Document of The World Bank Report No: ICR 00001276 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-71560) ON A LOAN IN THE AMOUNT OF USD 4.045 MILLION TO THE ST. KITTS AND NEVIS FOR AN HIV/AIDS PREVENTION AND CONTROL PROJECT (SECOND PHASE OF THE MULTI-COUNTRY HIV/AIDS PREVENTION AND CONTROL APL FOR THE CARIBBEAN) December 22, 2009 Caribbean Country Management Unit Human Development Sector Management Unit Latin America and the Caribbean Regional Office CURRENCY EQUIVALENTS (Exchange Rate Effective: December 22, 2009) Currency Unit = OECD Dollar (OECDS$) OECDS$2.70 = US$ 1.0 FISCAL YEAR July 1 ­ June 30 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency MTR Mid-Term Review Syndrome NAC National AIDS Council ARV Anti-retroviral NACHA National Advisory Council on BCC Behavior Change HIV/AIDS Communication NAS National AIDS Secretariat BSS Behavioral Surveillance Survey NGO Non-Governmental Organization CAREC Caribbean Epidemiology Center OECS Organization of Eastern CAS Country Assistance Strategy Caribbean States CBO Community Based Organization PAD Project Appraisal Document CHRC Caribbean Health and Research PAHO Pan American Health Council Organization CSO Civil Society Organization PCU Project Coordinating Unit FM Financial Management PDO Project Development Objective GDP Gross Domestic Product PLHIV People Living with HIV GFATM Global Fund to Fight AIDS, TB, PLWHA People Living with HIV/AIDS and Malaria (acronym no longer used) HAART Highly Active Antiretroviral PMTCT Prevention of Mother-to-Child Treatment Transmission HIV Human Immunodeficiency Virus QAG Quality Assurance Group ICR Implementation Completion QEA Quality Entry Assessment Report QER Quality Enhancement Review IEC Information Education and ST. KITTS St. Kitts and Nevis Communication AND ISR Implementation Supervision NEVIS Report SPNR Strategic Plan for National KAPB Knowledge, Attitude, Response Perceptions and Beliefs SW Sex Worker MAP Multi-country AIDS Program TB Tuberculosis MARP Most at Risk Population TTL Task Team Leader M&E Monitoring and Evaluation UNDP United Nations Development MOH Ministry of Health Program MSM Men who have sex with other VCT Voluntary Counseling and Men Testing Vice President: Pamela Cox Country Director: Yvonne Tsikata Sector Manager: Keith Hansen Project Team Leader: Shiyan Chao ICR Author N'Della N'Jie ST. KITTS AND NEVIS HIV/AIDS PREVENTION AND CONTROL PROJECT (Second phase of the Multi-Country HIV/AIDS Prevention and Control APL for the Caribbean) CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design .......................................................................... 1 2. Key Factors Affecting Implementation and Outcomes .......................................................................... 7 3 Assessment of Outcomes ..................................................................................................................... 12 4. Assessment of Risk to Development Outcome .................................................................................... 20 5. Assessment of Bank and Borrower Performance ................................................................................. 21 6 Lessons Learned................................................................................................................................... 23 Annex 1. Project Costs and Financing .......................................................................................................... 24 Annex 2. Outputs by Component.................................................................................................................. 25 Annex 3. Economic and Financial Analysis ................................................................................................. 29 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............................................. 29 Annex 5. Beneficiary Survey Results ........................................................................................................... 30 Annex 6. Stakeholder Workshop Report and Results ................................................................................... 30 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR...................................................... 31 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders........................................................ 42 Annex 9. List of Supporting Documents ...................................................................................................... 42 Annex 10. MAP ............................................................................................................................................ 43 Tables Table 1: Top 15 HIV/AIDS Prevalence Countries (end 2003) ....................................................................... 2 Table 2: Indicators before and after restructuring........................................................................................... 3 Table 3: Intermediate outcome indicators before and after restructuring ....................................................... 4 Table 4: Results framework for indicators that respond to PDO 1 ............................................................... 14 Table 5: Results framework for indicators that respond to PDO 2 ............................................................... 15 Table 6: Results framework for indicators that respond to PDO 3 ............................................................... 17 Table 7: PDOs weighted rating..................................................................................................................... 18 Table 8: Cost-effectiveness of various interventions types (US Dollars) ..................................................... 18 A. Basic Information KN: HIV/AIDS Country: St. Kitts and Nevis Project Name: PREVENTION AND CONTROL PROJECT Project ID: P076798 L/C/TF Number(s): IBRD-71560 ICR Date: 12/22/2009 ICR Type: Core ICR ST. KITTS AND Lending Instrument: APL Borrower: NEVIS Original Total USD 0.0M Disbursed Amount: USD 3.4M Commitment: Revised Amount: USD 4.0M Environmental Category: B Implementing Agencies: Ministry of Health and the Environment Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 03/26/2002 Effectiveness: 05/29/2003 05/29/2003 Appraisal: 12/11/2002 Restructuring(s): 05/09/2007 Approval: 01/22/2003 Mid-term Review: 05/30/2005 03/24/2006 Closing: 06/30/2009 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Quality at Entry: Government: Moderately Satisfactory Unsatisfactory Implementing Quality of Supervision: Moderately Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Moderately Overall Borrower Moderately Satisfactory Performance: Unsatisfactory Performance: i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry No None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 23 23 Health 72 72 Law and justice 5 5 Theme Code (as % of total Bank financing) Child health 13 13 HIV/AIDS 25 25 Health system performance 13 13 Personal and property rights 24 24 Population and reproductive health 25 25 E. Bank Staff Positions At ICR At Approval Vice President: Pamela Cox David de Ferranti Country Director: Yvonne M. Tsikata Orsalia Kalantzopoulos Sector Manager: Keith E. Hansen Charles C. Griffin Project Team Leader: Shiyan Chao Patricio V. Marquez ICR Team Leader: Shiyan Chao ICR Primary Author: Ndella Njie F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The project has three main objectives coherent with the country's Strategic Plan for the National Response to HIV/AIDS (SPNR): ii a) scaling up prevention programs targeting high-risk groups as well as the general population b) strengthening treatment, care and support for persons living with HIV/AIDS (PLWA) c) strengthening of the institutional capacity to respond to the epidemic Revised Project Development Objectives (as approved by original approving authority) The objective of the Project is to assist the Borrower to control the spread of HIV/AIDS and to mitigate its impact through: (a) scaling up prevention services for high risk and vulnerable groups and for the Borrower's general population; (b) expanding and strengthening treatment, care and support for people living with HIV/AIDS (PLWHA) and mitigating the impact to those infected and affected by the epidemic; and (c) strengthening the institutional capacity of the MOH, other government agencies and civil society organizations to ensure an effective multi-sectoral response to the epidemic (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Number of most-at-risk population members reached by HIV/STI prevention Indicator 1 : interventions in the last 12 months ( female sex workers; men with men sex) Total 490: Total - 1,564: Value 340 - MSM; 550 (2007); MSM - 1,051; quantitative or 100 - CSW; 600 (2008) CSW - 439; Qualitative) 50 - PLWHA unstated - 74 Date achieved 12/31/2006 05/09/2007 09/30/2009 Target exceeded: The Caribbean HIV/AIDS Alliance, an international Comments organization that works with high risk and vulnerable groups in AIDS (incl. % prevention was able to reach more than twice the number of MARPs identified at achievement) baseline. Indicator 2 : Number of condoms distributed in the last 12 months. 130,000 Value Total 111,187: Total 158,080 (2007) quantitative or 108,610 - St. Kitts 146,782 - St. Kitts 150,000 Qualitative) 2,577 - Nevis 11,298 - Nevis (2008) Date achieved 12/31/2006 05/09/2007 12/31/2008 Comments Target exceeded, but studies on condom use had not been done. It is anticipated (incl. % that a 6-country OECS KAPB survey will be conducted in 2010 to provide this achievement) information. Condom vending machines were procured and installed (45) Indicator 3 : Number of Individuals counseled and tested in the last 12 months. Value Total - 637 Total 1,558 700 (2007) quantitative or 589 - St Kitts 1,449 - St. Kitts 770 (2008) Qualitative) 48 - Nevis 109 - Nevis Date achieved 12/31/2006 05/09/2007 06/30/2009 Comments Target exceeded -more than twice the number of people reached, in comparison (incl. % to those targeted in 2008. iii achievement) Indicator 4 : Number of pregnant women reached with PMTCT services in the last 12 months. Value Total: 435 440 400 (2007) quantitative or 264 - St. Kitts 344 - St Kitts 450 (2008) Qualitative) 171 - Nevis 96 - Nevis Date achieved 12/31/2006 05/09/2007 12/31/2008 Comments Target not reached by a small margin (2%) - only public sector data was (incl. % collected. Some women prefer to deliver outside the island or use private achievement) physicians. These data are not captured. Number of HIV-positive pregnant women receiving a complete course of Indicator 5 : antiretroviral therapy to reduce the risk of mother-child-transmission Value 2 (2007) quantitative or 0 N/A 2 (2008) Qualitative) Date achieved 12/31/2006 05/09/2007 06/30/2009 Comments Indicator has been changed to an outcome indicator, see intermediate outcome (incl. % indicator, indicator 2. Note: the indicator was changed after project achievement) restructuring. Indicator 6 : Cumulative number of PLWHA receiving antiretrovial therapy. Value Total: 36 33 (2007) quantitative or Total: 23 23 - St. Kitts 43 (2008) Qualitative) 13 - Nevis Date achieved 12/31/2006 05/09/2007 09/30/2009 Comments Target not reached -the data provided is from public health facilities, as data (incl. % from the private sector was not collected. The total number of PLHIVs that need achievement) treatment, in comparison to those that seek treatment is unknown. Number of PLWHA reached through home based or community based activities Indicator 7 : or support groups. Value Total: 5 10 (2007) quantitative or 1 - St. Kitts Total: 15 20 (2008) Qualitative) 4 - Nevis Date achieved 12/31/2006 05/09/2007 05/31/2009 Target not reached. The service provided is through an integrated home based Comments care approach, through the Departments of Social and Community (incl. % Development. Persons are not required to disclose HIV status therefore data achievement) recorded may be underestimated. Number of completed biologic, behavioural and research studies (by type of Indicator 8 : population studied and type of study). 1 (2007) Value KAPB to be quantitative or 1 BSS 1 completed Qualitative) 1 (2008) Date achieved 12/31/2006 05/09/2007 06/30/2009 Comments (incl. % Target achieved - the next major study is a KAPB survey, anticipated in 2010 achievement) Number of a) Line Ministries and b) Implementing organizations e.g. Indicator 9 : NGOs/CSOs that submitted programme monitoring forms to be National AIDS iv coordinating authority in the last 12 months. 4 Line Ministries & 2 NGO/CSO Value 4 Line Ministry 0 - Line Ministries (2007) quantitative or 6 NGO/CSO 0 - NGOs CSOs 4 Line Qualitative) 3 FBO Ministries & 7 NGOs/CSOs (2008) Date achieved 12/31/2006 05/09/2007 09/30/2009 Comments The target was achieved -additional NGOs/CSOs applied for HIV grants. The (incl. % CSO-designated coordinator provided guidance in completing monitoring forms. achievement) Amount and percentage of government funding for each type of organization by Indicator 10 : HIV service delivery area (prevention, care/treatment, mitigation, systems strengthening and M&E) 2007/2008 (a) Prevention $253,000 EC; 17% HIV budget noted MOH total HIV budget; above. (b) $586,805 EC Care/treatment a)Prevention:$142,089 $954,000 EC; EC; 24% 63% HIV b)Care/treatment budget ; (c) $175,715 EC; 30% Advocacy & Value c)Advocacy and behavior quantitative or Behavior change N/A change; Qualitative) $101,036 EC;17% $54,000 EC; (d)Systems strength., EPI, 4% HIV Research, M&E: budget (d) $14,873;3% Systems e) Sustainable strenght.;surve management resp. illance,EPI,Re $153,092; 26% asearh & M&E $153,092 (26%) HIV budget. Date achieved 12/31/2006 05/09/2007 06/30/2009 Comments This indicator was not collected in previous ISRs and was dropped after project (incl. % restructuring. achievement) Number of organizations funded by type of organization (include types of civil Indicator 11 : society organizations, ministries, private sector and other) Total: 15 (4 Value Total: 23 (5 line line ministries; quantitative or 0 ministries; 13 11 CBOs) Qualitative) CSOs, 5 FBO) (2007) v Total: 10 (4 line ministries.; 6 CBOs) (2008) Date achieved 12/31/2006 05/09/2007 09/30/2009 Comments Target exceeded. The CSO/line ministry focal point in the project team was able (incl. % to mobilize and build capacities of civil society organizations and non-health achievement) line ministries so they could access project funds. Indicator 12 : Country couterpart contribution for HIV/AIDS in US$ (million) 2007: Government matches bank's Value exp. 2.1 $2,813,166 EC or quantitative or $173,351 EC million $1,049,688 US Qualitative) budgets for life of project 2008: not available Date achieved 12/31/2006 05/09/2007 06/30/2007 Comments (incl. % Target not reached achievement) Indicator 13 : Number of Line Ministries implementing work plans for HIV/AIDS 3 (Gender, Value education & quantitative or 0 Labour) Total : 5 Qualitative) (2007) 5(2008) Date achieved 12/31/2006 05/09/2007 05/31/2009 Comments Target was exceeded- All five line ministries in country were reached. This (incl. % indicator differs from indicator 9 because this specific indicator looks at achievement) including HIV activities into ministerial work plans. Indicator 14 : Number of persons trained Value 35 (2007) quantitative or Total: 32 32 30 (2008) Qualitative) Date achieved 12/31/2006 05/09/2007 06/30/2009 Comments This indicator was not collected in previous ISRs and was dropped after project (incl. % restructuring. achievement) vi (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Indicator 1 : % of HIV+ newborns from HIV+ mothers Value (quantitative Not available 50% reduction N/A or Qualitative) Date achieved 02/28/2003 06/30/2009 06/30/2009 Achievements unable to be determined - no baseline and too small ppln; however Comments retrospective surveys to compare # of pregnant women tested vs. #of live (incl. % births/year could be done over time. Currently - pub. stats show no new borns to achievement) HIV+ mothers. Percentage of HIV positive pregnant women receiving a complete course of Indicator 2 : ARV prophylaxis to reduce the risk of mother to child transmission Value (quantitative 100% N/A or Qualitative) Date achieved 06/30/2009 05/30/2009 Comments Achievements unable to be determined - no baseline too small ppln size; (incl. % however retrospective surveys to compare # of pregnant women tested vs. # of achievement) live births/year can eb done over time G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 06/17/2003 Satisfactory Satisfactory 0.04 2 10/08/2003 Satisfactory Satisfactory 0.24 3 06/03/2004 Satisfactory Satisfactory 0.26 4 12/09/2004 Unsatisfactory Unsatisfactory 0.26 5 03/26/2005 Unsatisfactory Unsatisfactory 0.26 6 07/01/2005 Unsatisfactory Unsatisfactory 0.26 7 12/28/2005 Unsatisfactory Unsatisfactory 0.26 8 10/17/2006 Unsatisfactory Unsatisfactory 0.26 Moderately Moderately 9 12/21/2006 0.33 Unsatisfactory Unsatisfactory 10 06/14/2007 Moderately Satisfactory Moderately Satisfactory 0.98 11 10/30/2007 Moderately Satisfactory Satisfactory 1.67 12 01/09/2008 Moderately Satisfactory Satisfactory 1.81 13 06/07/2008 Moderately Satisfactory Satisfactory 2.12 14 07/22/2008 Moderately Satisfactory Satisfactory 2.25 15 12/17/2008 Moderately Satisfactory Satisfactory 2.59 16 06/24/2009 Moderately Satisfactory Satisfactory 3.22 vii H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions 05/09/2007 Y MU MU 0.45 If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Unsatisfactory Against Formally Revised PDO/Targets Moderately Satisfactory Overall (weighted) rating Moderately Satisfactory I. Disbursement Profile viii 1. Project Context, Development Objectives and Design 1.1 Context as Appraisal Country background. St. Kitts and Nevis is a federation of two islands with an estimated population of 49,000 at the end of 2006. It is a middle-income country with an average life expectancy of 72.9 years. The country's economy is based on tourism with a declining share of agriculture. Unemployment is the lowest among OECS member countries and the UNDP Human Development Index ranks St. Kitts and Nevis 47th among 174 countries. Annual real GDP growth during the 1990's averaged about 4 percent, compared to a growth rate of 6.2 percent during the 1980's. Economic growth picked up again in 2004, with a real GDP growth rate of 6.4 percent, followed by another year of strong growth in 2005, when real GDP grew by 4.9 percent. The affairs of both St. Kitts and Nevis are addressed by the federal government. Sector background. The first HIV/AIDS case was reported in 1984 and by 2008 the country had a cumulative total of 301 cases. There were 28 deaths due to AIDS during the period 1984-1993 and 36 deaths were reported for the period 1994-2000. At the time of project preparation, epidemiologists considered the Caribbean (including St. Kitts and Nevis) at risk of seeing the HIV epidemic become "generalized" by spreading from groups at high risk through the wider population. Persons at high risk include sex workers, women who engage in transactional sex with multiple partners, groups of people with multiple concurrent sexual partners, and men who have sex with men (MSM). MSM accounted for about 3% of AIDS cases in 2001, which is considered to be seriously underreported, according to UNAIDS. Regulations enforce the criminalization of homosexual sex and sex work, and homosexuality is heavily stigmatized. This has impeded access to health education, prevention and HIV treatment, as well as information about behavior and health status of persons in these groups. The government responded to the epidemic in the mid-eighties by setting up a national AIDS program within the Ministry of Health, which depended on external assistance. They initiated testing, surveillance and research, protect blood supplies, and communication interventions. A national AIDS coordination unit was set-up (with a staff of two) in the Ministry of Health in the mid-nineties, when the AIDS situation worsened. Country assistance strategy and rational for Bank assistance. The AIDS epidemic claimed an estimated 36,000 lives in the Caribbean in 2004, making it the leading cause of death among young men aged 15-44 years in the region with the second-highest HIV prevalence second to Africa (2.3% in 2004), see Table 1. This translated to approximately 440,000 infected adults and children in 2004. There was a sense of urgency from the international community for the Bank to respond to the epidemic and to fund AIDS projects in the region. The OECS CAS (2001 and 2005) identified HIV/AIDS as one of its human development priorities for Bank lending. 1 Table 1: Top 15 HIV/AIDS Prevalence Countries (end 2003) Percent of population 15-49 years old with HIV/AIDS Africa Outside Africa Rank Country % of Rank Country % of Population Population 1 Swaziland 38.8 1 Haiti* 5.6 2 Botswana 37.3 2 Trinidad & Tobago* 3.2 3 Lesotho 28.9 3 Bahamas* 3.0 4 Zimbabwe 24.6 4 Cambodia 2.6 5 South Africa 21.5 5 Guyana* 2.5 6 Namibia 21.3 6 Belize* 2.4 7 Zambia 16.5 7 Honduras 1.8 8 Malawi 14.2 8 Dominican Republic* 1.7 9 Central African Rep. 13.5 9 Suriname* 1.7 10 Mozambique 12.2 10 Thailand 1.5 11 Tanzania 8.8 11 Barbados* 1.5 12 Gabon 8.1 12 Ukraine 1.4 13 Cote d'Ivoire 7.0 13 Myanmar 1.2 14 Cameroon 6.9 14 Jamaica* 1.2 15 Kenya 6.7 15 Guatemala 1.1 (*) Caribbean countries adopted from HIV/AIDS in the Caribbean Region: A Multi-Organization Review In 2000, the St. Kitts and Nevis government adopted the 2000 Caribbean Regional Strategic Plan of Action for HIV/AIDS, to which it contributed. It was within this framework that the MOH, together with stakeholders in-country, developed the first national strategic plan (2000-2005), which identified five priority intervention areas, which the World Bank HIV/AIDS program mirrored: (i) prevention, (ii) treatment, care and support, (iii) advocacy, (iv) surveillance, epidemiology and research, and (v) program coordination and management. 1.2 Original Project Development Objectives and Key Indicators According to the PAD (December 2002), the project aims to support selected activities of the St Kitts and Nevis Strategic Plan for the National Response to HIV/AIDS (SPNR) to assist government to control the spread of HIV/AIDS through three main objectives: (a) scaling up prevention programs targeting high-risk groups as well as the general population, (b) strengthening treatment, care and support for persons living with HIV/AIDS (PLWHA), and (c) strengthening St. Kitts & Nevis multi-sectoral institutional capacity to better respond to the epidemic. The ICR is assessing the revised PDOs as per the restructured document, see section 1.3. Indicators identified before and after restructuring, as stated in the PAD and the amended loan agreement are outlined in Section 1.3. 2 1.3 Revised PDO (as approved by original approving authority) and key indicators, and reasons/justification The St. Kitts and Nevis HIV/AIDS Project was approved on December 13, 2002 and became effective on May 29, 2003. A Mid Term Review (MTR) was conducted in March 2006, after which a decision to restructure the project was made due to slow project implementation and a fragmented results framework; see Section 2.2 for detailed information. The revised PDO as outlined in the Board approved restructured and amended loan agreement, (March 21, 2007) is as follows: (a) scaling up prevention services for high risk and vulnerable groups and for the general population; (b) expanding and strengthening treatment, care and support for PLWHAs and mitigating the impact to those infected and affected by the epidemic; and (c) strengthening the institutional capacity of MOH, other government agencies and civil society organizations to ensure an effective multi-sectoral response to the epidemic. The results framework for measuring achievements of the PDO were revised and aligned with project outputs - see Table 2 and Table 3. Table 2: PDO Indicators before and after Board approved restructuring Indicators No. Original indicators Revised Indicators 1 Legislation and regulatory reform No. of most-at-risk population members protecting PLWHAs human and civil rights reached by HIV/STI prevention instituted interventions in the last 12 months (female sex workers; men who have sex with men) 2 Positive anecdotal evidence and attitudinal No. of condoms distributed in the last 12 surveys related to PLWHAs and their months organizations 3 Acceptance of condom use, adolescent sex No. of individuals counseled and tested in education, VCT, MTCT and STIs clinics the last 12 months 4 % males and females 15+ years old using No. of pregnant women reached with condoms PMTCT services in the last 12 months 5 Average age of first sexual intercourse in No. of HIV-positive pregnant women males and females receiving a complete course of antiretroviral therapy to reduce the risk of mother-child-transmission [dropped in 2008 after project restructuring] 6 % males 15+ years old with more than one Cumulative number of PLWHA receiving sex partner last year antiretroviral therapy 7 % females 15+ years old with more than No. of PLWHA reached through home one sex partner last year based or community based activities or support groups 8 % of HIV/AIDS transmitted by blood No. of completed biologic, behavioral and transfusion in the federation research studies (by type of population studied and type of study) 3 Indicators No. Original indicators Revised Indicators 9 % voluntary testing and counseling No. of line ministries and implementing organizations e.g. NGOs/CSOs that submitted program monitoring forms to the National AIDS Coordinating authority in the last 12 months 10 % of HIV-positive newborns from HIV- Amount and percentage of government positive mothers funding for each type of organization by HIV service delivery area (prevention, care/treatment, mitigation, systems strengthening and M&E) [dropped in 2008 after project restructuring] 11 % of reported AIDS patients under ART No. of organizations funded by type of organization (include types of civil society organizations, ministries, private sector and other) [dropped in 2008 after project restructuring] 12 % opportunistic infections among Country counterpart contribution for PLWHAs HIV/AIDS in US$ (million) 13 Average time at work for HIV/AIDS No. of line ministries implementing work patient plans for HIV/AIDS 14 % of PLWHAs discriminated in public and No. of persons trained (according to type of work places, and among caregivers personnel and type of training) [dropped in 2008 after project restructuring] 15 Periodic `second generation' KAP survey results available for monitoring, evaluation and management performance 16 Available quarterly reports on tracking the course of the epidemic, detailed by `at risk' groups 17 Case-by-case information on PLWHAs for physicians and caregivers coded to preserve confidentiality Table 3: Intermediate outcome indicators before and after restructuring Intermediate outcome indicators No. Original indicator Revised indicators 1 No. of reported cases of positive HIV % of HIV-positive newborns from HIV- infection in testing programs positive mothers [added in 2008 after project restructuring] 2 % of HIV children born from HIV/AIDS % of HIV-positive pregnant women mothers receiving a complete course of ARV prophylaxis to reduce the risk of mother to child transmission [added in 2008 after project restructuring] 3 Deaths due to AIDS 4 Life expectancy of PLWHAs 4 Intermediate outcome indicators No. Original indicator Revised indicators 5 Satisfaction of HIV/AIDS patients and their families with home and community care available A year after the project was restructured, four process indicators were dropped (5, 10, 11, 14) and two outcome indicators were added (1 and 2). 1.4 Main Beneficiaries The project aimed to target the following beneficiary groups in the design and implementation of activities: (i) PLHIVs and their families, (ii) general community, (iii) high risk groups (e.g. SW, MSM, pregnant women, adolescents, young adults, military personnel, commercial drivers and tourism workers, and out of school youth), and (iv) line ministries, private and voluntary sectors, civil society organizations and local communities. 1.5 Original Components The project identified five priority components which are aligned with the St. Kitts and Nevis national strategic plan, 2000-2005. They are outlined in the PAD as follows: Component 1. Advocacy and behavior change (US$0.51 million, 11.2% of loan). This component would assist the government to create a favorable legal and policy environment that protects the rights of PLWHA (advocacy). It would also aim to maintain people's awareness of HIV/AIDS and prevention measures, promote behavior changes for safe sex practices and risk reduction, done through national and community campaigns (Information Education and Communication - IEC). Component 2. Prevention in high-risk groups and general population (US$1.13 million, 26.4% of loan). This component would finance activities to identify high-risk groups (SW, MSM, uniformed personnel, migrant workers, and hotel and tourism workers) and their informal networks, in order to target them with prevention and behavioral change interventions. The project would support: (i) IEC and awareness campaigns, (ii) strengthening VCT services, (iii) condom social marketing and distribution, (iv) PMTCT, (v) prevention and STI management, and (vi) improving the management of biomedical wastes. A strong emphasis will be laid on youths (both in and out of school). Component 3. Improving access to treatment, care and support for PLWHA (US$1.92 million, 43.1% of loan). The project would support capacity strengthening and upgrading current services available for providing treatment, care and support for PLWHA. This includes: (i) management of opportunistic infections and palliative care, (ii) introducing Highly Active Antiretroviral Treatment (HAART), (iii) strengthening health facilities and laboratory capacity including reconstruction of Pogson Health Facility / other health facilities and provision of lab equipment and reagents, (iv) pharmacy strengthening, and (v) home and community-based care for PLWHA. 5 Component 4. Surveillance, epidemiology and research (US$0.54 million, 13% of loan). The project would strengthen the disease surveillance system, through (i) the design and implementation of an integrated management information system for HIV/AIDS, to improve resource allocation and decision making and protect the confidentiality of medical records, (ii) the implementation of a second generation surveillance system, and (iii) the provision of training for the monitoring and evaluation of project activities and operational research. Component 5. Sustainable management response (US$0.30 million, 3.8% of loan). The project would support the creation and the initial operations of a "National Advisory Council on HIV/AIDS (NCHA)", whose mandate would be to provide policy guidance to the Prime Minister and his Cabinet, and oversee implementation and resources mobilization for HIV/AIDS. The project would provide resources to strengthen the institutional capacity and operations of the Project Coordinating Unit (PCU). 1.6 Revised Components. The five components were consolidated into three to simplify project execution during the project restructuring in 2007: Component 1. Scaling up HIV/AIDS response by civil society organizations, and line ministries (US$0.02 million). Support from the project will scale up ongoing activities in line with the Government's strategy of a multi-sectoral and multi-stakeholder response to the epidemic: IEC/BCC; sensitization and advocacy to address stigma and discrimination; distribution of condoms and care for PLWHA and orphans. Selected line ministries dealing with specialized population groups such as the Ministries of Education, Youth, Social and Community and Gender Affairs will be funded to provide services for both internal (own staff) and external clients. Component 2. Strengthening the health sector response to HIV/AIDS (US$3.04 million). This will support the health sector prevention and treatment services which include: (i) voluntary counseling and testing, (ii) distribution of condoms, (iii) strengthening of management of sexually transmitted diseases, (iv) strengthening laboratory services and blood safety, (v) prevention of mother-to-child transmission, (vi) opportunistic infections, and (vii) antiretroviral therapy and management of biomedical waste. Financing will cover civil works to upgrade health clinics which are critical for expansion of the services, training, consultant services, drugs and equipment. Component 3. Strengthening surveillance, monitoring and evaluation and institutional capacity for program management (US$0.77 million). This will support the newly established NACHA; the National AIDS Secretariat (NAS) within the Ministry of Health and the strengthening of the PCU in the Ministry of Finance, Sustainable Development, Information and Technology responsible for procurement and financial management. The component also supports the development of the national monitoring and evaluation framework with harmonized national HIV/AIDS indicators; epidemiological surveillance and development of the information platform to enhance the clinical management information system. Project funds will cover costs of staff, consultants, furniture, computer hardware and software. The project results framework will be separate but in line with the national monitoring and evaluation framework. 6 1.7 Other Significant Changes (in design, scope and scale, implementation arrangements and schedule, and funding allocations) Implementation arrangement and schedule. The original operations manual dated May 16, 2003 was revised in February 2007 to streamline and clarify roles and responsibilities of implementing agencies and institutions. Procurement processes for civil works were simplified, and procedures to provide grants to civil society organizations were documented. Financial management was simplified and staffing of the PCU was increased to accommodate project needs. Extension of the Project. The project closing date was extended by one year, from June 30, 2008 to June 30, 2009 to allow activities to be completed as project implementation was slow the first three years of the project, see section 2.2 (11.1% disbursement rate, as of May 2007). Global Fund. St. Kitts and Nevis is part of the GFATM grant to the OECS countries, (March 2005- February 2010) which provided funding for AIDS treatment, thus complementing the financing of the World Bank project. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Sufficiency of background analysis. St. Kitts and Nevis HIV/AIDS Project is part of the Bank's Multi-country HIV/AIDS Prevention and Control Adaptable Program Lending (MAP). A Bank study, `HIV/AIDS in the Caribbean: Issues and Options' served as the background analysis to prepare the MAP. The MAP for Africa was the Bank's first response to the epidemic - some of its elements were included in the St. Kitts and Nevis project design: (i) importance of high level government commitment and national leadership by establishing a coordinating body, i.e. NAS, (ii) building networks with NGOs and community groups to complement the work of public agencies, (iii) focus on treatment and care as a continuum, with advocacy and prevention, (iv) provide a focus on behavior change of most-at-risk groups as a key element of prevention and control, and (v) adopt implementation measures that are flexible and responsive to the epidemic as it evolves. Even though these elements were included in the project design, lessons from the Africa experience had not emerged then and therefore, it was difficult to determine what worked and what did not at the time. The background analysis did not critically examine the needs and country context of the federal government of St. Kitts and Nevis, including an adequate assessment of: (i) human resources and capacity (e.g. project staff, CSOs, NGOs, and line ministries) to efficiently respond to a multi-dimensional, complex HIV/AIDS project, (ii) CSO engagement (iii) institutional and implementation arrangements to carry out effective programming, (iv) twin island federation setting that operate under separate administrations and budgets, (v) absorptive capacity to spend financial resources to implement the HIV/AIDS project, and (vi) baseline data and/or proxies (evidence) to inform programming. 7 Assessment of project design. Project preparation was participatory, bringing in perspectives of various agencies (such as USAIDS, PAHO, CAREC, etc.) working in the sub-region and nationally. The project design addressed the main sector issues identified and discussed in the PAD ­ strengthening the health system and its surveillance system, epidemiological, behavioral and social risk factors for HIV/AIDS. The project design was in line with the Three Ones principle of ensuring that there is one coordinating body. Nevertheless, the project design was found to be overly ambitious and relatively complex for a country with limited human resource capacity in general, limited experience working with Bank rules and regulations, and new to the multi-sectoral response. Even though the project was fast-tracked, systems were not in place for an effective and efficient response. For example, civil society organizations that were in-country did not have the capacity to prepare proposals, manage and report on sub-projects in accordance with the project requirements. Plans to train them should have been instituted at the beginning of the project. Even though the project design was relevant and in line with the strategic priorities of the country, as outlined in the NSP 2000-2005, i.e. including all five component priority areas in the project was unrealistic given the limited labor force and capacity. The original indicators in the PAD were too many and too complex ­ the country did not have the health management information system infrastructure to collect data, monitor the project and respond to these indicators. The project design did not address operationally, how the two islands would work together given their administrative and financial set-up. Government/stakeholder commitment. The Prime Minister of St. Kitts and Nevis is recognized as a leader in the HIV/AIDS effort in the Eastern Caribbean. Political commitment came from the highest level and in 2005 a multi-agency review noted that government was spending its financial resources and that of donors on HIV/AIDS activities, signaling that AIDS was an important priority for the country. At the same time, government's level of commitment did not necessarily translate into political action at the operational level. Early on in the project, implementation suffered in the absence of key staff over an extended period of time. The first 18 months of the project experienced slow implementation and low disbursement of project funds (6.5% of the loan was disbursed by November 2004). Assessment of risks. The PAD identified and rated project risks, however some issues pertinent to the success of the project were overlooked. For example: (i) coordination of the HIV/AIDS response within and between St. Kitts and Nevis stakeholders, between the PCU and MOH, and the project implementers; (ii) institutional and implementation arrangements were not examined extensively, nor was the division of labor specified; (iii) human resource capacity to implement the project was not considered; and (iv) working within a twin island setting was overlooked. Project quality at entry. The project was complex and ambitious, given the capacity and human resource constraints of the country. Guidance provided by the Bank was not always in accordance with the country situation and the project staffs at the Ministry of Health were 8 not familiar with Bank rules and regulations, which should have been addressed at project onset. The operations manual did not adequately explain how the activities would be implemented and the institutional framework for implementation was set-up two years after the project became effective (in July 2005). Little attention was paid to the M&E of the project and CSO and non-health line ministry engagement was weak. The multi-sectoral response was new to the country, and integrating HIV/AIDS into sector plans was a challenge. Overall Quality at Entry. There was no Quality at Entry Assessment (QEA) by the Quality Assurance Group (QAG). This ICR rates the overall project quality and readiness as moderately unsatisfactory. 2.2 Implementation The loan was approved on January 22, 2003 and became effective on May 29, 2003. The project went through a Board approved restructuring in May 2007. Project implementation was extremely slow for the first three years of the project because: (i) institutional and implementation arrangements in the PAD and the initial operations manual were not clear, (ii) inadequate staffing and minimal human and institutional capacity, (iii) procurement and financial management procedures were not well understood by the project team, (iv) some procurement procedures did not fit into the context of a small island with limited suppliers, (v) challenges with procurement of civil works and information technology, led to cancelled tenders, (vi) low level of buy-in and engagement of civil society, and non-health line ministries, (vii) minimal country expertise and experience working with high risk and vulnerable groups, and (viii) high staff turnover within the Bank - four project managers over a six year project, each bringing in individual management styles and supervision teams. This high staff turnover created many implementation delays and affected the relationship between the Bank and the project team. The project was in danger of suspension and closure after twenty-four months of implementation. The turning point came after the mid-term review, when the project was restructured: · PDOs remained the same, but were restated more clearly; · Project components were simplified and changed from five to three; · A simple operations manual was developed, which focused on changing institutional arrangements and clarified roles and responsibilities of implementing agencies ­ allowing the simplification of grant applications from line ministries and civil society groups, as well as disbursements into the ministerial accounts; · Project indicators were changed to better align with project activities and country capacity; · Improved coordination among stakeholders and implementing agencies; · Increased staffing with hiring of a program assistant, lab technologist and task shifting of two existing staff to work part-time on M&E; · Joint programming and better understanding of technical issues and procedures resulted from the development of a stronger working relationship between the PCU within the Ministry of Sustainable Development and the Ministry of Health; 9 · Reduction in processing time of requests as a result of project staff capacity strengthening activities - procurement and fiduciary training on Bank rules and regulations, and; · Improved proposal writing and access to funds by civil society organizations and line ministries. Procurement. From the project onset, procurement was difficult, frustrating and a lengthy process for the project team who did not fully understand the project, Bank regulations and guidelines. The first procurement plan took over a year to develop. The operational manual did not provide guidelines on how the procurement team should work with civil society, and a system was not in place to provide funds to civil society. The Bank's procurement guidelines did not fit a small island scenario of procuring goods and services ­ few suppliers were available in-country, often leading to external bidding, which was a cumbersome process and often caused delays. A simpler model of procuring civil works was agreed by the PCU and the Bank after the mid-term review. After project restructuring, procurement of goods and services occurred at a faster rate, which led to the delivery of 90% of goods at the closing of the project, with the exception of the autoclave system and the IT platform. Biomedical waste supplies and materials and some equipment for the IT platform were purchased during the project implementation. The refurbishment of two health facilities in Nevis, also did not take place ­ see MTR section. Financial Management. During the mid-term review, the mission team noted that the project team was operating on outdated policies related to the management of special accounts ­ it was recommended that the government negotiate an interest bearing account with their Bank. Payment Schedule 1 was simplified as a result of the mid-term review (increase in percentage of expenditures to be financed and elimination of disbursement conditions). By the closing of the project, the financial management system was in place and operating effectively, however monthly bank statements continued to be submitted late; as did the audit. MTR, QER, and Extension. The project restructuring included a one year project extension. Implementation challenges were identified and solutions were proposed as stated in Section 2.2. The project extension allowed the project to complete the majority of its activities, totaling $3,367,114.88, or 83% of loan proceeds. Some activities were not completed: (i) setting-up the IT platform; (ii) procuring an autoclave for medical waste disposal; (iii) strengthening the M&E system; and (iv) refurbishing two health centers in Nevis. Some reasons for not completing these activities, include: (i) technical advice on the IT platform from Bank consultants was varied, inconsistent, sophisticated and expensive for country needs and local technical capacity was lacking to determine country needs, (ii) delays in obtaining information to tender materials and supplies for the autoclave system resulted in government seeking alternative financing mechanisms, (iii) lack of consistency and continuity in the provision of M&E technical assistance by the Bank, other donors and bilateral agencies, and (iv) the cost to refurbish Nevis health facilities was significantly higher than budgeted. The government decided not to request a second project extension. Instead, it has indicated that it will use its own resources to finance activities not completed under the World Bank project. 10 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E design. The indicators in the PAD were numerous (5 DO indicators, 17 intermediate outcome indicators, and 3 process indicators) given the capacity constraints of the country. There was a heavy reliance on data collection through KAP surveys and epidemiological reports even though a second-generation surveillance system was not in place on the island and the country was not equipped to conduct KAP surveys ­ overall research capacity in St. Kitts and Nevis is limited. Baseline data was not available at the beginning of the project and proxy data was not used, therefore target setting was a challenge. During project restructuring, the six-country OECS Behavioral Surveillance Survey, 2005-06 and anecdotal evidence were used as the baseline, which resulted in a revised, refined and harmonized framework that responded to national and donor reporting requirements. The number of indicators was reduced to 12 and aligned with internationally accepted UNAIDS UNGASS indicators. M&E implementation. Several consultants from various agencies (CAREC, CHRC, PAHO, UNAIDS, World Bank) provided M&E technical support to the project at various times during project implementation ­ an M&E system is under development. Data collection was difficult, particularly the consolidation of data from St. Kitts and Nevis. The project team had numerous indicators to report on, multiple partners to report to and limited tools to gather, analyze and synthesize the data. As a result, reporting requirements were not fulfilled. Specific measures were taken to build national M&E capacity in 2006. An MOU was signed between MOH and CHRC to provide M&E basic training to three staff (two from St. Kitts and one from Nevis) over a four month period (completed in 2007), who have been identified to carry out M&E duties part-time. Most of the indicators in the revised, harmonized results framework were process indicators; only two outcome indicators were identified. The MOH recognizes the M&E system requires additional strengthening and is working on making the necessary improvements. After project restructuring, the project team prepared progress reports, which were shared with World Bank supervision missions. Beyond reporting to the World Bank and other donor agencies, regular, systematic reporting to cabinet does not occur. The only major study related to HIV/AIDS that occurred in ST. KITTS AND NEVIS was the OECS BSS survey in 2005, which was used to provide baseline for the project. The project team will be involved in a KAPB survey in 2010 that will collect behavioral data to indicate outcomes and possible impacts of the HIV/AIDS response, vis-à-vis, provide the data to substantiate the success of the Bank project. Data collection, which will also inform this ICR (UNGASS reporting) has started, and will be completed in March 2010. M&E utilization. M&E data was not always used by decision-makers to inform policy. Data were reported to donor agencies and shared with limited stakeholders and implementers. 11 2.4 Safeguard and Fiduciary Compliance Environment. An environment assessment rated the project as B at time of appraisal. In 2006, a biomedical waste management system was set-up by a consultant who will return to the island to train staff on the system. A medical waste autoclave system was recommended for biomedical waste management, but not procured before the closing of the project. The project was in compliance with Bank safeguard policies. Financial Management (FM). Overall, FM quality improved significantly during implementation and the St. Kitts and Nevis project team complied with Bank fiduciary requirements. At the onset, FM was weak, with technical and fiduciary teams struggling to cope with their responsibilities. The situation changed after the mid-term review when the government of St. Kitts and Nevis took a more active role in monitoring project activities and hired a project accountant. A payment problem was encountered with the contractors of the Pogson Health Facility; however, it was resolved by project closing. External audit reports were received late each fiscal year, due to delays from the auditing firm. Procurement. All procurement was handled by the PCU. At mid-term, an ex-post review of procurement activities was done ­ the project team had complied with all Bank guidelines in all cases. 2.5 Post-completion Operation/Next Phase The HIV/AIDS project was a catalyst for change in St. Kitts and Nevis. It legitimized AIDS in-country, put HIV/AIDS on government's agenda and paved the way for other donors (e.g. leveraging funds from the Global Fund through the OECS regional project) to invest in AIDS. The country does not envision a follow-up HIV/AIDS project through the Bank; however, government has absorbed project staff to ensure program sustainability. In addition, government gave an indication that it would support the national HIV/AIDS response, including free provision of ART. The government has expressed interest in developing a health sector project focusing on non-communicable diseases following country elections in 2010. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation The objectives, design and implementation of the project are highly relevant and consistent with the country's current development priorities and with current Bank country and sectoral assistance strategies and corporate goals as expressed in the Poverty Reduction Strategy Papers, CASs, and Sector Strategy Paper. It is now known that the HIV epidemics in the Caribbean (including St. Kitts and Nevis) are complex and possibly unique, exhibiting neither the highly concentrated pattern of most countries nor the widely generalized pattern of Eastern and Southern Africa. This makes programming especially difficult, and puts a premium on employing heterogeneous prevention methods, which the project did. The 12 project objectives and project activities are also in line with country priorities as outlined in the previous (2000-2005) and recently completed National Strategic Plan (2009-2013) and the regional Caribbean HIV/AIDS response. However, more priority should have been given to strengthening the surveillance system to develop the needed data. 3.2 Achievement of Project Development Objectives St. Kitts and Nevis is a small island with a population of approximately 49,000 in 2006. Provision of health services and data collection capacity is limited ­ a population-based survey has not been carried out in St. Kitts and Nevis, nor have there been any other studies or assessment done to indicate the success of the national HIV/AIDS response. Overall, the major achievements of the project were (i) an IEC campaign that reached the general population, (ii) the reconstruction of health facilities and procurement of equipment and drugs has benefitted the entire population, and not only those living with HIV, and (iii) Bank-funded investments in building human capacity are being used now to implement other donor-led projects; and since the project closed, all project staff have been absorbed into the government structure and are working within the Ministries of Health and Sustainable Development. Some of the project targets were achieved, but there is limited quantitative data to substantiate whether the project has achieved its development objectives. As is typical of HIV projects in advanced epidemics, most indicators in the results framework are internationally recognized process indicators that do not measure DO results. The two outcome indicators in the results framework have no baseline data, but the country will be conducting its KAPB study in 2010 to determine changes in behavior. To assess project achievements, the ICR team also collected as much qualitative evidence and data as possible on physical changes before and after the Bank project. Before project restructuring: Before project restructuring, very few project activities were completed to meet the original PDOs, (11.6% disbursed before project restructuring) therefore, the PDOs are rated unsatisfactory. Under each PDO, the following achievements are noted: (a) Scaling up prevention programs targeting high-risk groups as well as the general population: (i) Eight sub-project by CSOs were undertaken (ii) VCT provided to pregnant women and their partners (iii) Purchased condom vending machines (b) Strengthening treatment, care and support for persons living with HIV/AIDS (PLHIV): (i) Refurbishment of three health facilities in 2005/6 (ii) Purchased laboratory equipment 13 (c) Strengthening St. Kitts/Nevis multi-sectoral institutional capacity to better respond to the epidemic: (i) Clinical Care Coordinator was hired (ii) Technical assistance provided for developing a biomedical waste management system (iii) Set-up and establish the national response under the auspices of NACHA and financed chair of NACHA (iv) Recruited project accountant and M&E consultant After project restructuring: After project restructuring, numerous activities were completed by the project team - achievements are noted below. Note ­ PDO ratings are based on achievements per the results framework and completion of activities related to the PDOs. PDO 1: Scaling up prevention services for high risk and vulnerable groups and for the general population. There is little evidence to indicate the success of the World Bank project in scaling-up prevention services for high risk groups because stigma and other barriers constrained the project team from doing much work that directly targeted MARPs. The IEC/BCC campaigns conducted during the life of the project have not been evaluated and therefore, the extent of its success is unknown. However, many of the implementers interviewed indicated that more people and communities were aware of HIV/AIDS today than before the project started. It is also likely that by legitimizing AIDS as a subject for public discussion, the project helped create the space for non-governmental groups (especially the Caribbean HIV/AIDS Alliance) to work directly with MARPs. It is anticipated that the upcoming KAPB study (2010) will provide data on the outcomes of the IEC/BCC campaigns. The PDO rating is based on the achievement of two process indicators and several key activities conducted under Component 1. See Table 4 for additional information. This PDO is rated moderately satisfactory. Table 4: Results framework for indicators that respond to PDO 1 1 Indicators Baseline Target Achieve Comments No. of most-at-risk 490 600 1,564 Target exceeded ­ twice the amount of population members people targeted was reached. In an reached by HIV/STI attempt to mitigate stigma and prevention discrimination, activities were interventions in the conducted by the Caribbean HIV/AIDS last 12 months Alliance, an international organization (female sex workers; in-country that works with MARPs men who have sex delivering prevention services. They with men) were not directly supported by the project. No. of condoms 111,187 150,000 158,080 Target exceeded. The OECS/BSS distributed in the last (2005) indicated that consistent condom 1 In the ICR data sheet, the information on the original target values is not provided due to the project restructuring and the formal revision of the original indicators 14 Indicators Baseline Target Achieve Comments 12 months use with SW among men between 25- 49 years was 57%. Eighty-five percent of men between 25-49 years used a condom at last sexual encounter with a SW. (Note ­ data should be interpreted with caution as denominators were small). Key prevention activities conducted by the project team focused on targeting the general population and included: (i) Stop the Cycle IEC/BCC campaign in the form of advertisements, bill boards, banners, and posters were visible throughout the island. Many other awareness campaigns were also conducted ­ see Annex 2 for a comprehensive list, (ii) distribution of advocacy/educational materials translated into Spanish to fit the needs of migrant populations, (iii) Fifteen awareness campaigns/projects were conducted by NGOs and line Ministries as part of their contribution to the national HIV/AIDS response, which totaled 1.6% of project expenditure ­ very few NGOs exist in St. Kitts and Nevis. Before the World Bank project, none of the line ministries were involved in the response to the HIV/AIDS epidemic and HIV/AIDS was rarely a topic of discussion. By the end of the project, public awareness on HIV/AIDS had increased and all line ministries had successfully identified and conducted prevention activities within their ministries. See Annex 2 for a comprehensive listing of all outputs generated under this PDO. PDO 2: Expanding and strengthening treatment, care and support for People Living With HIV/AIDS (PLHIV) and mitigating the impact to those infected and affected by the epidemic. The two outcome indicators in the project did not have a baseline, making it difficult to determine whether the targets have been reached. Three out of four process indicator targets under Component 2 have not been reached, however other major accomplishments are noted that substantiate the achievements of this PDO, see Table 5. This PDO is rated moderately satisfactory. Table 5: Results framework for indicators that respond to PDO 2 Indicators Baseline Target Achieve Comments No. of individuals 637 770 1,558 Target exceeded counseled and tested in the last 12 months No. of pregnant 435 450 440 Target not reached. Approximately 62% women reached of pregnant women are reached with with PMTCT PMTCT services. Those that receive care services in the last from private physicians or seek care 12 months abroad have not been captured. Cumulative 33 43 36 Target not reached. The reported data is number of PLHIV from public health facilities. Data from receiving the private sector is not collected. The antiretroviral total number of PLHIVs that need therapy treatment, in comparison to those that 15 Indicators Baseline Target Achieve Comments seek treatment is unknown. No. of PLHIV 5 20 15 Target not reached. The service provided reached through is through an integrated home based care home based or approach, through the Departments of community based Social and Community Development. activities or Persons are not required to disclose HIV support groups status therefore data recorded may be underestimated. % of HIV-positive N/A 50% N/A Data not available. Statistical modeling newborns from reduction has not been done on the island due to the HIV-positive small size of the country; however mothers retrospective surveys to compare number of pregnant women tested versus number of life births per year could be done over time. % of HIV-positive N/A 100% N/A Data not available. Statistical modeling pregnant women has not been done on the island due to the receiving a small size of the country; however complete course of retrospective surveys to compare number ARV prophylaxis of pregnant women tested versus number to reduce the risk of life births per year could be done over of mother to child time. transmission Targets were not reached as a result of: (i) stigma forces many positive patients to seek health care services outside the public sector ­ either from private physicians on the island, or in neighboring countries, (ii) nutritional and social support is demand driven, however issues of stigma and discrimination may be another reason why PLHIVs do not actively seek support when needed, even though it is readily available. Greater emphasis should have been made by the project team to (i) collect data from private physicians, who provide care to the majority of HIV/AIDS patients and (ii) expand community based coverage of PLHIVs. Stigma remains a major problem in St. Kitts and Nevis. Significant achievements under this objective include: (i) reconstruction of Pogson Health Facility that provides comprehensive health care services to residents of several rural communities ­ coverage is approximately 10,000 people; (ii) procure and distribute equipment to strengthen laboratory and pharmaceutical services, which is not solely limited to HIV/AIDS; (iii) project funds purchased second line drugs and provided them free of charge, while first line drugs were provided through the Global Fund grant and the Brazilian Government, free of charge, (iv) 45 condom vending machines were installed, and (v) significant capacity building for the provision of PMTCT and VCT services (21 sites) to approximately 1,998 beneficiaries. Planned activities that did not occur: (i) procurement of a medical waste autoclave system and (ii) the refurbishment of two health facilities in Nevis, see Section 2.2-2.5 for more information. 16 PDO 3: Strengthening the institutional capacity of the MOH, other government agencies and civil society organizations to ensure an effective multi-sectoral response to the epidemic. Significant strides were achieved in capacity building of project staff, civil society and line ministries in areas of fiduciary management, procurement, grant preparation and use of funds and reporting. However, two major activities were not accomplished at the end of the project ­ setting-up and operationalizing the IT platform and M&E system. Furthermore, HIV related activities have not been mainstreamed into work plans and budgets. The PDO is rated moderately satisfactory. Component 3 of the restructured document responds to this PDO, and the indicators used to measure success are indicators 9, 11 and 13 (see Table 6 for more information). Other outputs stated in the project document are also highlighted. Note ­ none of these indicators had a baseline. Table 6: Results framework for indicators that respond to PDO 3 Indicators Baseline Target Achieve Comments No. of Line Ministries (LM) N/A 4 LMs 4 LMs The target was achieved ­ and implementing 7 NGOs 6 NGOs additional NGOs/CSOs organizations e.g. NGOs/CSOs 3 FBOs applied for HIV grants. The that submitted program CSO-designated coordinator monitoring forms to the provided guidance in National AIDS coordinating completing monitoring authority in the last 12 months forms. No. of organizations funded by N/A 4 LMs 5 LMs Target exceeded. The type of organization (include 6 CBOs 13 CSOs CSO/line ministry focal point types of civil society 5 FBOs in the project team was able organizations, ministries, to mobilize and build private sector and others) capacities of civil society organizations and non-health line ministries so that they could access project funds. No. of Line Ministries (LM) N/A 5 5 Target achieved implementing work plans for HIV/AIDS0 The MOH did not have prior experience working with CSOs and had to quickly learn how to manage their projects. The HIV/AIDS coordinator was also the CSO/line ministry focal point working closely with representatives from line ministries and civil society, which was important in jump-starting the multi-sectoral response (2007), which up to this point had not been implemented. The project funded five ministries and 18 civil society organizations to implement HIV/AIDS activities in communities. Approximately 20 project staff benefited from capacity building training and have been retained by the government after the closure of the project. More resources were allocated and spent on capacity building activities, based on the need for staffs to implement the project as outlined in the re-structured document. The IT platform was problematic because the country did not have the capacity to determine its needs and the Bank equally did not provide appropriate technical advice, see section 2.2 for more information. The M&E system also had many drawbacks related to 17 in-country capacity and the Bank's inability to provide consistent technical assistance - see section 2.2 for more information. Table 7: PDOs weighted rating No. Rating Against Against Revised Overall Comments Original PDOs PDOs 1. Rating Unsatisfactory Moderately Significant satisfactory improvement 2. Rating value 2 4 3. Weight (% 11.1% (US$0.45 83.2% (US$3.36 disbursed million/US$4.05 million/US$4.05 before/after million) million) PDO change) 4. Weighted 0.2 3.3 3.5 value (2x3) 5. Final Rating 4 Moderately (rounded) satisfactory 3.3 Efficiency As part of the horizontal APL for AIDS in the Caribbean, this project was covered by the economic analysis conducted for the program as a whole. Accordingly, the PAD did not include a separate economic analysis for St. Kitts and Nevis. Both the PAD and the ICR team did not conduct a rigorous economic analysis of the project. However, other indicators were reviewed; see Table 8 which shows interventions believed at the time to be cost- effective. Table 8: Cost-effectiveness of various interventions types (US Dollars) Cost Sex worker STI Voluntary ARV in IEC to ARV effectiveness interventions Management counseling pregnancy change Therapy and testing against vertical risky transmission behaviors Cost per HIV $8-12 $218 $249-346 $276 $1,324 N/A infection averted Cost per DALY $0.35-052 $9.45 $12.77-17.78 $10.51 $66.2 $720-2,355 saved Efficiency Ratio 0.6-1 48 9-11 44 N/A Dependence on Low Medium High High Low High adequate health care system Source: Ainsworth and Teokul, 2000 In the PAD, the first four activities in Table 8 accounted for 49% of planned project costs, however when compared to actual expenditures, no funds were spent on these activities according to the June 2009 financial management report. This is inconsistent with the data provided in the results framework, which indicated that VCT targets were exceeded and PMTCT targets fell short of being achieved by 3%. 18 Approximately 69% of project funds were spent on strengthening the health facility and laboratory capacity, which did not include other prevention services such as condom distribution, VCT and PMTCT, OI, ARV and biomedical waste management. The health facilities provide comprehensive care, which serves the general population and not only those who are HIV-positive. Only six percent of project funds were spent on prevention services, including IEC/BCC campaigns when 50% of young women and men aged 15-24 years correctly identified ways of preventing HIV and rejected major misconceptions about HIV transmission. The project did not work directly with MARPs, who are potential drivers of the epidemic; however, another organization which is experienced in working with these hard-to-reach populations exceeded project targets. The operational cost of the project was 0.8% of the loan. In the years since the project was prepared, the professional literature has cast increasing doubt on the efficacy of some interventions and on the feasibility of calculating the discrete benefits of many others. It now appears more likely that some of the most important outcomes of HIV programs are the threshold effects they produce on norms and behaviors through the cumulative impact of multiple interventions. As many of the benefits of the project are intangible, they are impossible to quantify, however in the interviewers conducted by the ICR team, project staff and beneficiaries indicated that the project made a significant difference in the lives of people from St. Kitts and Nevis, providing an environment where HIV and AIDS issues could be discussed. The ICR team rated the efficiency of the project as moderately satisfactory. 3.4 Justification of Overall Outcome Rating Rating: Moderately satisfactory The project objectives, design and implementation are highly relevant and consistent with country development priorities, and Bank CAS and corporate goals. Even though qualitative data and physical changes observed indicate that the World Bank project had made a difference in the lives of the people of St. Kitts and Nevis and PLHIV's are better off today than six years ago ­ the overall outcome rating is moderately satisfactory because inadequate quantitative data is available to corroborate the outcomes of the project. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impact, Gender Aspects, and Social Development The ICR team did not undertake a specific assessment on gender and/or poverty impact; however it noted that the project targeted most-at-risk populations such as MSM and SW. The Caribbean HIV/AIDS Alliance was able to reach approximately 2,669 people from October 2007 to September 2009, through individual health promotion programs. Through the Bank project, food vouchers were provided to PLHIVs who needed nutritional support to improve adherence to treatment, as well as comprehensive home based care, which included psycho-social support. Four line ministries implemented activities that touched on: Gender (teen mothers, low-income women, MSM, SW), Education (HIV/AIDS education policy under review by donor agencies, peer education and female empowerment programs all incorporate HIV/AIDS into the curriculum), Youth (youth groups use the media and 19 youth parliament as a means to tell their story and advocate for change), Labor (HIV/AIDS work place policy forthcoming with support from ILO, in-house staff training on HIV/AIDS has taken place). (b) Institutional Change/Strengthening Some institutional changes were beneficial to the project team and the society as a whole: (i) a strong working relationship developed between two ministries - Ministry of Sustainable Development and Ministry of Health, which led to joint programming and a better understanding of technical issues and Bank procedures and processes; (ii) capacity of project staff, line ministries and civil society organizations was strengthened and resulted in leveraged financing from other agencies such as Global Fund, PANCAP, etc. The strengthened capacity allowed for more effective program implementation; (iii) establishment of NACHA as an advisory and approval board for HIV/AIDS projects. (c) Other Unintended Outcomes and Impacts (positive or negative) The project did not anticipate working with the private sector; however towards the end of the project, they actively participated in the IEC/BCC campaigns. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops N/A 4. Assessment of Risk to Development Outcome Rating: Moderate The government of St. Kitts and Nevis has absorbed all of the project staff after the project closed. They will continue to manage the national HIV/AIDS response, using the skills acquired from the project. This ensures sustainability and continuity of the program. The government is committed to continue to provide free ART for PLHIV even after the World Bank and Global Fund projects close in 2009 and 2010 respectively. It is not clear whether the government will continue to provide grants to line ministries and civil society organizations so they can continue to work with their constituents to deliver prevention programs. Stigma against PLHIVs may continue to drive the epidemic even further underground making it difficult to conduct effective prevention, care and treatment programs among MARPs and other vulnerable populations. The OECS BSS reported that only 1- 5 % of population 15-49 years St. Kitts and Nevis expressed accepting attitudes towards people living with HIV and AIDS. 20 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry (i.e., performance through lending phase) Rating: Unsatisfactory The project was prepared in a short period of time, was in line with country assistance strategy, national strategic plan of the country, and had commitment from the highest level of government - the Prime Minister of St. Kitts and Nevis was a recognized leader and advocate in the fight against HIV/AIDS in the sub-region. The project included a component that focused on strengthening the overall health system. Consultations took place with other donors in the sub-region during project design. The project complied with Bank fiduciary and environmental regulations; however, several issues were not considered at project entry: (i) country situation/context was not considered when designing the project, i.e. level of engagement of CSOs, (ii) institutional and implementation arrangements were not well defined in the project document and operational manual, leading to delays in project implementation by 2.5 years, (iii) the project design was overly ambitious for the level of human and institutional capacity available in-country, (iv) absorptive capacity to spend the resources, especially in an environment where Bank rules and regulations were not well understood, (v) project indicators were too many and not realistic given the country situation, (vi) twin-island set-up and operational nuances particular to each island, (vii) political commitment did not translate into institutional commitment in St. Kitts and Nevis. (b) Quality of Supervision (including of fiduciary and safeguards policies) Rating: Moderately satisfactory The project went through four task team leaders during the project life cycle, from May 2003 through June 2009, each with its own team make-up. There was little continuity, and the St. Kitts and Nevis team noted that each new Bank project team brought a learning curve that led to set-backs and implementation delays. The country was limited in implementation capacity, and the Bank could have taken an active and frequent supervisory role during the first few years of project implementation to ensure the project had set-up systems and was on track to achieving results (see section 2.2-2.5). It was not until mid-way through the project that the third TTL changed the dynamics of Bank's engagement with the project team. The Bank's project team was able to identify and resolve implementation bottle necks, and provide consistent, frequent, hands-on technical assistance and advice as quickly as possible, which led to the achievement of development objectives. (c) Justification of Rating for Overall Bank Performance Rating: Moderately unsatisfactory 21 The overall rating for the Bank performance is moderately unsatisfactory, due to the quality at entry rating being unsatisfactory, whereas the quality of supervision was rated as moderately satisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Moderately satisfactory The government's commitment to the project was very strong at the project design stage; however, this did not translate into institutional commitment, and thus faltered during the first two years of project implementation. Readiness to implement the project, implementation arrangements and capacity were relatively weak as the project was initially coordinated by the Permanent Secretary of the two ministries respectively, until the appointment of appropriate staff. Implementation issues were not fully resolved until the third year of the project. Counterpart funding was provided on time by the government and the team was in compliance with fiduciary requirements. Government also increased its contribution to the project from $460,000 to $1.01 million to cover the increased construction costs of Pogson Health Facility. Attempts were made to strengthen the M&E system, however more work needs to be done in this area. Coordination and partnership with the World Bank was initially rocky, however by the time the project was restructured, a strong relationship had developed. The government retained its entire project staff at the closure of the project. (b) Implementing Agency or Agencies Performance Rating: Moderately satisfactory The Ministry of Health is the technical arm of the HIV/AIDS project, whereas the PCU, Ministry of Sustainable Development was responsible for all fiduciary aspects. These teams worked very closely together and are located in the same building, which makes it easier for joint programming. At the onset of the project, there were internal coordination issues which led to delays. For example, back-up arrangements were not in place when staffs were away from the duty station, which caused delays in project implementation. After the mid- term review and project restructuring, momentum was gained by the project team, and they were able to implement most project activities and disburse approximately 83% of the loan within two years. Additional staffs were brought on board to assist with project implementation, monitoring and evaluation. At the end of the project, an M&E system is still not in place; however three staff members attended a four-month training at CHRC in Trinidad and Tobago. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately satisfactory 22 The overall rating for the Borrower performance is moderately satisfactory, due to the government and implementing agency performances rated as moderately satisfactory. 6. Lessons Learned The following lessons were learnt from the project: · Project design: Project design should match the country context and the capacity available in-country. Using a template model that may have worked in other countries creates implementation delays and unrealistic expectations. This applies especially to commitment by all stakeholders, especially CSOs and to establishing the appropriate institutional framework for program implementation. The project design could have had more of a capacity building and systems development emphasis. · Project coordination: Technical and fiduciary teams struggle to cope with responsibilities at inception in a country that is a first time borrower and where collaboration between more than one ministry is key to successful implementation. Therefore, ensuring that the operations manual is simple to use and clearly outlines institutional and project team roles and responsibilities is essential to the success of the project. · M&E: The capacity to implement M&E must be identified and addressed at the design stage and a budget assigned to it. This is especially important when no baseline data are available and need to be collected within the first year of the project. If that is not possible then proxy data should be used so that performance and outcomes can be measured and monitored. · Partnerships: Political commitment does not necessarily translate into ownership by implementers and beneficiaries of services. The Bank, regional organizations (CHRC, UNAIDS on behalf of the UN system) and other donors (GFATM) in this case needed to build stronger partnerships and coordinate activities. Lack of coordination shows up more readily in technical assistance for M&E. · Staff retention: The ability to retain technical and fiduciary staff after project closure is a necessary condition to guarantee operational sustainability. In the case of St. Kitts and Nevis, the skills and experience of trained staff were retained by absorbing the staff in the Government establishment and therefore staff will be available to continue controlling the spread of the HIV and mitigate its impact. · Bank Staff Continuity: Four TTLs over a six year period for a first time borrower and a small country is bound to result in poor client relationships, inconsistent policy and operational advice, less than satisfactory fiduciary and safeguards management, and insufficient proactive engagement with public and private partner agencies. 23 7 Comments on Issues Raised by Borrower/Implementing Agencies/Partners The Borrower reviewed and provided comments on the draft Implementation Completion Report for the St. Kitts and Nevis HIV/AIDS Prevention Project. The comments which were incorporated into the document were related to clarifying data and information presented in the project preparation, design and implementation sections of the document. (a) Borrower/implementing agencies ICR contribution: See Annex 7 (b) Cofinanciers: N/A (c) Other partners and stakeholders: N/A Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent), as of June 30, 2009 The loan disbursement was completed, October 30, 2009; therefore finance data presented in this table is through June 30, 2009 which is the project closing date. Appraisal Actual/Latest Percentage of Components Estimate (USD Estimate (USD Appraisal millions) millions) Original Advocacy and behavior change 0.52 0.06 11.9% Prevention 1.13 0.07 6.5% Treatment care and support 1.92 0.65 33.7% Surveillance, detection and 0.55 0.03 5.6% research Sustainable management 0.30 0.15 51.5% Revised (after restructuring) Scaling up HIV/AIDS response by civil society organizations, community based organizations, 0.02 0.13 650% faith based organizations, private sector and non-health line ministries Strengthening the health sector 3.04 3.07 101% response to HIV/AIDS Strengthening surveillance, monitoring and evaluation and 0.77 0.39 51% institutional capacity for program management Total Baseline Cost 8.24 4.55 Physical Contingencies 0.00 0.00 Price Contingencies 24 Appraisal Actual/Latest Percentage of Components Estimate (USD Estimate (USD Appraisal millions) millions) 0.00 0.00 Total Project Costs 8.24 4.55 Front-end fee PPF 0.00 0.00 Front-end fee IBRD 0.04 0.04 Total Financing Required 8.28 4.59 (b) Financing Appraisal Actual/Latest Type of Co- Estimate Estimate Percentage Source of Funds financing (USD (USD of Appraisal millions) millions) Borrower 0.46 1.05 228% International Bank for 4.05 3.37 83.2% Reconstruction and Development The borrower contribution at the end of the project is significantly higher than what was anticipated at project appraisal. Mid-way through the project, construction costs in the Caribbean increased and during project restructuring, the government agreed to increase its contribution to the project from US$ 0.46 to $2.1 million. However, the government was not able to meets its $2.1 million counterpart contribution. Annex 2. Outputs by Component (Costs in US$ was provided by the PCU, as of October 30, 2009) Component 1: Scaling up HIV/AIDS response by civil society organizations, and line ministries (US$0.02 million) Although the implementation of this component experienced considerable delays in the early stages, thirty two project proposals were approved and funded by the end of the project, ten by line ministries and nineteen by CSOs. The projects targeted a wide cross section of the population from the young to the elderly, and persons infected and affected by HIV/AIDS. Through the CSO - Facilitating Access to Confidential Testing, Treatment and Support Group (FACTTS), this project was able to support PLHIV in various ways: 15 PLHIV received food vouchers on a monthly basis from December 2008 to June 2009. Others were able to participate in training exercises and workshops both nationally and regionally to enhance confidence in peer advocacy activities. 25 The project was able to sensitize the general public through activities geared towards behavior change, and the reduction of stigma and discrimination. Some of the awareness campaigns implemented included: Men Make a difference (2005); Women, Girls and HIV (2006); ABCDE of HIV (2006); Know your Status Campaign (2006); Respect I...My life, My choice, My rights (2007); Keep the Promise (Lead, Empower Deliver (2007); and Keep De Promise (2008). Eleven and twenty-one activities were organized by line ministries and civil society organizations respectively, as follows: Implementing Ministry Project Name Amount funded by project (US$) Department of Youth HIV/AIDS Awareness Troupe, 13,227 Choices: Knowing is Beautiful Ministry of Health Clinical Care Team Sensitization 4,282 Workshop Tourism, Sports, and Culture Creating together a new Vision for 3,713 Kicking AIDS Out for Healthy Living in the Caribbean Nevis HIV/AIDS Committee HIV/AIDS Awareness Troupe for 6,119 Culturama 2007 Department of Gender Affairs Teen Mothers Support 3,545 Department of Gender Affairs HIV/AIDS Work Plan: 830 Teen Mothers HIV/AIDS Awareness Ministry of Education and The More You Know Project 5,037 Youth Ministry of Social and HIV/AIDS Work Plan 5,597 Community Development National AIDS Secretariat Vibes in the World of Sexuality 5,901 Ministry of Education HIV/AIDS Work Plan 5,597 Department of Youths HIV/AIDS Work Plan 4,515 58,363 Implementing Agency Project Name Amount funded by project (US$) Sandy Point High School Five C's Campaign Video Message 1,679 Phunn Makers Jambalaya HIV/AIDS B Aware 14,925 Carnival Troupe St. George's Anglican Project Abstinence 1,866 Church FACTTS CRN Workshop 2,869 Haynes Smith Youth Club HIV/AIDS Prevention through 3,731 Performing Arts Youth Impact Ministries Abstinence Till Marriage (ATM) 597 Network Youth Impact Ministries HIV/AIDS Peer Education Training 1,691 26 Implementing Agency Project Name Amount funded by project (US$) Network Molineux Youth in Action Express Yourself ­ HIV/AIDS and 5,058 Club Youths Caribbean Vybes Gospel Extravaganza 3,731 Magazine and Ancient Order Wesleyan Holiness Youths HIV/AIDS and Christian Youth 1,866 Media in Support of Media Sensitization Project 4,129 People Living with HIV/AIDS National Carnival Queen Contestants Fighting 3,675 Committee HIV/AIDS Rotary Club of St. Kitts `Jenny Lives Positively with 2,985 HIV/AIDS' Comic Book Illustration FACTTS HIV/AIDS Workshop 1,979 FACTTS The Nutrition Assistance Support 9,795 Program St. Kitts-Nevis Football Kicking the Trend 7,649 Association Beacon OF Hope Turn Around Generation 5,434 Ministries Zion Moravian Church Zion Youth Fest 2009 3,119 LAUGH Entertainment Stand up Comedy Show ­ "Life No 3,783 Dun Yet" Island Girls/His Glory Rendezvous 3,731 Design St. Kitts Fire and Rescue HIV/AIDS Sensitization 5,597 Club 89,916 Component 2: Strengthening the health sector response to HIV/AIDS (US$3.04 million) The MOH hosted several activities geared towards promoting advocacy and behavior change, including the annual World AIDS Day Campaigns and VCT testing days. Forty- five condom vending machines were procured through a MOU with OECS/PPS, drugs were purchased and distributed free of charge to persons infected with HIV, including pregnant women. Three health centers and one medical facility were rehabilitated in St. Kitts ­ Cayon, Newton, Basseterre and Pogson, respectively. The two health centers identified in Nevis were not rehabilitated. 27 The PCU was able to procure equipment under this component to strengthen health facility capacity. These include audiovisual equipment, a DT 60 II analyzer, and other laboratory equipment which were installed and operational. Materials and supplies were also purchased to support the current biomedical waste management disposal system at the general J. N. France General Hospital. A Clinical Care Coordinator was also contracted and retained through the end of the project, while a laboratory technologist was contracted for twenty months. Description Amount in (US$) World AIDS Day Campaigns 103,212 Purchase of Condom Vending Machines 19,403 Purchase of Condoms and Lubricants 13,286 Purchase of ART Drugs 66,489 Purchase of Audiovisual Equipment 31,600 Laboratory Technologist Contract 45,432 Purchase of Laboratory Equipment (DRC) 204,102 Purchase of Equipment (Johnson & Johnson) 18,759 Refurbishment of Health Centers 104,344 Construction of Pogson Medical Facility 2,430,276 Biomedical Waste Management System Consultant 36,859 Purchase of Biomedical Waste Materials and Supplies 99,381 Clinical Care Coordinator Contract 46,562 3,219,705 Component 3: Strengthening surveillance, monitoring and evaluation and institutional capacity for program management (US$0.77 million) The MOH encountered several obstacles with designing the National Health Information System. However, the PCU was able to procure the required equipment in a timely manner. The chair of NACHA was appointed after the establishment of the advisory committee on July 18, 2005. The project financed the contracting of a project accountant. Three staff members within MOH participated in a four-month monitoring and evaluation internship at CHRC in Trinidad and Tobago. Project staff and implementers directly involved with the project received additional training from the World Bank and other agencies. All project staff were retained by the Government of St. Kitts and Nevis following completion of the Project. Description Amount (US$) Purchase of Equipment for National Health Information System 223,925 Training of MOH and PCU Staff 44,372 Chair of NACHA 17,910 Purchase of Office Furniture 135,045 Purchase of Computers 20,538 Purchase of VCT Items 3,903 28 Project Accountant 37,062 Monitoring and Evaluation Consultant 25,534 508,289 Annex 3. Economic and Financial Analysis N/A Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Supervision/ICR Shiyan Chao Senior Health Economist LCSHH TTL Mary Mulusa Senior Operations Officer LCSHH TTL Gregory C. Becker Consultant LCSHH Consultant Knowledge Carmen Carpio Knowledge Management Officer LCSDE Management Officer Willy L. De Geyndt Consultant LCSHH Consultant LCSHS- Mary A. Dowling Language Program Assistant Assistant DPT Financial Svetlana V. Klimenko Sr Financial Management Specialist LCSFM Management Fernando Montenegro Torres Sr Economist (Health) LCSHH Judith C. Morroy Consultant LCSPT Procurement Aracelly Woodall Senior Program Assistant LCSSO Assistant Ndella Njie Operations Analyst HDNGA Analyst Emmanuel N. Njomo Consultant LCSFM Consultant John Stephen Osika Consultant LCSHH Consultant Marta G. Ospina Consultant LCSPT Consultant Norma M. Rodriguez Procurement Analyst LCSPT Procurement Jean Rutabanzibwa-Ngaiza Consultant AFTHV Consultant Zukhra Shaabdullaeva Consultant LCSHH Consultant Seyoum Solomon Consultant FEU Consultant Luis Tineo Senior Infrastructure Specialist GPOBA Specialist AFTH1 - Harry Toews Wiebe Consultant Consultant HIS Melinda Santiago Team Assistant HDNOP Assistant Maria Elena Paz Gutzalenko Team Assistant LCSHH Assistant 29 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY02 3 57.24 FY03 6 38.31 FY08 0.00 Total: 9 95.55 Supervision/ICR FY03 1.74 FY04 6 48.66 FY05 12 50.96 FY06 18 86.24 FY07 16 94.09 FY08 14 72.17 FY09 15 77.91 FY10 1 3.20 Total: 82 434.00 Annex 5. Beneficiary Survey Results N/A Annex 6. Stakeholder Workshop Report and Results N/A 30 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR (As submitted by the Borrower) St. Kitts and Nevis HIV/AIDS PREVENTION AND CONTROL PROJECT COMPLETION REPORT 31 An assessment of the Operations, Objective, Design, Implementation and Operational Experience The Loan Agreement, No. 7156-SC, for the HIV/AIDS Prevention and Control Project between the Government of St. Kitts and Nevis (GST. KITTS AND NEVIS ) and the International Bank for Reconstruction and Development (IBRD) was endorsed on February 28, 2003 and became effective on May 29, 2003. An amount of US$4,045,000.00 was provided to finance the National response to HIV/AIDS through focusing on the following five priority areas for intervention: · Advocacy and Behaviour Change · Prevention · Improved Access to Care for PLWA · Surveillance, Epidemiology and Research · Sustainable Management Response The objective of the Project was to control the spread of HIV/AIDS through scaling up prevention programs targeting high-risk groups as well as the general population, strengthening treatment, care and support for persons living with HIV/AIDS (PLWA) and finally, strengthening of the multi-sectoral institutional capacity to better respond to the epidemic. Key performance indicators were determined and included in the Project Appraisal Document (PAD). The PAD, Loan Agreement and the Operations Manual were the documents which governed the operations of the Project. The Project design was satisfactory however procedural details especially regarding the approval and implementation of projects by the civil society organizations (CSOs) and Government line ministries were ambiguous. Initially, this resulted in a slow uptake of funds from this budget line. Further, other international donors which financed activities as part of the national response to HIV/AIDS required that additional performance indicators be introduced and monitored. Consequently, the Ministry of Health was confronted with the overwhelming task of monitoring a large number of indicators. As a result of the abovementioned issues it was recognized and agreed by the World Bank and the Government that the Project should be restructured. The restructuring exercise included a revision of the Operations Manual and corresponding amendments to the Loan Agreement. This also facilitated the harmonization of all the indicators used for all the donor agencies involved in the HIV/AIDS interventions in the Federation and a simplification of the project design by realigning the Project components with the Project objectives. As a result, the Project components and priority areas were streamlined to reflect the following: 32 · Scaling up HIV/AIDS Response by Civil Society Organizations and Line Borrower's Ministries · Strengthening the Health Sector Response to HIV/AIDS · Strengthening the Borrower's Surveillance, Monitoring and Evaluation and Institutional Capacity for Program Management The restructuring of the Project which became effective in June 2007, proved to be beneficial as there was an increase in the implementation and disbursement rate shortly thereafter. Moreover, it improved the prospects for meeting the Project objectives. An assessment of the Outcome Scaling up HIV/AIDS Response by Civil Society Organizations and Line Borrower's Ministries Under this component, the Project aimed to finance subprojects undertaken by Civil Society Organizations (CSOs) to increase awareness of HIV/AIDS, provide training and care for PLWA. The submission of proposals for subprojects increased significantly during the latter part of the Project. While eight (8) subproject proposals were approved and implemented prior to the restructuring process, twenty one (21) were approved and implemented subsequent to the date it became effective. Some of the activities undertaken by the CSOs included: · The production of a comic book geared towards alleviating stigma and discrimination of PLWA. This book was distributed to children at the primary school level. · A Nutrition Assistance Support Program which financed food vouchers to PLWA. · Several workshops and training programs · HIV/AIDS awareness carnival troupes · Trivia games geared towards increasing HIV/AIDS awareness Strengthening the Health Sector Response to HIV/AIDS Intervention in this component targeted: · The reduction of stigma and discrimination against people living with AIDS · The design and implementation of information, educational, communication and behavioral change programs · The carrying out a national program to promote condom use and increase distribute of condoms · Upscaling voluntary counseling and confidential HIV/AIDS testing program through the initiation of public national testing days and the provision of the necessary laboratory equipment and reagents to provide in-country capability for HIV testing. 33 · The strengthening of the technical and institutional capacity of the Borrower's health facilities and laboratories including the rehabilitation of the Pogson Health Facility · Improving the management biomedical waste in the country Most activities earmarked under this project were successfully implemented. The MOH launched several awareness campaigns to reduce stigma and discrimination, to inform, educate and communicate behavioral change messages. Recognizing the expansion of the Spanish speaking community in St. Kitts and Nevis, a decision was made to create awareness campaigns targeting this segment of the population through the recruitment of a Spanish Translator. Some HIV/AIDS awareness materials created in English were translated to Spanish. Audiovisual equipment was purchased and distributed to Health Centres to support continuous education and VCT programs. Further the MOH implemented several VCT campaigns, distributed both male and female condoms and have installed several condom vending machines in specific areas in St. Kitts and Nevis. The MOH and PCU attempted to procure electronic billboards to further strengthen and sustain the HIV/AIDS awareness campaign. Two attempts were made at the procurement process. No bids were submitted for the first procurement process, while one bid was submitted by the stipulated deadline during the second attempt. Unfortunately, the financial proposal of the bid substantially exceeded the budget and the bidding process was therefore cancelled. Additionally, the MOH and PCU proceeded with the necessary arrangements to recruit an IEC/BCC Specialist to work with various stakeholders in order to design and guide implementation of a comprehensive communication strategy to support the national HIV/AIDS Programme. Regrettably, after the evaluation process it was discovered that there were no suitably qualified applicant who was available to undertake the assignment. Consequently, the MOH decided to utilize its staff in the execution of the IEC/BCC activities. Despite these two setbacks, the MOH continued awareness campaigns through the use of promotional items, brochures, flyers and t-shirts financed by the Project. With regards to the Health facilities, the Project financed the renovation of three (3) health centres namely, the Cayon, Basseterre and Newtown Health Centres and the construction of the Pogson Medical Facility. Work on two additional health centres in Nevis was not accomplished due to the delays in completing the necessary procurement process. In addition, several pieces of equipment were purchased for the laboratory at the Joseph N. France General Hospital in order to increase the capacity of HIV diagnosis and management. A consultant was recruited to devise a system for the biomedical waste management. The resulting proposal included the procurement of supplies, materials and a new autoclave system. The PCU and MOH were successful in purchasing the supplies and materials however there were difficulties encountered during the procurement of the autoclave system which resulted in extensive delays. Towards the end of the Project, a decision was made not to proceed since there was no longer adequate time to complete the procurement process. The Government of St. Kitts and Nevis will seek an alternative source for financing this very important piece of equipment. 34 Strengthening the Borrower's Surveillance, Monitoring and Evaluation and Institutional Capacity for Program Management Under this component, funds were allocated for the establishment and operation of the National Advisory Council on HIV/AIDS (NACHA), strengthening of the institutional capacity for the implementation of the national HIV/AIDS program and disease surveillance and strengthening the PCU in fiduciary management. The NACHA was established in June 2005 and chaired by a medical processional who is actively involved with the issues related to HIV/AIDS in the Federation. Officers from the PCU and the MOH benefited from training workshops financed by the World Bank on HIV/AIDS program implementation and fiduciary matters. Officers were also given the opportunity to attend workshops jointly funded by other donor agencies on aspects that were HIV/AIDS related. A notable training exercise was the internship training of three officers made possible by the Caribbean Health Research Council (CHRC). The Officers were trained in Monitoring and Evaluation techniques and have been deployed to assist with the monitoring of the HIV/AIDS indicators. The procurement of IT equipment to support the development of the country's surveillance system had proven to be a challenge primarily due to a lack of in-country expertise in this particular area. Several attempts and consultancy resources were utilized to conceptualize the design of this platform however this was not finalized by the end of the Project execution period. The Department of Technology, however, was able to identify the key pieces of equipment that would complement and form the foundation of the new system. The MOH and PCU with the assistance of the Department of Technology were able to procure and finance these pieces of equipment through the Project. Evaluation of the Borrower's performance The Government of St. Kitts and Nevis experimented with a new model for implementing a major Project which required scarce skills and knowledge. Project coordination and management was therefore shared between two ministries namely the Ministry of Sustainable Development and the Ministry of Health. A Project Coordination Unit (PCU) within the Ministry of Sustainable Development was mandated to carry out the fiduciary management of the Project. The PCU was staffed with a Project Coordinator, Project Accountant, Procurement Officer and Administrative Assistant. This Unit had already acquired some experience in applying the World Bank procedures since it was intimately involved in the implementation of previous IRBD funded Projects such as the Emergency Recovery and Disaster Management Project and the Emergency Recovery Project. Additional training opportunities during the implementation of the Project also assisted in strengthening skills and updating knowledge of revised Bank procedures. Further, the PCU fulfilled all fiduciary responsibilities as stipulated in the Loan Agreement. A financial management system was maintained including records, accounts and financial statements in the format acceptable to the Bank to reflect the operations, resources used and 35 expenditures related to Project activities. Financial Monitoring Reports (FMRs) were submitted on a quarterly basis and annual audits were conducted. The Ministry of Health was responsible for technical matters and collaborated with the relevant stakeholders in fulfilling the requirements of the Project. The NACHA and CSOs also provided support to project implementation. The PCU and the MOH met and communicated regularly to monitor Project implementation, to resolve any issues that can create bottlenecks and also to update Project plans. During the early stages of the Project, the execution of activities occurred at a very slow pace thus resulting in a low disbursement of loan funds. This was partly due to the unfamiliarity with the Bank procedures by the technical officers at MOH, the uncertainty regarding the responsibilities of key players and weakness in the Project design. Subsequent to various training sessions with the MOH staff and the restructuring of the Project, implementation and disbursement increased dramatically. The Government of St. Kitts and Nevis further demonstrated commitment to the achievement of the Project objectives through exceeding the financial contribution requirements under the Loan Agreement. Overall the Government of St. Kitts and Nevis was able to accomplish the objectives of the project. Therefore, the general performance can be considered satisfactory. Evaluation of the Bank Performance The Project has been through four (4) Task Teams since the inception. These many changes were inconvenient and resulted in a weak Bank-GST. KITTS AND NEVIS coordination. The third task team however worked with the Project for the longest tenure and made a significant impact in terms of project implementation and management. This team recognized the need for the restructuring of the Project and worked diligently and in close collaboration with the MOH and PCU in the completion of this process. The PCU and MOH therefore wish to recognize the invaluable contribution to project implementation made by Mrs. Mary Mulusa and her team. The regular missions to the Federation and the development of a valuable working relationship resulted in a significant improvement in project implementation. Easy access to Bank staff, quick responses to correspondence, advice and the availability of Bank staff to assist during critical periods have contributed in part to the overall accomplishment of project objectives. In general, the World Bank's performance can be rated satisfactory. Proposed Arrangements for Future Operation The HIV/AIDS Prevention and Control Project had been a very different experience compared to previous World Bank funded projects undertaken by the Government of St. Kitts and Nevis. In particular, the working relationships with the CSOs had proven to be 36 more complex than originally anticipated. Given the rich experience provided through this Project the PCU and MOH have identified some arrangements that can be instituted when implementing or managing projects of a similar nature: · A new modality for engaging CSOs should be establish in order to encourage early buy-in the overall objective of the project, to inform CSOs of their contribution to the project and to strengthen the organizations' capacity to prepare, implement and manage projects. · Work programs should be integrated for several ministries. · The commencement of the HIV/AIDS Prevention and Control Project provided leverage to attract additional resources to support the current and future work in this area. During the execution of the Project other opportunities to access resources from other donor agencies to address different aspects of the national response to HIV/AIDS were presented to the Government of St. Kitts and Nevis. The acquisition of these funds has assisted the Government to sustain its national response to HIV/AIDS. Therefore under future initiatives, efforts should be made to explore additional resources in order to promote the sustainability of the project/program. Lessons Learnt 1. As far as possible, flexibility must be built into the project design to facilitate unexpected events which can delay project implementation. 2. Where technical deficiencies are noted in country, particularly in relation to bids/proposals, evaluation and development of appropriate specifications and terms of reference, resources should be provided from the project to recruit competent short-term consultants to assist where necessary. 3. Knowledge of the procurement procedures of the World Bank should not be confined to the officers at the PCU but should be extended to the personnel of the implementing technical agency and other stakeholders. This would aid in expediting the implementation of the project activities. 4. Having the same officers on the Bank and Beneficiary's team, as far as possible, during the tenure of the Project can assist with continuity, consistency and avoid delays in Project implementation. Where this is not possible, efforts should be made to establish formal handing over procedures to improve project specific knowledge within the team at any given point. 37 Appendices Project Costs and Financing (Before Reconstruction) (a) Project Cost by Component (in US$ million equivalent) Appraisal Actual/Latest Components Estimate (US$ Estimate (US$ Percentage of million) million) Appraisal 1. Advocacy and Behaviour Change 505,000.00 59,508.80 11.78% 2. Prevention 1,131,411.00 93,151.38 6.41% 3. Access to Treatment, Care and Support for PLWA 1,918,000.00 662,917.43 34.56% 4. Surveillance, Epidemiology and Research 545,250.00 30,186.31 5.54% 5. Sustainable Management Response 295,750.00 156,724.90 52.70% Total Baseline Cost 4,395,411.00 1,002,488.82 22.32% Physical Contingencies Price Contingencies Total Project Cost 4,395,411.00 1,002,488.82 22.32% Project Preparation Facility (PPF) Front-end fee (IBRD only) 40,450.00 40,450.00 Total Financing Required 4,435,861.00 1,042,938.82 23.03% (b) Financing Appraisal Actual/Latest Type of Source of Funds Estimate (US$ Estimate (US$ Percentage of Financing million) million) Appraisal Government Revenue 460,000.00 159,773.37 34.73% IBRD Loan 4,045,000.00 883,165.33 21.83% 38 Project Costs and Financing (After Reconstruction) (a) Project Cost by Component (in US$ million equivalent) Appraisal Actual/Latest Components Estimate (US$ Estimate (US$ Percentage of million) million) Appraisal 1. Scaling up HIV/AIDS Response by CSO & LM 200,000.00 147,174.44 73.59% 2. Strengthening Health Sector Response to HIV/AIDS 3,554,411.00 3,217,829.14 89.95% 3. Strengthening Surveillance, M&E, and Institutional Capacity for Program Management 641,000.00 591,105.44 92.08% Total Baseline Cost 4,395,411.00 3,956,109.02 89.52% Physical Contingencies Price Contingencies Total Project Cost 4,395,411.00 3,956,109.02 89.52% Project Preparation Facility (PPF) Front-end fee (IBRD only) 40,450.00 40,450.00 100.00% Total Financing Required 4,435,861.00 3,996,559.02 89.61% (b) Financing Appraisal Actual/Latest Source of Funds Type of Financing Estimate (US$ Estimate (US$ million) million) Government Revenue 460,000.00 797,393.70 IBRD Loan 4,045,000.00 3,199,165.93 39 Gove rnme nt of St. Kitts and Ne vis HIV/AIDS Prevention and Control Project World Bank Loan No. 7156-SC Uses of Funds by Project Activity For the period ended August 31, 2009 in EC Dollars A ctual P lanned Variance P A D /ii C urrent Year-To C umulative C urrent Year-To C umulative C urrent Year-To C umulative Life o f P ro ject A ctivities /i N o tes Quarter D ate To -Date Quarter D ate To -Date Quarter Date To -D ate P ro ject 1. S caling up HIV/A ID S R es po ns e by C S Os and Line M inis tries 58,427 175,696 397,371 60,000 180,000 400,000 (1 ,573) ( 4,304) ( 2,629) Civil So c iety Organisatio ns 37,467 1 1 5,559 254,404 30,000 120,000 250,000 7,467 (4,441 ) 4,404 Line Ministries 20,960 60,1 38 142,968 30,000 60,000 150,000 (9,040) 1 38 (7,032) 2 . S trengthening the Health S ecto r R es po ns e to HIV/A ID S 399,1 04 2,049,823 8,632,429 407,700 2,071 ,200 8,601 ,200 ( 8,597) ( 21 ,377) 31 ,229 Advo c ac y and Behavio ur Change 9,987 68,249 276,608 10,000 70,000 275,000 (13) ,751 (1 ) 1,608 Co ndo m So c ial Marketing and Dis tributio n 35,607 35,607 87,624 35,000 35,000 85,000 607 607 2,624 Strengthening VCT - - - - - - - - - P harmacy Strengthening - - 1 91 78,1 - - 180,000 - - (1,809) Strengthening Heath Fac ilities /Labo rato ry Capac ity 57,435 103,378 1,086,956 60,000 100,000 1,050,000 (2,565) 3,378 36,956 Rehabilitatio n o f P o gs o n Health Fac ility 56,430 1,557,371 3,1 6,51 41 - 1,550,000 6,500,000 56,430 7,371 3,1 1 41 P reventio n and Co ntro l o f STls - - - - - 5,000 - - (5,000) P reventio n o f MTCT - - - - - 5,000 - - (5,000) Management o f Oppo rtunis tic Infectio ns and P alliative Care - - - - - 5,000 - - (5,000) Intro duc ing HAART - - - - - 5,000 - - (5,000) Impro ved Mgmt o f Bio -med Was tes 236,945 266,342 365,1 24 300,000 300,000 365,000 (63,055) (33,658) 1 24 Ho me &Co mmunity-Bas ed Care fo rP L W A 2,700 18,876 124,785 2,700 16,200 126,200 - 2,676 ,41 (1 5) 3 . S trengthening S urveillance, M o nito ring & Evaluatio n, and 546,31 3 663,573 1,593,625 548,000 654,000 1,602,000 (1 ,687) 9,573 ( 8,375) Ins titutio nal C apacity fo r P ro gram M anagement - - - - - - - - - Strengthening the co untry' s c apacity in Epidemio lo gy - - 3,1 1 61 - - 15,000 - - (1,839) Setting up an integrated, c o mputerized health info rmatio n s ys tem 539,1 75 600,1 20 600,1 20 540,000 600,000 600,000 (825) 1 20 1 20 STD/HIV/AIDS Info rmatio n Sys tem (IS) and Clinic al MIS - - - - - - - - - P ro jec t Implementatio n Suppo rt 2,349 46,397 51 0,535 3,000 43,000 505,000 (651 ) 3,397 5,535 P ro jec t Co o rdinatio n Unit -P CU - 1,050 152,968 - 1,000 160,000 - 50 (7,032) Mo nito ring and Evaluatio n - - 120,545 - - 125,000 - - (4,455) Operating Expenditure 4,788 16,007 94,1 71 5,000 10,000 90,000 (21 2) 6,007 4,1 71 Audit - - 02,1 1 25 - - 107,000 - - (4,875) 4 . Lo an Fee 109,21 5 1 09,21 5 5 . Other/N o n-Wo rld B ank Financed 74 1,903 43,752 125 1,950 44,500 ( 51 ) ( 47) ( 748) So cial Sec urity - 1,033 22,008 - 1,050 21 ,500 - (17) 508 So cial Service Levy - 657 4,1 1 07 - 700 12,000 - (43) 2,107 Bank Charges 74 1 19 7,224 25 100 10,000 49 19 (2,776) Other - 94 41 2 1 00 100 1,000 (1 00) (6) (588) To tal P ro ject Expenditure 1,003,917 2,890,995 10,776,392 ,01 1 5,825 2,907,150 10,756,915 ( 1 ,908) 1 6,1 ( 1 55) 19,477 N OTES /i: The items under"P ro jec t Activities " will be tho s e agreed between the Bo rro wer and the Bank at the time o f apprais al, and as reflected in the P AD. /ii: Figures enterfro m the P AD; if amendments have o c curred, us e updated figures fo und in the lates t P SR (fo rmerFo rm 590). US /iii: The fo llo wing rate was used to c o nvertio n - 1 Do llar= $ 2.6882 EC /iv: May be bro ken do wn into appro priate c las s es : advertis ement c o s t and bank c harges /v: Economic and Financial Analysis The project had a direct impact on the lives of those individuals who received support financially in the form of food vouchers for a seven month period, and also those who were able to receive medication free of cost. This allowed them to have more disposable income and provided them with the means of meeting their other obligations. Further, this allowed for continued employment and less days away from work as a result of morbidity associated with HIV/AIDS. The food vouchers also provided revenue for the business owners who partnered with FACTTS, thus increasing their income. The tax on this income further creates revenue for the Government which ultimately contributes to the GDP and the economic status of the Federation. The Project also supported the reconstruction of the Pogson Health Facility as well as the renovation of three (3) health centres on St. Kitts thereby enabling increased access to medical and health care to at least 10,000 persons including vulnerable groups of the population, namely women, children and young people who are considered the most at risk group to HIV/AIDS. These individuals, many of whom are from lower socio- economic environments, would not normally be in a position to pay for health care delivered in the private sector. The project has therefore contributed positively to ensuring that individuals remain healthy so that they may lead worthwhile and productive lives. These activities will be far reaching as persons are now fully aware of the epidemic and are now more inclined to monitor their sexual behaviour and ensure that they are protected. This will positively influence the economic stability of the country as the number of infected persons is expected to decrease significantly in the future. 41 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A Annex 9. List of Supporting Documents 1. Analysis of HIV/AIDS Epidemic in St. Kitts and Nevis, 1984-2006 2. Strategic Plan for the National Response to HIV/AIDS in St. Kitts and Nevis, 2000-2005 3. Project Appraisal Document for the First Phase of the Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending for the Caribbean Region 4. Project Appraisal Document for the HIV/AIDS Prevention and Control Project, December 13, 2002 5. Country Assistance Strategy Progress Report, September 18, 2002 6. Project Loan Agreement, February 28, 2003 7. World Bank Aide-memoires (2003-2009). 8. Implementation Status Reports (2003-2009). 9. HIV/AIDS in the Caribbean Region: A multi-organization review, November 2005 10. Behavioural Surveillance Surveys (BSS) in Six countries of the Organization of Eastern Caribbean States (OECS), 2005-2006 11. Mid-term review report, 2006 12. Caribbean Region HIV/AIDS Service Provision Assessment Survey, 2006 (St. Kitts and Nevis) 13. Amendment to loan agreement and proposal to restructure the project, March 21, 2007. 14. UNAIDS UNGASS Report 2008 15. National HIV/AIDS Strategic Plan - St. Kitts and Nevis, 2009-2013 42 Annex 10. MAP