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By teversing present trends of Iow utiiization of primary health care centers, the project will help pfovide affordabie basie health services of adeąuate ąuality to some of the poorest segments of the Burkinabe population. The health component would directW benefit about three million peoplc (30% of Buririna Faso*8 population) who will gain access to ąuality health care. Second, policy reforms in the areas of low-cost essential drugs, decentralization and cost recovery will-together with training of health and supervisory 8taff~improve the ąuality of health care deltowy nationwide. The project'8 emphasis on substituting expensive brand-name diugs with Iow cost generic drugs will both benefit patients by reducing their financial burden during sickness episodes, and make possible the implementation of a cost recovery system, which is reąuired for morę sustainable and efficiently functioning health senrices at all levels of the system. Third, provision of additional surgical facilities at the district level and training of generał practitioners in surgery should contribute to morę immediate medical/surgical interventions in emergency cases, and at the same time, reduce clogging at Hospitals. Fourth, the nutrition component would help reduce the high rates of anemia among expectant mothers which are a major cause of Iow birthweights. Furthermore, dispensing of iodine and yitamin A should greatly reduce the incidence of goiter and mental retardation, and blindness resulting from vitamin A deficiency. Fifth, by sustaining the achievements of the Onchocerciasis Control Programme (OCP), the endemic disease control component would ensure that about 17% of Burkina'8 agricultural lands—with fertile soils—would remain available for the production of foodstuffs and other important agricultural commodities. It would also prevent recurrence of onchocerciasis and major outbreaks of human trypanosomiasis as well as eradicate dracunculiasis which affects about 34% of the viilages in Buririna—the highest prevalence of any Sahelian country.

The project faces three major risks. The first risk is that the expected procurement of essential generic drugs and their distribution may be slow to materialize. To address the procurement risk, the Ooverament has approved the reąuired legislation and, with Bank assistance, established CAMEO, an organizaiion designed to undertake the importaticn and distribution of essential generic drugs. The Govemment has provided assurances that the CAMEG will meet performance criteria agreed upon by IDA and the Govemment Furthermore, supenrision during the first half of the project (through 1997) will focus heavily upon satisfactory implementation of training and drag 8tock/financial management arrangements in the health facilities so as to ensure adeąuate cost-recovery and hence the continuous availability of essential drugs. The second risk is that resistance to redeployment of doctors and other medical Staff into rural areas will prevent adeąuate staffing of district health centers. To address this risk, the Government has, prior to negotiations, developed aad begun to implement an action plan, acceptable to IDA, to ensure the reąuired redeployment and that the personnel concerned remain where posted and carry out their assigned responsibilities. The third risk is the time reąuired for regaining confidence of the population in the health care centers, especially in light of the proposed cost recovery scheme coupled with the recent devaluation of the CFA franc. To mitigate this risk, a moderate level of cost recovery would be gradually implemented so as not to result in a disincentive for people to utilize the primary level of the health care system. Initially, essential, generic drugs will be provided free of charge in a largo number of rural areas pending the establishment of workable cost-recovery mechanisms. Success in ensuring the wide availability of Iow cost generic drugs via the CAMEG will be critical in addressing this risk.