Disbursement Arrangements: The entities have already satisfactory experience in using report based disbursements in the original project, thus, the same approach will be maintained in the context of Additional Financing. Upon IDA Grant / TF effectiveness and request from the Recipient, the Bank will advance ceiling amounts, which will be equivalent to a cash forecast for 2 quarters as provided in the six monthly unaudited Interim Financial Report, in each of the designated accounts. The Designated Account will be used for all payments inferior to twenty percent of the DA ceiling and the frequency of replenishment applications will be the period set out in the Financing Agreement for provision of Interim Financial Reports.   14. Disbursements by category: The table below sets out the expenditure categories to be financed out of the IDA Grant / TF Grant proceeds. This table takes into account the prevailing Country Financing Parameter for Burkina Faso in setting out the financing levels, which allows for up to 100% financing. However, the annual disbursement percentage of the IDA Grant for the pooled HIV/AIDS component will be determined by the Association on the basis of annual joint program reviews (in April/May) and work programs finalized by December 15 each year for agreement with IDA. Amount of IDA Amount of TF Percentage of eligible Financing allocated Grant allocated expenditures (including Disbursement category (in million $US) (in million $US) taxes) Goods, Services, Operating costs and Training for Component (A) 18.00 0 100% (Nutrition Strategic Plan) Goods , Services, Operating costs Such percentage of the and Training for each Annual Work expenditures included in Program included in Component 18.00 0 each Annual Work (B) (excluding laboratory Program as the Association may 34 refurbishing/equipping) (HIV/AIDS determine and notify to Strategic Framework) the Recipient in its Annual Confirmation for said Annual Work Program Goods and Services, for laboratory refurbishing/equipping for 0 3.029,158 100% Component (B)(HIV/AIDS Strategic Framework) TOTAL AMOUNT 36.00 3.029,158 15. Financial Reporting and Monitoring: The current content and format of the IFR are deemed acceptable to IDA. The IFR of the AF will use the same format and content. The Interim Un-audited Financial Reports (IFR) of the two implementing entities will continue to be prepared every semester and submitted to the Bank (e.g. 3 months after the end of each semester). The IFRs will also be used for disbursement purposes. At the end of each fiscal year, the project will prepare annual financial statement with content and format similar to the ongoing initial project. There is no overdue IFR at the time of the preparation of this Additional Financing 16. Auditing: PADS and SP/CNLS-IST existing external auditors will have their ToR and contract amended to integrate the proposed Additional Financing transactions. It is worth noting that as per the existing audit arrangements, all districts, sub national entities, and NGOs receiving PADS and SP/CNLS-IST proceeds are subject to external audit. There is no overdue audit report at the time of the preparation of this proposed Additional Financing. The auditors will provide one single opinion on the annual financial statements in compliance with IFAC Standards on Auditing. In addition to the audit reports, the external auditors will be expected to prepare a Management Letter giving observations, comments, and providing recommendations for improvements in accounting records, systems, controls and compliance with financial covenants in the Financing agreement. The audit reports will be submitted to IDA not later than 6 months after the end of each fiscal year. In line with the new access to information policy, project will comply with the Bank disclosure policy of audit reports (e.g. make publicly available, promptly after receipt of all final financial audit reports (including qualified audit reports) and place the information provided on its the official website within one month of the report being accepted as final by the team. 17. Implementation Support Plan: FM implementation support mission will be combined with original project and consistent with a risk-based approach, and will involve a collaborative approach with the entire Task Team (including procurement). Given overall risk rating, the financial management specialist on-site visit will be once a year. 18. Conclusions of the FM Assessment: The overall control risk is Medium Likelihood. The proposed financial management arrangements for this project are considered adequate to meet the Bank’s minimum fiduciary requirements under OP/BP10.02. The assessment recommended among other measures (i) the amendment the terms of reference of the external auditors to include the additional financing; (ii) the recruitment of one accountant and one internal auditor at PADS (iii) and the appointment of the Internal Auditor as well as Financial Controller at (SP/CNLS-IST). 35 ANNEX 5: PROCUREMENT ARRANGEMENTS BURKINA FASO HEALTH SECTOR SUPPORT AND MULTISECTORAL AIDS PROJECT (HSSMAP) ADDITIONAL FINANCING II A. Procurement methods 1. Guidelines: Procurement for the proposed project would be carried out in accordance with the World Bank’s "Guidelines Procurement of Goods, Works and Non-Consulting Services under IBRD Loans and IDA Credit and Grants by World Bank Borrowers " published by the Bank in January 2011; and "Guidelines Selection and Employment of Consultants under IBRD Loans and IDA Credit and Grants by World Bank Borrowers" published by the Bank in January 2011. 2. Procurement of Goods and non consulting services: Goods and non consulting services procurement will be done using the Bank’s SBD for all ICB and SBD agreed with the Bank for National Competitive Bidding (NCB) International Competitive Bidding (ICB): Each goods contract package estimated to cost US$500,000 equivalent and more per bid package would be procured through International Competitive Bidding. National Competitive Bidding (NCB): For the supply of goods contract estimated to cost less than US$500,000 equivalent and locally available at commercial price would be procured through National Competitive Bidding (NCB) procedures acceptable to IDA. Shopping: Procurement for readily available off-the-shelf goods that cannot be grouped, or standard specification commodities for individual contracts of less than US$50,000 equivalent, may be procured under shopping procedures as detailed in paragraph 3.5 of the "Guidelines Procurement of Goods, Works and Non-Consulting Services under IBRD Loans and IDA Credit and Grants by World Bank Borrowers " published by the Bank in January 2011 and the Guidance on Shopping Memorandum" issued by IDA, June 9, 2000. The requests of solicitation will specify that offers should be submitted sealed and opened at a public opening session. Direct contracting for Goods: This may be only used on an exceptional basis and with the prior approval of the Bank in accordance with the provisions of paragraph 3.7 of the Procurement Guidelines. Procurement from United Nations Agencies: In accordance with the provisions of paragraph 3.10 of the Procurement Guidelines, UNICEF will continue to provide procurement and supply services to the MOH to facilitate timely procurement of items required for the implementation of the nutrition program. Items like therapeutic food, and nutrition relevant drugs may be procured from the United Nations Agencies (i.e., UNICEF warehouse) provided that: (i) the number of suppliers is limited; (ii) the UN agency is uniquely or exceptionally qualified to procure such 36 goods and related incidental non-consulting services, if any; and (iii) the Recipient uses the standard form of Agreement between a Recipient and a UN agency for the procurement of supplies and provision of certain services agreed by the Bank. 3. Selection of Consultants: Consulting services foreseen will be procured with the most appropriate procurement method allowed by the World Bank Guidelines and included in the Procurement plan approved by the Association : (a) Quality and Cost Based Selection (QCBS); (b) Least Cost Selection (LCS); (c) Selection under a Fixed Budget (FBS); (d) selection based on the Consultant’s Qualification for the selection of firm for contract estimated to cost less than US$100,000; (e) Single Source (SS) Selection shall be used with the World Bank’s agreement for services in accordance with paragraphs 3.8 to 3.11 of the consultants Guidelines. All terms of reference will be subject to the World Bank prior review. Short lists of consultants for services estimated to cost less than US$100,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. Consultant services meeting the requirements of section V of the Consultants Guidelines will be selected under the provisions for the Selection of Individual Consultants through the comparison of the curriculum vitae of at least three qualified individuals. The use of civil servants as individual consultant or as a team member of Consultants firms will strictly follow the provisions of Article 1.9 to 1.11 of the Consultants’ Guidelines. 4. Operating Costs: Operating costs would include the incremental expenses incurred on account of Project implementation, consisting of reasonable expenditures for office supplies, vehicle operation and maintenance, communication and insurance costs, banking charges, rental expenses, office and office equipment maintenance, utilities, document duplication/printing, consumables, travel cost and per diem for Project staff for travel linked to the implementation of the Project, and salaries of contractual staff for the Project (but excluding salaries of officials of the Recipient’s civil service). Operating cost items will be procured using the implementing agency’s administrative procedures that are acceptable to the Association. For services (car maintenance, computer maintenance etc.) to be financed through operating costs, the project will proceed by service contracting for a defined period. 5. Training, Trade fair, Workshops, Study Tours, and Conferences: All training to beneficiary staff, trade fair and workshops under the Project will be conducted on the basis of programs, which should be approved by the World Bank as part of the Annual Work Program, and which shall, inter alias, identify: (a) the objective of training, fair and workshops envisaged; (b) the personnel to be trained or criteria for selection; (c) the institutions which will conduct the training or organize the fair or selection method; (d) the duration of the proposed training or fair and (e) an estimate of the cost. B. Assessment of the Agency’s Capacity to Implement Procurement The assessments found that the former procurement specialist at the SP/CNLS level has resigned. The new one has been recruited but has a limited knowledge in World Bank procedures. In order to mitigate the lack of experience of the project staff for procurement, it was agreed that the procurement staff at SP/CNLS level will be trained on World Bank procedures. The overall procurement risk has been assessed as Medium Likelihood. 37 C. Procurement Plan The implementing agencies, at appraisal, developed procurement plans for project implementation of the first 18 months which provide the basis for the procurement methods. These plans were agreed to by the Beneficiary and the Bank Delegation on April 27, 2011, and are available at the PADS and the SP/CNLS-IST offices. They will also be available in the projects’ database and in the Bank’s external website. The Procurement Plans will be updated in agreement with the Project Team annually or as required to reflect actual project implementation needs. Detail of procurement arrangement involving International Competition 1. Goods, and Non Consulting Services: (a) List of contract packages which will be procured following ICB Estimated Expected Domestic Review by Ref. Contract Cost (US$ Procurement Prequalification Bid- Preference Bank (Prior No. Description million Method (yes/no) Opening (yes/no) / Post) equivalent) date 1 2 3 4 5 6 7 8 Component A 1 Reproduction of 1,146,031 ICB No No Prior 01/08/12 35,000 flipcharts Anthropometric 2 540,694 ICB No No Prior 12/9/11 equipment 3 Ready to use 1,001,464 SSS No No Prior 11/16/11 Therapeutic Foods Component B 4 Vehicles, 550,000 ICB No No Prior 09/30/11 5 Laboratory 1,650,000 ICB No No Prior 12/15/11 equipment 38 2. Consulting Services : (b) List of consulting assignment with short list of international firms Ref. Description of Assignment Estimated Cost Selection  Review by Bank  Expected Proposals No. (US$ equivalent) Method  (Prior / Post)  Submission date 2 3 4 5 Component A None Component B 1 Financial Audit 2011, 2012, 300,000 QBCS Prior 09/12/11 2013 2 Technical Procurement Audit 300,000 QBCS Prior 10/16/11 2011, 2012, 2013 3 Impact evaluation 200,000 QBCS Prior 12/25/11 D. Fraud, Coercion, and corruption All procuring entities, as well as bidders, suppliers, and contractors would observe the highest standard of ethics during the procurement and execution of contracts financed under the project in accordance with paragraphs 1.16 & 1.17 of the Procurement Guidelines and paragraph 1.23 & 1.24 of the Consultants Guidelines. E. Frequency of Procurement Supervision In addition to the prior review, supervision the capacity assessment of the implementing Agency has recommended the Bank will conduct a procurement supervision mission every 6 months, so that the ratio of post review is at least 1 to 5 contracts. F. Publication of General Procurement Notice (GPN) An additional General Procurement Notice (GPN) would be advertised in the United Nations Development (UNDB) and the Client connection in addition to local newspapers of wide national circulation after this Second Additional Financing is approved. Specific Procurement Notice for all goods and works to be procured under International Competitive Bidding (ICB) and Expressions of Interest (EOI) for all consulting services costing the equivalent of US$200,000 and above would be published in the UNDB and in national press