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G. Lessons tearoed 2.50 The design of the proposed project corrects two weaknesses identified in Operations Evaluation Department audits of World Bank health projects. These weaknesses have also hampered implementation of the First Health Project (FHP) in Burkina Faso. They are: (1) lack of decentralization, and (2) lack of improvement in the quality of care. PDSN emphasizes decentralization coupled with training and supervision through district management teams designed to improve the quality of care, and priority is given to improving the quality of services of existing structures. There are three other lessons to be learned from the implementation of the FHP. First, emphasis on providing buildings and other inffastructure will accomplish little if complementary changes in health care policy are not forthcoming. It became elear by 1988 that decentralization of health care services would be essential to project success but virtually all project activities were concentrated on the implementation of the investment component. Dialogue on the need to give the peripheral health facilities morę autonomy and discussions on the drug supply/distributioo/importation did not start until after the 1988 mid-term review of the FHP-too late to achieve timely adoption of the necessary complementary policy reforms. Under the proposed project these policy issues have been addressed during preparations and most necessary actions have been taken prior to negotiations. Second, despite a sizable project/Govemmert input for training under the FHP, the impact of the training on improved health care is unknown. To avoid such a recurrence in the proposed project, IDA will review and approve the content of training programs prior to their implementation, and the Government will introduce a monitoring system under which supervisors will-at regular intervals-report on the accomplishments/shortcomings of former trainees. Third, introduction of the necessary policy reforms took too long under the FHP because agreement on these reforms was sought through policy dialogue during project implementation rather than earlier during the processing of the project. Under the proposed project virtually all policy reforms have been addressed up front, prior to negotiations.

A. gcajęęt Ratopsle

3.1 Low life expectancy and high infant and maternal mortality rates partly reflect the Iow quality, unavailability, and underutilization of Burkina's health services. The second Five Year Development Plan calls for an ambitious program of construction and upgrading of health facilities during the 1991-95 period. To reach the rural and urban poor, improvements in, and ezpansion of, basie health facilities receive highest priority. Budgetary constraints preclude fmancing the basie health program without donor assistance. System-wide reforms such as those proposed by this project involving the organizational structure of the health delivery system, redeployment of Staff, basie financing mechanisms, and the reform of the pharmaceutical system go beyond most donors' scope of intervention because of the extensive analytical work and policy dialogue required to get these reforms accepted and ensure that they are implemented. Health problems caused by micronutrient deficiencies such as blindness, cretinism, anemia, etc., could be corrected through relatively low-cost remedia! action. The country's tight financial situation would make it difficult to continue the activities necessary for surveillance of the areas cleared from onchocerciasis and to prevent recrudescence of the disease. Integrating trypanosomiasis control and dracunculiasis eradication activities with control maintenance of onchocerciasis ("Devolution Plan") would be a cost-effective approach to eliminating these endemic diseases and