Document of The World Bank FOROFFICIAL USEONLY ReportNo: 28236 PROJECTAPPRAISAL DOCUMENT ONA PROPOSED LOANINTHE AMOUNT OFUS$3.5 MILLION CREDIT INTHE AMOUNT OF SDRl.25 MILLION(US1.75 MILLIONEQUIVALENT) AND GRANT INTHE AMOUNT OF SDRl.25 MILLION(US$1.75 MILLION EQUIVALENT) ( U S 7 MILLIONEQUIVALENT) TO ST. VINCENT AND THE GRENADINES FOR AN HIV/AIDS PREVENTIONAND CONTROL PROJECT INSUPPORTOFTHETHIRDPHASE OFTHEMULTI-COUNTRYHIV/AIDSPREVENTIONAND CONTROL PROGRAMFORTHE CARIBBEANREGION May 27,2004 CaribbeanCountryManagementUnit HumanDevelopmentSector ManagementUnit Latin America and the Caribbean RegionalOffice This document has a restricteddistributionand may be usedby recipientsonly in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (ExchangeRateEffective: April 6, 2004) CurrencyUnit = EasternCaribbeanDollar (EC$) US$ 1 = EC$2.68 U S $ l = SDR0.689 FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS II csw cso II CommercialSex Workers Civil Societv Organization II HAART Highly Active Antiretroviral Therapy HIV HumanImmune-DeficiencyVirus FOROFFICLALUSEONLY HPIU HealthPlanningandInformationUnit IBRD IIInternationalBank for ReconstructionandDeveloDment SBD ~ StandardBidding Document SOE Statement of Expenditure SQL Structured Query Language ss Single Source STD Sexually TransmittedDisease STI SexuallyTransmittedInfection This document has a restricted distributionand may be used by recipients only in the performanceof their official duties. I t s contents may not be otherwise disclosed without World Bank authorization. Vice President: David de Ferranti Country Director: Caroline D. Anstey Sector Director: Ana-Maria Arriagada Sector Manager: Evangeline Javier Sector Leader: William Experton Task Team Leader: Mary T. Mulusa ST.VINCENT ST VINCENT AND THEGRENADINES . AND THE GRENADINESHIV/AIDSPREVENTIONAND CONTROL CONTENTS Page STRATEGICCONTEXTAND RATIONALE ........................................................................ 1 1. Country and sector issues.................................................................................................... 1 2. Rationale for Bank involvement.......................................................................................... 2 3. Higher level objectives to which the project contributes...................................................... 2 PROJECTDESCRIPTION ...................................................................................................... 3 1. Lendinginstrument............................................................................................................. 3 2. Program objective andphases............................................................................................. 3 3. Project development objective and key indicators ............................................................... 4 4. Project description .............................................................................................................. 4 5. Lessonslearned and reflected inthe project design.............................................................. 7 6. Alternatives consideredand reasonsfor rejection................................................................ 8 IMPLEMENTATION ............................................................................................................... 8 1. Partnership arrangements.................................................................................................... 8 2. Institutional and implementation arrangements ................................................................... 9 3. Monitoring and evaluation of outcomes/results ................................................................. 11 4. Sustainability .................................................................................................................... 11 5. Critical risks andpossible controversial aspects ................................................................ 12 6. Loadcredit conditions and covenants................................................................................ . . 12 APPRAISALSUMMARY ....................................................................................................... 13 1. Economic and financial analyses....................................................................................... 13 2. Technical.......................................................................................................................... 13 3. Fiduciary .......................................................................................................................... 14 4. Social................................................................................................................................ 14 5. Environment..................................................................................................................... 16 6. Safeguardpolicies............................................................................................................. 17 7. Policy readiness................................................................................................................ 17 Annex 1: Country and Sector or Program Background ........................................................ 18 Annex 2: Major RelatedProjects Financedby the Bank and/or other Agencies .................22 Annex 3: ResultsFramework and Monitoring ....................................................................... 23 Annex 4: DetailedProject Description .................................................................................... 38 Annex 5: Project Costs............................................................................................................ 43 Annex 6: Implementation Arrangements ............................................................................... 44 Annex 7: FinancialManagementandDisbursementArrangements ..................................... 53 Annex 8: Procurement .............................................................................................................. 58 Annex 9: Economicand Financial Analysis ............................................................................ 67 Annex 10: SafeguardPolicy Issues .......................................................................................... 73 Annex 11:Project Preparation and Supervision .................................................................... 83 Annex 12: Documentsinthe Project File ................................................................................ 84 Annex 13: Statement of Loansand Credits ............................................................................ 85 Annex 14: Country at a Glance ............................................................................................... 86 Map No.13500 ST. VINCENT AND THE GRENADINES HIV/AIDSPREVENTION& CONTROLPROJECT PROJECTAPPRAISALDOCUMENT LATINAMERICA AND CARIBBEAN LCSHH Date: May 27,2004 Team Leader: MaryT. Mulusa CountryDirector: CarolineD. Anstey Sectors: HIV/AIDS/HT-Targeted Health Sector ManagerjDirector: Ana-MariaArriagada Themes: FightingCommunicable Diseases/HIV/AIDS(P) ProjectID: PO76799 Environmentalscreening category: Partial Assessment LendingInstrument: SpecificInvestment Safeguardscreeningcategory: B LoadCredidGrant [XILoan [XICredit [XIGrant [ ] Guarantee [ 3 Other: For Loans/Credits/Others: Total Bankfinancing(US$m.):US$7.0 millionequivalent. Proposed terms: IBRDLoan(US$3.5 million): 5 years graceperiod, 15 years repayment, 0.85% per annum commitmentchargefor 4 years and0.75%, thereafter. IDA Credit (SDR 1.25 million): maturity35 years; 0.75% per annumcommitmentcharge. IDA Grant (SDR 1.25million): Terms waivedfor 2004per IDAGrants Ey04Implementation Guidelines ANDDEVELOPMENT INTERNATIONALDEVELOPMENTASSOCIATION 0.85 0.90 1.75 IDA GRANTFORHIVIAIDS 0.85 0.90 1.75 FinancingGap Total: 4.14 4.61 8.75 Borrower: St. Vincent andThe Grenadines ResponsibleAgency: Ministryof Healthandthe Environment(MOHE) AdministrativeCentre Kingstown, St. Vincent andThe Grenadines Tel: 784456 1111Ext.511/512; 784457 2586 Fax: 784457 2684 Expectedeffectiveness date: October 30,2004 Expectedclosingdate: June 30,2009 Does the project depart from the CAS incontent or other significant I oNo respects?Ref. PAD A.3 Does the project require any exceptions from Bank policies? Ref. PAD D.7 No Have these been approved by Bank management? _ _ N/A I s approval for any policy exception sought from the Board? N/A Does the project include any critical risks rated "substantial" or "high"? o Yes Ref. PAD C.5 Does the project meet the Regional criteria for readiness for o Yes implementation? Ref. PAD D.7 Project development objective Ref. PAD B.2, TechnicalAnnex 3 The development objective of the project is to support the national program that aims to prevent and to control the spread of HIV/AIDS and to mitigate the socio-economic impact of the disease on the population. The project will use a two pronged strategy: targeting interventions at highrisk groups and implementing non-targeted activities for the general population. Successful achievement of the development objective will: (a) have highrisk groups use safe sexual practices; (b) enhance knowledge in the generalpopulation of the negative societal and family impact of the disease; (c) prolongthe lives of infected persons and provide care and support to their families; and (d) reduce the degree of stigma and discrimination associatedwith the disease. Project description [one-sentence summary of each component] Ref. PAD B.3.a, Technical Annex 4 The Project will finance four Components as follow: Component1. Scaling-upHIV/AIDS Response by CivilSociety Organizations(US$0.98 million). The project will empower civil society groups to respond effectively to the HIV/AIDS epidemic by providing support to communities andto groups that are normally difficult to reach through regular public servicesparticularly highrisk commercial sex workers (CSW),menhaving sex with men (MSM), prisoners and vulnerable groups (orphans and youth). Component2. Scaling-upthe Response by LineMinistries (US$1.60 million). The project will support line ministries to expand the following HIV/AIDS initiativesfor their staff and the population groups they serve through their official mandates: information, education, communication/ behavior change communication; condom distribution; care for the infected and affected families; and work place policy formulation including reduction of stigma and discrimination. Component3: Strengtheningthe Health Sector Responseto HIV/AIDS (US$3.48 million). This component will support strengthening, upgrading and expansion of HIV/AIDS prevention, treatment (including anti-retroviral therapy) and care services delivered through the health care system. Component 4. Strengthening Institutional Capacity for ProgramManagement and Monitoring& Evaluation (US$2.55 million). The project will support institutional capacity building for coordinating and managing the Government's National HIV/AIDS Program; and, strengtheningprogram monitoring and evaluation (M&E). Which safeguard policies are triggered, if any? Ref. PAD D.4, TechnicalAnnex 10 Safeguard PoliciesTriggered by the Project Environmental Assessment (OP/BP/GP 4.01) Yes Significant, non-standard conditions, ifany, for: Ref. PAD C.7 Board presentation: June 29,2004 under streamlined procedures. Loadcredit/Grant effectiveness: October 30, 2004 Covenants applicable to project implementation: As referred in Section 5.01. of the Loan AgreementDevelopment Credit Agreement and Development Grant Agreement, the following events are specified as conditions of effectiveness: (a) the Project Account has been opened and an initial amount in EC Dollars of at least one hundred and fifty thousand Dollars equivalent ($150,000) has been deposited therein; (b) the Operational Manual has been approved by the Bank and adopted by the Borrower; (c) the Annual Work Plan for the first year of the Project has been approved by the Bank; and (d) the auditors referred to in Section 4.01 (b) (i) of this Agreement have been appointed. STRATEGICCONTEXTAND RATIONALE 1. Countryandsector issues St. Vincent and The Grenadines (SVG) inthe EasternCaribbean consists of 32 islands, the largest of which, St. Vincent, is the commercial and political center where 90 percent of the population resides. As with other countries inthe region, SVGi s subject to special development challenges due to its small size and vulnerability to external shocks. Despite a set of relatively good social indicators, which improved during the 1980's and 1990's, between 1996-2000 approximately 38 percent of the country's population lived in absolutepoverty, the highest percentageinthe Organization of Eastern Caribbean States (OECS) sub-region of which SVG is a member state. The HumanImmune-Deficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) prevalence rate in the adult population of the Caribbean i s currently estimated to be 2.3 percent, the highest outside of Sub-SaharanAfrica. The data on the trends of the epidemic in SVG, like many other countries in the Caribbean, have some limitations; nonetheless, it indicates a growing problem with the highest yearly recorded incidence of the HIV/AIDS cases occurring in2003. In 2002, HIV/AIDS was ranked as the sixth leading cause of death inthe country and cumulatively 688 cases of HIV and 391 cases of AIDS have beenrecorded since 1984, the start of the epidemic; 370 individuals are known to have died of AIDS. The adult prevalence rate was estimated by the Caribbean Epidemiology Centre (CAREC) and the Centresfor Disease Control (CDC)to be 0.9 percent in 2001. However, epidemiological country statistics show a much lower rate, probably due to the fact that the country prevalence rate i s based on health facility visits. HIV is primarily contracted through heterosexualcontact and a small number (estimated at 6 percent) through homosexual or bisexual transmission. Vertical transmission i s estimated to account for about 2.3 percent of all reported cases of HIV. The growing feminization of the epidemic is of concern especially in a country where a large number of households are headedby women. While inearlier years the male/female ratio of seropositive people was 8: I,the difference has narrowed substantially to a ratio of 1.8: 1. Women currently account for 31percent of adults living with HIV/AIDS inSt. Vincent and The Grenadines. The age distribution of HIV/AIDSfollows patterns experienced inother countries: most HIVpositivecases (60 percent) are inthe 25-55 age group; the 15-24 year age group accountsfor 19.7 percent, those over 50 year 8 percent andthe 5-14 year age group accounts for 0.7 percent. The infected include a broad spectrum of the population, both the unemployed and the employed (entertainment and service sectors, farming, laborers, protection officers, fishermen, vendors, sailors, shop assistants, teachers, students and health care workers). Despite highlevels of general information on HIV/AIDS,positive behavior change has not beennoted inSt. Vincent andThe Grenadines. Although the HIVIAIDSprevalence rate i s still low, the population inthe Caribbean i s highly mobile and the epidemic is growing quickly in a number of other countries. Inaddition, early initiation into sexual activity by both males and females appears to be common. This calls for early intervention to avoid a rapid growth of the epidemic. The Government of St. Vincent and The Grenadines (GOSVG), with the assistance of the World Health Organization (WHO), established a responseprogram following the identificationof the first HIV/AIDS case in 1984. While many activities were undertaken, it became apparent to the Government that it neededto do more to reduce the growing incidence of HIV, provide support programs for peopleliving with HIVIAIDS (PLWHA), provide behavior modification programs and address gender issues related to the epidemic. Basedon a situation analysis and broad 1 consultative process with all key stakeholders, the Government prepareda NationalHIV/AIDS and Sexually Transmitted Infections (STI) Strategic Plan 2001-2006, which was updated in February 2004 (Strategic Plan 2004-2009). The plan is basedon the Caribbean Strategic Plan of Action for HIV/AIDS and proposes five main strategies: (1) strengthening inter-sectoral management, organizational structures and institutional capacity; (2) developing, strengthening and implementingHIV/AIDS/STI Prevention and Control programs with priority given to youth and highriskhulnerable groups; (3) strengthening care, support and treatment programs for people living with AIDS and their families; (4) conducting research; and (5) upgrading surveillance systems. The proposed SVG HIV/AIDS Prevention and Control Project will support the implementation of this national HIV/AIDS strategy. 2. Rationale for Bankinvolvement The World Bank will provide additional resourcesto supplement the national budget and the limited external funding to finance highpriority cost-effective interventions for HIV/AIDS. The project will enable the ongoing national response to be expandedand inparticular will enhance the responseof all Government ministries and civil society organizations. Bank support will: (a) contribute directly to immediate scaling-up of ongoing initiatives; (b) help to strengthen antiretroviral treatment that has already been introduced in the treatment program; (c) share lessons learned from implementing HIV/AIDSprojects under the current multi-country and multi- sectoral projects inAfrica, the Caribbean, Brazil and other parts of the world; (d) support technical guidance and share best practices (interventions, technology, coordination and implementation modalities) obtained through its coordination with other UNagencies under the auspicesof UNAIDSas well as with other multi-lateral and bilateral donodfunding agencies; and (e) help to ensure that key policy issues at national, regional and global levels are addressed. The project will generatelarge externalities by strengthening the coordination and implementation capacity of public and private institutions in order to builda sustainablebase for the national response. Project activities are HIV/AIDS specific but the current health system i s too weak to ensure their successfulimplementation. Creating an enabling environment for HIV/AIDS prevention and control means strengthening clinical laboratory services; disposing safely of biomedical waste; buildinga disease surveillance capacity supported by an up-to-date information technology platform; modernizing the procurement, storage and distribution of pharmaceuticals and medical supplies; ensuringeffective collection of blood and the safe storage; transportation and application of blood units; and upgrading the technical and interpersonal communications skills of various categories of health workers. Therefore, the project will strengthenhealth care delivery in the country by providingthe right environment for implementing HIV/AIDS interventions. 3. Higher levelobjectives to which the project contributes The project i s consistent with the World Bank's Country Assistance Strategy (CAS) for the EasternCaribbean Sub-region of June 4, 2001. The CAS identifies the needto address HIV/AIDS inSVGas amatter of urgency. The project will support the goals of the Government's National Strategic Plan 2004-2009 for HIV/AIDS, which are to reduce the incidence of HIV/AIDS, reduce mortality from it and offer support to people living with HIV/AIDS and their families. The project is part of the World Bank's Caribbean Multi-Country HIV/AIDSPrevention andControl Adaptable Program Lending supporting the Caribbean 2 Regional Strategic Plan of Action for HIV/AIDS that i s the basis for each country's HIV/AIDS Strategic Plan. PROJECTDESCRIPTION 1. Lendinginstrument The Project i s funded through a Specific Loan/Credit/Grant under the thirdphase of the Bank's Caribbean Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending(APL) approved inJune 2001. Through the APL, support has beenprovided to the DominicanRepublic, Barbados, Jamaica, Grenada, St. Kitts and Nevis, Trinidad andTobago, Guyana and the Pan Caribbean HIV/AIDS Partnership. The St. Vincent and The GrenadinesHIV/AIDSPrevention and Control Project will be funded through a blend of IDA grant (25 percent), IDA credit (25 percent) and IBRDloan (50percent). 2. Programobjective and phases The Bank's CaribbeanMulti-Country HIV/AIDSPrevention and Control APL of US$l55.0 million i s basedon the Caribbean Regional Strategic Plan of Action for HIV/AIDS agreed among all stakeholdersin the region, including donors. The overall development objective of this APL is to assist the Caribbean countries in: (i)preventing the spreadof HIV/AIDSand reducing transmission among high-risk groups; (ii) improving access of PLWHA to care that i s effective, affordable and equitable within the context of the government health policy; and (iii) strengthening their institutional capacity to respond to HIV/AIDS ina sustainable way. Each country's project under the APL depends on the stage of the epidemic, income levels, and the socioeconomic status of the affected persons. The APL i s implementing in three phases with countries qualifying for support after they have demonstratedadequatepreparation to implement an expanded HIV/AIDSprevention and control program and meet the following eligibility criteria: (i)have a satisfactory national strategic planbasedon the Regional Strategic Action Plan; (ii)demonstratenational commitment and leadership, (iii) an implementation strategy that adopt i s multi-sectoral and involves multiple stakeholders in the public, private, NGO and community areas; (iv) have sustainable fiduciary implementation arrangements (financial, legal, procurement and regulatory); and (v) have clearly defined institutionalarrangements for monitoring and evaluating the epidemic. St. Vincent andThe Grenadinesmeets the eligibility criteria for World Bank assistanceunder the APL. Ithasasatisfactory strategicplan-"The HIV/AIDSStrategic Plan2004-2009" - basedon the Caribbean Regional HIV/ALDS Strategic Plan of Action. The plan was prepared in a participatory manner involvingkey stakeholders and the Government has approved the plan. The leadership's commitment has beenenhancedby the establishment of the National AIDS Council (NAC) to be co-chaired by the Prime Ministerand the Minister of Health. The Government has adopted a multi-sectoral andmultiple stakeholder implementation strategy and has demonstrated commitment, through the selection of key ministries to lead the multi-sectoral responseand by developing modalities for engaging civil society organizations to participate inresponding to the epidemic. It has reviewed its institutionalframework and put in place a sustainable structure for coordination andimplementation o f the national HIV/AIDSprogram. 3 3. Projectdevelopment objective and key indicators The objective of the Project i s to assist the Government incontrolling the spreadof the HIV/AIDS epidemic through: (a) the scaling up of programs for the prevention of HIV/AIDS,targeting in particular both HIV/AIDS High-risk Groups and the generalpopulation; (b) the scaling up of programs for the treatment and care of people living with HIV/AIDS; (c) the reduction of the degree of stigma and discrimination associatedwith HIV/AIDS; and (d) the strengthening of the institutional capacity of the Ministry of Health and Environment (MOHE), other related government agencies and civil society organizations to ensurethe effectiveness andthe sustainability of the Project. Annex 3 presents indicators to measurethe success of the national program in general and of the project inparticular. Key indicators will track progressin achieving the desired program and project impact and outcomes by measuring: (i) changesin the prevalence and incidence rates of HIV/AIDS inthe generalpopulation andinhighrisk groups; (ii) to antiretroviral therapy access and to treatment for opportunistic infections by infected persons; (iii)support for affected households and orphans; (iv) accepting and non-discriminatory attitudes by the population towards victims o f the disease in the workplace and in the community. More specific indicators will monitor the outputs from usingcorrect processesand timely inputs that are causally related to project impact and outcomes. The following outputs will be monitored frequently: (i) positive HIV cases identified, counseled and treated; (ii) cases traced and STI treated; (iii) number of condoms distributed; (iv) pregnant women testing positive andreceiving antiretroviral therapy; (v) blood units screenedbefore transfusion; (vi) physicians and nurses trained inmanaging HIV/AIDSpatients; (vii) orphans identified and caredfor; (viii) HIV/AIDS IEC messagesaired inthe mass media; and (ix) Civil Society Organizations (CSOs) actively engagedin the national HIV/AIDS response. 4. Projectdescription The project will cost US$8.75 million and will be implemented over a periodof five years. It will be financed through an International Bank for Reconstruction and Development (IBRD)loanof US$3.5 million, International Development Association (IDA) credit of SDR 1.25 million (US$1.75 million equivalent) and an IDA grant of SDR 1.25 million (US$1.75 million equivalent). The Government will contribute US$1.75 million. Project financing will complement the Government's own funding and already securedor expected funds from the Global Fund,Pan-AmericanHealthOrganizationhVorldHealthOrganization( P A H O N O ) , the European Union (EU) and the United Kingdom-see annex 2. Component 1. Scaling-up HIV/AIDS Response by Civil Society Organizations (US$0.98 million). The project will empower communities to respond effectively to the HIV/AIDS epidemic. Civil society organizations (CSOs) such as Non-Governmental Organizations (NGOs), Community-Based Organizations (CBOs), faith-based organizations (FBOs) and the private sector have access to difficult-to-reach groups that are particularly highrisk commercial sex workers (CSW), menhaving sex with men (MSM),prisoners and vulnerable groups (orphans andyouth). Civil society organizations will be able to request grants to support new or ongoing projects for HIV/AIDS prevention, treatment and care, and mitigation. These groups will be invited to prepare subprojectsfor funding in accordance with eligibility criteria specified in the project 4 operations manual. Activities that could be implemented by these organizations include behavior change information, education and communication, support to orphans, provisionof care for PLWHA, and distribution of condoms. The project will also finance capacity buildingfor the csos. Component 2. Scaling-up the Response by Line Ministries(US$1.60 million). The project will support line ministries to expand initiatives inaccordance with priorities in the National Strategic Plan for HIV/AIDS 2004-2009. The project will support crosscutting activities focusing on prevention of HIV/AIDS and STIs through: training, information, education, communication/ behavior change communication; condom distribution; treatment and care for the infected and affected families; and work place policy formulation including reduction of stigma and discrimination. There are HIV/AIDS-related interventions that are specific to a particular ministry's external clients, for example, students, teachers and parentsfor the Ministry of Education, the hotel and restaurantindustry for the Ministry of Tourism and Culture, and PLWHA's, orphans,juvenile delinquents and school dropouts for the Ministry of Social Development. Interventions will be tailored by each of the ministries to their respective clients. The Ministry of Tourism andCulture, the Ministry of Social Development, and the Ministry of Education, Youth and Sports will leadthe way by preparing work plans for fundinginthe first year of project implementation. Focal points in these three ministries have been identified to coordinate each ministry's HIV/AIDSplanning, implementation, monitoringand evaluation and they will receive training to enhancetheir skills to coordinate their respective ministry's HIV/AIDS response. All ministries are expectedto be included inthe project by the end of the third year of project implementation Component 3: Strengthening the Health Sector Response to HIV/AIDS (US$3.48 million). This component will support strengthening,upgrading and expansion of HIV/AIDSprevention, treatment and care services delivered through the health care system. This will include capacity building, especially of primary health care services, to ensure that that they are strengthenedand staff are adequately trained to respond to HIV/AIDSparticularly given the fast changing knowledge and technology. Specific areas of support include the following: a) Information, Education and CommunicatiodBehavior Change Communication (IEC/BCCj. Behavior change i s at the center of controlling the spread of HIV/AIDS. The project will support the IEC/BCC activities including: development and dissemination of IEC/BCC materials; installation of an electronic billboard; and use of television, radio and newspapers. b) Provision and distribution of condoms. The project will support the procurement and distribution of condoms through the Government's health care network, by civil society organizations and non-health sector ministries. c) Ensuring safety ofblood supplies. The project will support expansion of blood storage capacity and community campaigns to increasethe number of blooddonors. d) Voluntary Counseling and Testing (VCTj. Support will beprovided to the ministry to develop an effective VCT services in all the nine health districts of the country. Support will include: refurbishment of 18 VCT rooms; development, distributionand updating of the VCT protocol; equipment, test kits and supplies; and, training of counselors. 5 d) Sexually TransmittedInfections (STZs). Support to managementof STIs will include: strengthening o f the syndromic approach; provision of drugs, diagnostics, training of health workers; and, refurbishment of the examinatiordcounseling room at the STD clinic. e) Provision and distribution of condoms. The project will support the procurement and distribution of condoms through the Government's health care network, by civil society organizations and non-health sector ministries. f ) Treatment care and support of PLWHA. The project will support services for PLWHA including: STDs, treatment of opportunistic infections, anti-retroviral therapy; prevention of mother-to-child transmission of HIV/AIDS including the treatment of mothers with anti-retroviral drugs (PMTCT-PLUS); and support of nutritionalinterventions for PLWHA. Support will include: procurement, storage and distribution of pharmaceuticals, equipment and supplies required for effective managementof HIV/AIDS; strengthening of the laboratory capacity to assist in the diagnosis, treatment and care of PLWHA through (training of staff, equipment including those for CD4l cell count, rapid test kits, laboratory reagentsand a laboratory technologist to support the laboratory service); training of health care workers on the treatment protocols for managementof HIV/AIDSand sensitization to reduce stigma and discrimination of HIV/AIDSpatients; and, care and support initiatives includinghome-basedcare and nutritional support. g) Policyformulation and technical guidance. The project will support policy formulation and technical guidance provided by the MOHE. h) Promotion of a safe workplace. The project will support implementation of safe work place procedures as well as general awareness and sensitization of health workers. i)BiomedicalWasteManagement. Theprojectwillsupporttheimplementationofthe Government's biomedical waste managementplan. Component4. StrengtheningInstitutionalCapacity for Program Managementand Monitoring & Evaluation (US$2.55 million). The project will support institutional capacity buildingfor scaling-up the national responsethrough financing of technical advisory services, training, staffing, equipment, goods and general operating costs of the following activities: a) Strengthening institutional capacityfor coordinating and managing the Government's National HZV/AZDS Program. The project will support the newly-established NAC and its operating arm, the National AIDS Secretariat (NAS), located inthe MOHE. It will also provide support to the Country Coordination Mechanism Council (CCM) responsible for evaluating demand-driven CSO proposals. Specialized skills will be added to the NAS to coordinate and oversee project implementation. An already existingProject Coordination Unit (PCU) for externally financed projects located inthe Ministry of Finance, Planning and Development (MOFPD)will support the financial managementandprocurement activities of the project. b) Strengtheningprogram monitoring and evaluation (M&E). The project will support: (a) program implementation monitoring; (b) epidemiological surveillance; and (c) HIV/AIDS/STI clinical managementinformation system (CMIS) and required information technology (IT) CD4: white blood cells (T- lymphocytes) 6 platformfor the main public hospital andfor 18 VCT selected health centers. The CMIS will generate HIV/AIDS/STI information for decision making at the point of service through online electronic medical records (EMR) that record: VCT, antenatalcare, PMTCT, Antiretroviral treatment (ART) and STIs interventions. It will protect the confidentiality of medical records; improve the reliability of the notification, surveillance and M&Einformation allowing validation and cross reference analysis from multiple databases; and contribute to reductions in underreporting, redundant testing and improved turn around time indiagnostic procedures. Project support will include technical assistance, training, three behavioral surveys, acquisition of hardware and software, andequipment and suppliesto enablethe production and analysis of valid and reliable data. The project will complement the MOHE Pilot Project with the Ministry of Telecommunications, Science, Technology and Industry (MTSTI)for implementing MOHE's connectivity to the GOSVG's Backbone and Wide Area Network (WAN) in Kingstown, and the MOHE'scommunications network linking selectedhealth facilities. This support will be complemented by assistancefrom CAREC and the regional HIV/AIDSproject being supported by the World Bank. 5. Lessonslearnedand reflected inthe project design The project incorporates lessonsoutlined inthe Caribbean Multi-Country HIV/AIDSPrevention and Control APL and the lessons learned inthe implementation of the first Phaseof the Africa Region HIV/AIDSPrevention and Control APL (summarized inthe MAP2 Report P7497 AFR). They include: a) The need for high-level political commitment and leadership to confront the epidemic and deal with stigma and discrimination which slow down an effective response. The establishment of the multisectoral NAC, co-chaired by the Prime Minister and the Minister of Health, will accord the necessary visibility and stature to the HIV/AIDS effort. b) A comprehensive approach of prevention, treatment, and care with emphasis on prevention as the most cost-effective means of managing the epidemic. The project has included funding for behavior change through IECBCC as an important prevention intervention and the provision of Antiretroviral (ARV) drugs for treatment. c) Rapidly changing prices and technology have madepossible the faster introduction of antiretroviral treatment including Highly Active Anti-retroviral Treatment (HAART) inresource poor settings. The project will coincide with the international implementation of the 3 by 5 initiative2. The project will support capacity buildingincludingtraining of health care workers and strengthening the diagnostic capacity of laboratories. d) Monitoring andevaluation is critical inthe scaling-up of the national response. Strengthening surveillance to provide timely information for policymakers on the trends of the epidemic, and managementinformation for better program managementof the response are important features of this project. e) The Multi-country HIV/AIDSAPL projects have beenprepared as fast-track emergency responses. However, experience shows a slowing down of momentum after project launch. The development of the operations manual and first year implementation and procurement plans will * The initiativeaims to ensurethat 3 million peopleare receiving antiretroviral treatment by 2005. 7 ensure that implementing agencies have adequateplans for initiating their activities. Particular attention was paid to identifying a number of HIV/AIDSactivities of line ministriesand CSOs that are ready for scaling up for inclusion in the first year's work plan3. In addition, key actions in the procurement plan will be initiated as early as possible so that following project effectiveness the procurement i s expedited. f) All key stakeholdersare recognized as important inthe fight against HIV/AIDSand it is important to ensure that mechanismsare put inplace for line ministries, NGOs and other key civil society groups to participate in implementation. A number of line ministries and some experienced NGOs have been involved inpreparing the project and indeveloping implementation modalities. Technical assistancewill be provided duringproject implementation to all stakeholders. g) Priority is accordedto fiduciary mechanisms(financial management, accounting, procurement, review and approval procedures) andthe provisions for contracting out of services where in-house capacity i s inadequate. Strong financial management and procurement for the proposed project will be ensuredby a PCUlocated inthe MOFPD that already manages the two World Bank financed Emergency Recovery Project and the Disaster Management Projects. 6. Alternatives considered and reasons for rejection The following alternative approacheswere considered: (a) A health sector investment loan. This alternative was rejected on the grounds that while the health sector accounts for a significant proportionof a country's responseto the HIV/AIDS epidemic, it is not sufficient for achieving a significant impact inslowing it down due to the wide range of socio-economic factors (social, cultural, economic, legal, gender, etc.) that condition people's behavior and fuel the epidemic. There i s a need for a multi-sectoral approachthat deals with prevention, treatment and mitigation of the impact -- a significant proportion of which are outside the direct influence of the health sector. (b) An operation targeting high-riskand specific vulnerable population groups was rejected becausethe HIV/AIDSepidemic i s likely to move rapidly from specific groups to become generalized in the population especially given the highlevel of the epidemic incountries inthe region and the high population mobility. The project supports the Government's approach of providing support to both targeted interventions as well as for the generalpopulation in line with identifiedneeds. IMPLEMENTATION 1. Partnership arrangements This section is not applicable. CSOs and line ministries tend to be very slow in initiating project activities. 8 2. Institutionalandimplementationarrangements The Government has proposed the following governance structure for the national HIV/AIDS response: InstitutionalArrangements Responsibility for determining the strategic content andthe direction for implementing the HIV/AIDS Program in SVGingeneraland this project inparticular will be vestedinthe NAC to be co-chaired by the Hon. PrimeMinister andthe Minister of Health. This will provide strong visibility and accountability of the national response and the project to the Cabinet and to the broader public. The NAC will advise the Government on HIV/AIDS policy, set project priorities, advise on budget parameters, advocateandpromote the active involvement of all sectors and organizations in implementing HIV/AIDS actions, createpartnerships to broaden the national responseto HIV/AIDS, mobilize resourcesinternationally and locally to support the efforts, and be accountable to the public for the successful execution of the HIVlAIDS Strategic Plan 2004- 2009. The NAC would be accountableto Cabinet for project results. The NAC consists of representativesfrom the public and private sectors and would have between nine and thirteen members with approximately equal representation from Government and civil society and with initial but renewable appointments for two years. The Director of the NAS will act as Secretary to the NAC and will: (i) interface between the public and the Government on matters of HIV/AIDS/STI advocacy; and (ii)serve as a major point of contact between the Government and the international HIV/AIDS community. The day-to-day work o f coordinating program implementation will be executed through the NAS. The NASwill be the operating armof the NAC and will implement its decisions. The HIV/AIDS/STITechnical Unitinthe MOHEwill be expandedand strengthenedto assume the NAS's technical andcoordinating responsibilities entrusted to itunder the national response.The NASwill not implement the national responseas this will fall to the implementing agencies. The responsibilities of the NAS will be twofold: (i) providing technical support to the implementing agencies inplanningand preparing the project's work plans, andmonitoringand evaluating results; and (ii)supporting the implementing agencies with efficient and transparent financial and procurement managementservices. The NAS will coordinate implementation of the proposed project. The Government has appointed a Director for the NAS who will manage the HIV/AIDS/STI technical unit locatedinthe Ministry of Health & Environment and liaise with the PCUlocated in the Ministry of Finance, Planning and Development. The Director of the NAS reports to the PermanentSecretary of MOHEand coordinates the functions of the fiduciary unit through the Director of Planning of the MOFPD. The NASwill handle all matters related to designing and implementing prevention, promotion, diagnosis, treatment, care and support activities and for coordinating all HN/AIDS prevention and control work programs and plans to be executed by the three types of implementing agencies (describedbelow) ensuring that all proposed activities are inline with the National Strategic Plan. The PCUinthe MOFPD will handle all matters relatingto financial managementand procurement processes. The core staff for this unit already exists in the MOFPD. The PCU will be responsible for financial management tasks and for procurement activities and is staffed by a 9 project manager, a financial managementspecialist, a procurement specialist and appropriate administrative support personnel. The Councilof the CountryCoordinatingMechanism(CCM) will review and evaluate proposals for subprojects submitted by CSOs that are to be funded under this project. Its executive Council consists of the chairs of the six subgroups (Maternal and Child Health; Monitoring andEvaluation; Surveillance; Training; Care and Support; and Fundraising) that conform the CCM and their deputies. After evaluating the demand-driven civil society proposals, the Council will refer the recommendedproposalsto the NAS for approval andto the NAC for ratification. ImplementingAgencies The proposedproject would be implemented by three implementing agencies under the coordination of the NAS.The MOHE will be the lead executing agency and will be directly responsible for implementing the health sector's prevention, treatment, care andmitigation interventions. It will also support, coordinate and oversee program implementation by non-health ministries and by civil society implementing units through the NAS. Line Ministries: A number of national ministries and agenciesinthe public sector will assume responsibility for HIV/AIDSprevention and control and will establish their own programs to promote behavior changes and contribute to the prevention of HIV transmission among the populations and target groups that they normally serve. The first three line ministries to be included from the start of the project are the Ministry of Education, Youth and Sports, the Ministry o f Tourism and Culture, and the Ministry of Social Development. Other line ministries will be invited tojoin forces and will gradually be included as part of the national HIV/AIDS program. The Ministrv of Social Development consists of six unitsdealing with gender, family services, skills training, community development, local government and the KingstownTown Board. Populations potentially at risk for the Ministryof Education, Youth and Sports are school age children and out of school youth. The Ministrv of Tourism and Culture's high riskpopulation groups are water sports and tour operators, taxi drivers and street vendors, andhotel and restaurant service workers. A focal point - an individual identified ineachparticipating Ministry - will coordinate and manageHIV/AIDS-related activities intheir respective institutions, adapting the components of the national responseto the specific needsand characteristics of their constituencies and target populations. A sectoral HIV/AIDSCommittee will support andprovide guidance to the focal point person. Line ministries will receive technical and financial support for developing and implementing work programs from the NAS. A person in the NAS will be assignedto work with line ministries. Civil Society Organizations: CSOs will be fully involved indesigning and implementing key project activities especially at the community level and in working with highrisk population groups. NGOs, FBOsand CBOs, and other private sector entities will be invited to initiate new HIV/AIDS prevention and control activities or to extend andor continue those that they are currently managing. A network of NGOs has been established. SelectedNGOs may also be invited to perform specific functions such as IEC/BCC activities or to support formulating andor implementing work programs of line ministries as specified in the Operations Manual. Technical and financial support for program development and for program implementation will be provided by and through the NAS. Many civil society organizations are relatively small, of recent 10 origin and do not have the necessaryfiduciary and managerial structure to enter into performance- basedcontracts with the NAS. CSOs will submit proposals with costedwork programs to be financed under the proposedproject. Proposalswill be evaluated by the CCM and ratified by the NAC. CSOs will be heldaccountablefor results and for transparency in their administrative, financial andtechnical operations. 3. Monitoringand evaluation of outcomesh-esults A full time MonitoringandEvaluation (M&E) consultant within the NASwill be responsible for: (i)developing an overall M&Eplan including manuals, implementation procedures, tools, data flowcharts and a budget; (ii) strengthening the monitoring systems to ensure soundoutput and process monitoring; and (iii) validating data by random sampling recording and aggregating processes and by examining large variations inhistorical trends. Evaluation of the outcome and the impact of project performance on achieving the development objectives will be done through periodic behavioral surveys of high-riskgroups, household surveys of the generalpopulation, workplace surveys of a random sample of companies, and health facility surveys. Baseline markers and targets will be establishedfor measuring progress. Outcome/impact indicators are listed inAnnex 3. Monitoringprogramperformance and productivity of service providers will be done on an ongoing basis using managementreporting mechanisms. Service statistics will be collected regularly at the points of service and reported on a monthly basis to document progress being made andto show variations that occur. Input,process and output indicators are listed in Annex 3. 4. Sustainability The following factors will contribute to program sustainability after project completion: (a) strong political support and leadership for dealing with HIV/AIDSby the National AIDS Council establishedby the Cabinet on February 23,2004 that aims to increaseparticipation of all sectors with support of the Country Coordination Mechanism representingthe private sector, NGOs and CBOs; (b) financial sustainability over the mediumterm given the Government's commitment that upon completion of the project, it will continue to provide inthe budget at least the equivalent of the amount of the annual counterpart contribution to this project, for the HIV/AIDS programs and seek additional external funding as needed; (c) an enabling national programs policy and legal environment with the Government willing to revise the legal and regulatory framework to address issues of stigma and discrimination; and (d) implementation sustainability and ownership by key stakeholders (line ministries, civil society and communities). 11 5. Critical risksand possible controversial aspects Risk Risk Rating Risk MitigationMeasure From Outoutsto Obiective Inadequate commitment and involvement M A multi-sectoral National AIDS Council co- of politicaland administrative leadership in chaired by the Prime Minister and the Minister the-responseto the epidemic. of Health was established by the Cabinet. Project implementing agencies do not have H The National AIDS Council and the National sufficient authority, leadership, and AIDS Secretariat were created by the Cabinet to capacity to meet HIV/AIDS prevention and provide national leadership; additional staffing; control objectives. training and technical assistancewill be Drovided. Stigma and discrimination slow down the The project is supporting a broad range of expansion and use of services. interventions that address stigma and discrimination including: IEC to different target groups and to the general population; work place policies, training and sensitization of leaders at national and community level and care givers including health workers; and, revision of legislation. From Componentsto Outputs Insufficient capacity among line ministries Focal points for HIV/AIDS have been appointed and civil society groups inthose line ministriesthat will lead inthe first year o f the project. This will be done for all ministries that will be involved in the project. Training and technical assistanceto strengthen implementation capacity of line ministries and CSOs are supported under the project. NASPCU capacity inadequate especially H Additional staff will be recruited to strengthen with respect to procurement and financial the technical capacity of the NAS in the MOHE management. and the financial management and procurement capacity of the PCU inthe MOFPD. Technical assistance and regular training will be provided to the staff. Overall Risk Rating H RiskRating- H(High Risk), S (Substantial isk),M(Modest Ris ),N(Negligib1e or Low Risk) 6. Loadcreditconditionsand covenants Effectiveness Conditions. Project Management: The Borrower will have: (i) adopted a work plan approved by the Bank for the first year; and (ii) adopted the operations manual approved by the Bank. Fiduciary: (i) auditors have been appointed, and (ii) Project Account has been opened and the the an initial amount of $150,000 has been deposited therein. 12 APPRAISAL SUMMARY 1. Economic andfinancialanalyses The economic impact of HIV/AIDS has been conducted for a number of countries in the Caribbean, which due to the similar context, are relevant to SVG. It has beenestimated that the economic cost of untreated HIV/AIDSinterms of foregone Gross Domestic Product (GDP) growth inTrinidad and Tobago and Jamaica is likely to be between 1percent and 1.5 percent per annum. Similarly, savings and investment inTrinidad and Tobago and Jamaica are forecast to fall by 16.9 percent and 16.5 percent respectively over a five-year period while employment in agriculture and services will drop by 4.4 percent and7.5 percent, respectively, if the HIV/AIDS epidemic continued unchecked? There are strong reasons for public intervention to reduce the riskinthe society as a whole: (a) HIV/AIDS is acommunicable diseasewhich inflicts negative externalities on society and apurely private responseis therefore likely to fall short of the social optimum; (b) information regarding HIV transmission is imperfect; (c) HIV makespeople vulnerable to other infectious diseases including tuberculosis; (d) some individuals (spouses, newborns, victims of rape, accident victims who needblood transfusions) cannot control their own riskto HIV infection; and (e) early intervention i s necessary to reduce the costs of treatment and mitigation in later years. SVG, like other countries inthe Caribbean, has limitedresources for dealing with the HIV/AIDS epidemic. The country has selecteda range of internationally recognized cost-effective interventions for implementing its strategic HIV/AIDSplanfor the period2004 to 2009. They include STImanagement, interventions for high risk groups, voluntary testing and counseling, prevention of mother-to-child transmission and antiretroviral treatment. The recurrent cost generatedby the project is significant andmost of it will be met from external sources duringthe project life. Thus, it i s not expected to develop into a major demandon MOHE recurrent budget over the life of the project. The incremental cost of the project will be due to the increasein the staff dedicated to HIV/AIDSwork and costs of drugs and maintenanceof equipment purchasedunder the project. The GOSVG i s committed to funding the health sector and HIV/AIDSactivities. It allocated 5 percent of the recurrent budget and 12.4 percent of the development budget to Healthincluding HIV/AIDS inthe 2004 annual budget. To sustainthe project after completion, the Government has undertaken to continue to allocate in the annual budget an amount equivalent to the annual counterpart contribution to the project, for HIV/AIDS activities. 2. Technical The project will support the country's HIV/AIDSNational Strategic Planthat is basedon regionally and internationally acceptedbest practices for HIV/AIDSand was prepared in consultation with a broad range of stakeholdersin the country. The plan seeks to: (i) strengthen institutional capacity to manage an expandedresponse to establish a treatment and support network system for PLWHAs and their families; (ii) use a holistic approachto provide targeted prevention and control programs for adolescents, young adults, and highrisWvulnerable groups; (iii) researchandtrainingprograms;(iv)upgradesurveillancesystems;and(v)implement conduct advocacy programs. The main challenge will be to strengthen the health care delivery system in HIV/AIDS in the Caribbean: Economic Issues-ImpactandInvestmentResponse, `Working Paper. HealthEconomics Unit, Universityof West Indies, St. Augustine, 2000 and `Modelling the Macroeconomic Impactof HTV/AIDSinthe English-Speaking Caribbean: the Case of Trinidad andTobago and Jamaica,' Working Paper, CARECIUWIIPAHOIWHO, 2000. 13 SVG to deliver the expanded services through a decentralized system. The project will support strengthening the health care delivery system, improving diagnostic capacity of the laboratory system and enhancing the skills of staff (doctors, nurses and laboratory staff). The role of NGOs will be expandedinprevention, care and support to complement the efforts of the Government. SVG will work with CAREC and CDC in order to ensure the technical expertise required for laboratory testing, VCT, PMTCT, STIs and HIV/AIDSpatient management. The project will strengthen the information system to support management of clinical records, case management data and secondgeneration surveillance data. SVG will also strengthenits diagnostic capacity including acquisition of CD4 equipment. 3. Fiduciary The PCUcurrently located inthe MOFPD, which has experience inprovidingprocurement and financial management support to World Bank-financed projects, will be responsible for fiduciary activities of the project andwill have overall financial and accounting responsibilities for the project. Financial management responsibilities will include: (i) maintenance of accounting records, (ii) processing disbursements, (iii)preparation of project financial statementsin accordance with Bank guidelines, (iv) managementof bank accounts, (v) managementof financial information systems, (vi) preparation and submission of quarterly financial managementreports, (vii) preparation and submission of withdrawal applications, (viii) coordination with auditors duringthe annual financial audit exercise, and (ix) adoption of remedial financial management actions, as necessary,duringproject implementation. The PCU's core staff, which includes the program manager, the Financial Management & Accounting Specialist and the Procurement Specialist, i s already inplace and will be supplementedby additional staff. LoadCrediVGrant funds will be disbursedto aunique Special Account (SA) maintained ina commercial bank acceptableto the World Bank. Since accounting will be centralized at the PCU, no additional Special Account for Loadcredit funds will be necessary and all financial transactions will flow directly from the PCU's Special Account. The PCU will execute all payment orders on behalf of line ministries (including the Ministry of Health), which will receive financial support for specifically approved activities in their annual work plans. The PCU will also disburse funds to FBOs, NGOs and CBOs to implement the demand-driven component of the project. Indoing so, the PCU will utilize the disbursement procedures applicable to community-driven development projects, as explained inFiduciary Managementfor Community-Driven Development Project: A Reference Guide (May 2002). The initial disbursement into the Special Account will be an advance, and subsequentrequestsfor replenishment of the SA will be basedon the monthly submission of Statement of Expenditures (SOEs). 4. Social Key socialissuesrelevant to project objectives The HIV/AIDSepidemic in St. Vincent and The Grenadines - as inall countries - i s fueled by a complex set of social, economic, cultural, legal and physiological factors. There i s a lack of empirical data on the social and behavioral norms, attitudes andbehaviors of females and males in SVG. Nevertheless, two critical issueshave beendetermined to beparticularlyrelevant inthe spread of the epidemic: gender inequality, and stigma and discrimination. Gender Roles and Relations inSt. Vincent and The Grenadines are similar and comparable to those of other Caribbean nations and gender issues, particularly gender-basedinequalities in 14 power relations, participation and access to resources, lie at the heart of the HIV/AIDS epidemic. Risk and vulnerability differ by sex and age andthe increasing feminization of the epidemic i s indicated by the narrowing male-to-female ratio of seropositive individuals (from 8: 1initially to 1.8: 1 currently). In2003,27 percent of confirmed HIV cases were female. Dominant gender norms, particularly the machismo culture, ensure that young boys and men are socialized into a culture which supports their early initiation into sexual activity and places significant value upon high risk behaviors such as frequent andmultiple sexual partners, thus promoting the notionthat men ought to be knowledgeable and experiencedin sexual matters. Simultaneously, females may be left uninformedand dominated and dependentupon males with limited ability to negotiate safe sex. The youth - particularly young girls - are especially vulnerable inthis regard and may have limited control over their own health as well the timing, nature and `safety' o f intercourse and gender-based violence. Available data indicate that young girls also engage in early highrisk sex. Teenage pregnancy rates are highand in 2002,22 percent of total births occurred among girls aged 10to 19. Transactional relationships were noted to be relevant particularly (but not exclusively) among females and males involved inthe tourist industry. The relevance of gender- based violence, rape and incest have been noted along with drug abuse and alcoholism but no baseline data is available to substantiatethe scale of these issuesin the SVGcontext. Vulnerable and ut risk groups. Groups identified as being especially vulnerable and at risk include: `at risk youth' -particularly out-of-school boys and girls; young girls; AIDS orphans; Men having sex with men (MSM), PLWHA; transient workers (sailors etc); prisoners and Commercial Sex Workers (CSWs). Stigma and discrimination surround HIV and AIDS and evidence suggests that PLWHAand their families and AIDS orphans and other socially stigmatized and at risk groups such as MSMand CSW's suffer from severe forms of discrimination. The highly stigmatized nature of MSM(homosexuality i s illegal) forces MSMto maintain secretive private lives. This culture of silence and denial further fuels the epidemic and precludes the accessingof information, services and treatment. Issuesof confidentialitywere found to be extremely significant. Participationof key stakeholders inthe project. The project will support the activities of a broad group of stakeholders. The FBO and NGO community and other civil society organizations -asrepresentedthroughtheNationalNGONetwork-areincorporatedintotheprojectdesign and will be implementing agenciesfor initiatives inprevention, care and support to be financed and facilitated through Component 1. These organizations represent and are comprised of individuals from some of the most vulnerable and at risk segments of society ( e.g. male and female youth [inand out of school], PLWHA) who are undoubtedly well positioned to reach and influence their communities. The project will support the strengthening of the capacity of these civil society organizations through: traininginIECBCC; home basedcare; financial management, monitoring and evaluation and other project managementskills. All ministries are expectedto implement HIV/AIDSprograms by the thirdyear of the project. However, three non-health sector ministries -the Ministry of Education, Youth & Sports, the Ministry of Tourism and Culture, and the Ministry of Social Development -will be supported in the first year of implementation. All ministries will be supported inimplementing workplace policies and in developing and promoting IECBCC materials as well as promoting and distributing condoms. Advocacy to reduce discrimination will also be a cross-cutting feature of the efforts of all ministries. The focal points of each of the ministrieswill be appointed (focal 15 points for the first three ministries to participate inthe first year have beenidentified) to coordinate planning, implementation and M&E. Institutional arrangements that ensure that the project achieves its social development outcomes. Several strategic entry points have beenidentifiedfor ensuring that gender issues are adequately addressedinthe project. The project will support the efforts of the Gender Affairs Division inthe Ministry of Social Development including: a) training of their own staff on the relationships between gender and HIV/AIDS;b) sensitizing all the other government ministries to the importance of addressinggender-basedinequalities and gender issuesin their policies and in the services for the SVG society more broadly; c) promotionof sex disaggregateddata as a basis for improvingpolicy formulation; d) incorporating gender issues in community sensitization in HIV/AIDS activities, radio programs andinterventions targeted at specific segmentsof the population (e.g. in and out of school boys and, girls). The Gender Divisioni s well placed to make a considerable contribution to the Government's efforts at combating the epidemic in a gender responsive manner. Inaddition, capacity buildingefforts will be supportedthrough the NGO network. The network members will be assistedthrough sensitization sessions on gender and HIV/AIDSand forums for addressingstigma and discrimination. Their outreach activities among MSMwill be supported (gender sensitive training materials and condom distribution for example). Finally, gender specific M&Eindicators will be incorporated into the design of the population basedsurveillance surveys, household surveys and workplace surveys as well as the seroprevalencestudies among the youth and highrisk groups, and STDpatients. 5. Environment The project has a Category B environmental rating. Most of the project activities are not expected to generate adverse environmental effects as a significant proportion will be preventive activities. Treatment i s expected to generate some medical waste. A biomedical waste management assessment and aplan for its implementation were preparedin 2001 (under aWorld Bank-funded program to address the problem of solid and ship-generatedwastes), coordinated by the Natural ResourcesManagement Unit of OECS, with the goal of protecting the environment for six members of the OECS. The plan recommended a number of priority actions for dealing with biomedical waste. They include: strengthening the regulatory framework; increasedcapacity of health facility workers in managementof medical waste disposal through training and adoption of key practices such as segregationof waste; purchaseand installation of equipment for disposal of biomedical waste. The Government has allocated an equivalent of EC$600,000 inthe 2004 capital budget for purchasing biomedical waste disposal equipment. The project will finance training of health workers in waste disposal and management. 16 6. Safeguardpolicies 7. Policy readiness No policy exceptions are sought. The project has beenpreparedin accordance with the provisions of the Caribbean Multi-Country HIV/AIDS Prevention andControl. The Bank has assessedthe Government as beingready in terms of having a policy inplace for HIV/AIDS that i s elaborated inthe National HIV/AIDS Strategic Plan, the commitment of the leadership, the institutional framework for managementof the overall National HIV/AIDSProgram and the strengthening of project managementcapacity. Specifically, the Government has adopted a new institutional framework for coordinating the program. The establishment of the NAC and the CCM will ensure a multi-sectoral response. The Ministry of Health, key line ministries andthe CCM are representedon the NAC. Provisions have been made and budgeted for strengthening the project's implementation capacity. * By supporting theproposed project, the Bank does not intend to prejudice thefinal determination of thepnrties'claims on the disputed areas 17 Annex 1: Country and Sector or ProgramBackground St. Vincent And The Grenadines HIV/AIDS Prevention And ControlProject Strategic Context The proposed project is consistent with the World Bank's Country Assistance Strategy (CAS) for the Eastem Caribbean Sub-region of June 4,2001. The CAS identified the need to address HIV/AIDS inSt. Vincent andThe Grenadines as a matter of urgency. The project will support the goals of the Government's National Strategic Plan 2004-2009 for HIV/AIDS, which are to reduce the incidence of HIV/AIDS, to reduce mortality from HIV/AIDSand to offer support to people living with HIV/AIDS and their families. The project is part of the World Bank's Caribbean Multi-Country HIV/AIDSAPL supporting the Caribbean Regional Strategic Plan of Action for HIV/AIDSwhich i s the basis for eachcountry's HIV/AIDS Strategic Plan. Main Sector Issuesand Government Strategy Country and Sector Background. St. Vincent and the Grenadine's economic performance has shown some favorable improvements inrecent decades. Real GDP growth that averaged2.3 percent between 1993-97 (with significant volatility mainly causedby fluctuations inthe banana industry) improved to 4.5 percent during 1998-2000, principally as a result of tourism-related activities, construction and an increaseinbananaproduction. Nevertheless, the CAS notedthat despite the relatively good social indicators, approximately 38 percent of the population lived in absolutepoverty in 1995 and at that time it was the highest inthe OECS sub-region. The CAS places great importance on the needto assist governments in tackling HIV/AIDS. Although the epidemic inthe country is not generalized andi s currently concentrated inhigh-risk populations, the potential for rapidescalation is real. HealthStatusandthe healthcaresystem. The country's healthprofile is that of a country that has already gone through the epidemiological transition. The first five common diseases responsible for clinic visits have been similar from year to year and account for approximately 65 percent of all clinic visits. They are mostly chronic diseases and include hypertension, diabetes, the combination of diabetes and hypertension, arthritis by itself or combined with another chronic disease. The life expectancy for males was 69.5 years in 1991 compared to 68.1 years in2001. The life expectancy for females increasedfrom 74.2 years in 1991to 75.4 years in2001. The Crude BirthRate decreasedduringthe 1990sranging from 24.1 per 1,000 in 1990 to 19.3 per 1,000 in2001 and the rateof natural increaseinthe population declined from 18.1 per 1,000 in 1990 to 12.3 per 1,000 in 2001. Delivery of health care services inthe country i s dominated by the public sector with MOHE leading the organization, managementand provision services. Private sector health services are relatively small and consist of medical, dental and pharmacy services. Many doctors and dentists work in both the private and public sectors. The HIV/AIDS Epidemic inSt. Vincent and The Grenadines. The Caribbean region i s second only to the Africa region in adult prevalence rates of HIV/AIDSinfection. The first case of AIDS inthe country was reported in 1984. CAREC estimates that the adult prevalencerate of HIV in the country is 0.9 percent. Surveillance data from MOHE are derived from hospital records and 18 have shown figures lower than CAREC estimates. The country, therefore, has an opportunity to prevent the epidemic from escalating andposing a significant problem to its socio-economic development as it has in other countries. The majority of HIV infections in the country are through heterosexualrelationships and a small number of infections (estimated at about 6.1 percent) are through homosexual or bisexual transmission. Vertical transmission i s estimated to account for about 2.3 percent of all reported cases of HIV. The national responseto HIV/AIDS inthe country has been ledby MOHE reaching out to other ministries on HIV/AIDSissues and establishing links with civil society organizations. The epidemiology department of the MOHE leads surveillance for HIV/AIDS inthe country. Current information available inthe epidemiology department regarding HIVprevalence inthe country is not sufficiently reliable becauseof the non-systematic way in which it is collected. The MOHE acknowledges the shortcomings in its HIV/AIDS surveillance system and has identified this as an area for strengthening duringthe implementation of this project. GovernmentStrategy. The Government, with the assistanceof WHO, established a response program following the identification of the first HIV/AIDS case in 1984. The program included information, education and communication (IEC), condom distribution, blood screening, testing and counseling, antenatal surveillance and patient care. A formalized system of care and treatment offering antiretrovirals to HIV/AIDS patients was introduced inAugust 2003. It becameincreasingly apparent to the Government that it neededto do more to reduce the growing incidence of HIV, provide support programs for PLWHA,provide behavior modification programs and address gender issuesrelated to the epidemic. Basedon a situation analysis and a broad consultative process with all key stakeholders, the Government preparedthe National HIV/AIDS/STIStrategic Plan 2001-2006 and updatedit in February 2004. The plan is basedon the Caribbean Strategic Plan of Action for HIV/AIDS and proposes five main strategies (Strategic Plan 2004-2009): (1) Strengthen inter-sectoral management, organizational structures and institutional capacity; (2) Develop, strengthen and implement HIV/AIDS/STIPrevention and Control programs with priority given to youth and high risWvulnerable groups; 3) Strengthen care, support and treatment programs for people living with AIDS andtheir families; 4) Conduct research; and 5) Upgrade Surveillance Systems. The proposed St. Vincent and The Grenadines HIV/AIDSPrevention and Control Project will support the implementation of this National HIV/AIDSStrategic Plan. Status of Service Delivery for HIV/AIDS The current process of basing HIV/AIDSsurveillance on cases reported duringclinical presentation at the main hospital captures mostly patients inthe late stages of HIV/AIDSinfection. The HIV/AIDS unit confirms this limitation by the fact that many of the patients identifiedby this method soon develop full blown AIDS. Treatment of Sexually Transmitted Diseases (STDs) is carried out inthe country through a system of STD clinics. However, the syndromic approach for the treatment of STDs has not yet been developed and applied in the country. There are no designatedrooms for HIV/AIDS VCT. Counselors have to compete with physicians for counseling space and time. HIV test results are usually received after one week, due to the needto accumulate samples before running the testing machines. The blood transfusion service in the country routinely tests blood for, among others, HIV. There is, however, a shortage of storage 19 space for blood, reagentsfor testing blood and in-service training of staff. Pharmaceuticals (including antiretrovirals), equipment and medical supplies are procured through PPS (Pharmaceuticals Procurement Service), ajoint procurement arrangementsfor the OECS. Services for prevention of mother-to-child transmission of HIV are fairly well developed, based on the nevirapine protocol. Care is provided for both the baby and mother, who i s able to continue antiretroviral treatment as part of regular care (which i s free at the point of service) for PLWHA. The country currently has about 26 patients on anti-retroviral therapy. This is fully funded by the Government. Management of patients on antiretroviral therapy i s centralized at the Milton Cat0 Memorial Hospital, under the management of the clinical head of the HIV/AIDS unit. The supply of pharmaceuticals, laboratory equipment including CD4 count capacity, and ongoing training of health care providers are limited. Current Surveillance Protocols and Information Systems. The evaluation of the HIV/AIDS surveillance system made inNovember 19995by the MOHEin collaboration with the CAREC concluded that the sensitivity of the surveillance system (cases diagnosed divided by cases reported in 1998)was 85 percent for AIDS cases and 80 percent for HIV tests. The evaluation team and interviewed clinicians agreedthat private sector underreporting of cases was due to confidentiality issues. HIV antibody testing i s done in the National Public Laboratory inthe Milton Cat0 Memorial Hospital (MCMH) and in four private institutions. In2004, the MOHE Epidemiology unit initiated the capture of HIV testing statistics at private laboratories and clinics. However, not including individual identification pertest, raises the possibility of double counting. The current HIV/AIDS surveillance system is limited to the existing notification data available in the Epidemiology Unitincluding:(i) HIV-AIDS Case Notification System. Current data collection and processing systems are manual and lack the flexibility of online information for analysis and decision-making. Although a databaseusingEpiInfo was developed, its population with case-basedhistorical data was discontinued. The case-basedHIV/AIDS records are manually stored in the Infectious DiseaseUnit at the M C M Hwith coded lists available at the National Epidemiological Unitinthe MOHE. The request for an HIV Antibody Test form contains a national identification code basedon patient's initials and date of birthto protect patient confidentiality. However, the current IDlacks a uniqueidentifier mechanismto prevent redundanciesor errors, and limits access for contact tracing; (ii) Biological Surveillance: No sentinel surveillance has been done to determine the prevalence of HIV-AIDS invulnerable groups. The MOHE carried out the first seroprevalencesurvey during 1994-1995 with screening of 4,613 pregnant women. HIV testing inpregnant women beganin 1998;since then voluntary testing and counseling for HIV has been made available during antenatal care inthe public sector; (iii)Behavioral Surveillance: Existingbehavioral data i s limited to the risk factors related to HIV transmission and demographic information available inthe laboratory request form for HIV antibody test. Behavioral surveys are not carried out on a regular basis. Only three main behavioral studies have been carried out inthe past: two of the general population in 1990 (CAREC and Systems Caribbean 1990-1991)and 1997 (St. Vincent PlannedParenthood Association/ Dynamic Action Center) and one in the population of male prisoners in Kingstownin 1990 (see Matrices 1and 2 inthe Surveillance Evaluation Report, 1999for detailed results). The 1997 survey repeateda number of questions inthe earlier study but focused on eight high-risk communities in St. Vincent. No behavioral studieshave been carried out inthe Grenadines. A Source: Evaluationof the HIV/AIDS SurveillanceSystems, St. Vincent andThe Grenadines, 22-26November, 1999, MOH&E andCARECPAHOAVHO. 20 country-wide survey under execution by the St. Vincent PlannedParenthood Association and funded by UNICEFfor people aged 10to 24 will measureknowledge, attitudes and behavior towards HIV/AIDS. The draft report will be available by the end of May 2004. As indicated inthe Strategic Plan2004 -2009, the operational capacity of the surveillance system will require upgrading and introducing clinical managementinformation system, information technology and processesto generate accurate andtimely informationto target effectively the response, including behavioral interventions for at-risk populations. Current Information Technolow Platform. The Health Planning and InformationUnit (HPIU) processesseveral databases implemented with CAREC support. These include COMDIS for communicable diseases, MORTBASE for mortality, the Public Health Laboratory Information System (PHLIS) and M C Hfor Maternal and Child Care. Except for the PHLISdatabase, which i s partially used at the National Laboratory and the Epidemiology Unit, those databases are not available at the point of service where the needs interms of data processing, reporting and analysis have grown with the current MTCT and will be critical with the introduction of VCT and ARV treatment among others. Test confirmation carried out by the NationalPublic Lab has aturn around time of up to two weeks. All public health facilities lack computerized applications to support health information systems. Except for new initiatives in the MCMHthat prepareda HospitalInformation SystemPlan in 2001 and i s currently procuring hardware and software, most available PCs inthe hospitals and health centers visited duringproject preparation, are obsolete or lack the required maintenance and technical support. However, new facilities including some that were recently remodeled (the new building for the MOHE andthe Environmental Building)are cable ready. The Administration Unitin the MOHE is currently implementing the government financial and accounting package (SmartStream), and the MOHE i s part of the Pilot Project of the Ministry of Telecommunications, Science, Technology and Industry (MTSTI), for the connectivity to the SVG's Back bone andWide Area Network (WAN) inKingstown. The MOHEconnectivity and Internet access will be available free of charge through the MTSTIback bone including Internet and e-mail services. Milton Cat0 Memorial Hospital connectivity will be completed by MTSTI before the end of 2004. 21 Annex 2: Major Related Projects Financed by the Bankand/or other Agencies St. Vincent And The Grenadines HIV/AIDS Prevention And Control Project Relatedprojectsunder implementation: 1. WHOPAH0 is providingtechnical assistancefor HIV/AIDS (EC$80,000 is includedinthe 2004 budget). The fundingsupports development of standards, protocolsandevaluationtools, andfellowships. 2. The EuropeanUnioni s providinggrants amountingto EC$210,000in2004 for drugdemand reductionandprimaryhealthcare. 3. The CaribbeanDevelopmentBank i s financingequipment for biohazardwaste management (EC$600,000) andcompletionof a solid waste managementproject(EC$150,OoO providedinthe 2004 budget). Projectsinthe pipeline: (a) SVG may obtainfundingfrom the GlobalFundsupportto the OECS countries,US$20,000 is projectedfor 2004. (b) The UKDepartmentFor InternationalDevelopment(DFID) may provideUS$l.O million to support the sub-regionalcoordinationmechanismfor HIV/AIDS. 22 Annex 3: ResultsFramework and Monitoring St. Vincent And The Grenadines HIV/AIDS PreventionAnd ControlProject a) Project Design Summary and EvaluationIndicators Reliable, consistent and timely data for use as a baseline are very limited. A country-wide survey was carried out in November 2003 to measure the knowledge o f and attitude towards HIV/AIDS of a random sample of 400 young people aged 10to 24. Data are being analyzed and a first draft of the results will be available end May 2004. This survey - financed by the United Nations Chilren's Fund(UNICEF)and executed by the St. Vincent PlannedParenthoodAssociation - will provide some baseline data for assessing behavioral change inthe same age group duringproject execution. Other behavioral and epidemiological baseline data will need to be collected through behavioral and seroprevalence surveys duringthe first year of project implementation. The St. Vincent HIV/AIDS Strategic Plan 2004 - 2009 provides some quantified targets that are incorporated inthis framework. Hierarchy of objectives Indicators Baseline and Targets Means of Critical verification assumptions Sector-Related CAS Sector Indicators: Goal Secular trends in ry Reports: I Bank mission) Reducerisks of growing incomegrowth and Country poverty, especially incomedistribution Economic Other macro among vulnerablegroups maintainedby income Reportsand economic and (women, children, International socialvariables dependent persons) Agencies within and Studies beyondthe Economic growth and control of the incomeprotection governmentare neutral or favorable Project Development Ob, :tives Key Project Impact NationalStrategic PlanIndicators and Targets National commitmentto Standards of care reviewedand updatedby Official an effective HIV/AIDS December2004 Government response documents Treatmentprotocols developedby December2004 and statistics Referral and follow up systems specified by December2004 Training programsfor providers, PLWHAs and their families developedby December2004 By mid 2005, legal and policy measuresto guard the humanrights of all PLWHA and their significant others in place NGOscontractedto provide care for PLWHAs and their families 23 Hierarchyof objectives Indicators Baselineand Targets Means of Critical verification assumptions Prevent and control transmission of HIV Baseline: 100cases Reduce incidenceof % of HIV positive Target: 10%decreasein Statistical HIV/AIDS ingeneral cases incidence rate records population % of AIDS cases Baseline: 75 cases Target: 15% decrease in incidence rate I NationalStrategicPlanI licatorsandTargets Target highrisk groups I Public awareness By 2008, at least 30% of respondentsdemonstrate knowledge of HIV and STIprevention methods Behavioral surveys I By 2008, at least 50% of businessesin the Tourism Preventionwithin Industry with workplace programs for education Tourism sector among staff Surveys by Ministry of By 2008, all taxi drivers' associations Tourism Taxi drivers implementing workplace preventionprograms 60% of taxi drivers report protected sex practices Behavioral By September 2008,50% of all primary, secondary surveys I and tertiary level students receive upgraded Life Youth in and out of Skills and HIV and STIprevention instruction at School least twice monthly surveys Indicators Baselineand Targets ualitv o f life of people # of PLWHA receiving Baseline: 26 (2003) National vital living with AIDS ARV treatment Target: 180 statistics Case Fatality Rate Baseline: 63% (2003) Target: 40% I Reduction in % of Baseline: TBC' Population impact of HIV/AIDS on children under 15 years Target: based ersons infected and of age that have lost behavioral affected either father, mother or survey both parents TBC: To be collected. 24 Key Project Outcomes Advance safe sexual (From objectives and practices among Median age at which Baseline: TBC outcomes to goals) vulnerablehigh risk young men and women Target: Population based populations aged 15-24have had behavioral Determinants of health first penetrative sex survey outside the control of % males and females Baseline: TBC Frequency: the project remain 15+ years old with Target: beginning, mid neutral or favorable more than one sex and end of 5-year partner last year plan % men and women 15+ Baseline: TBC years old using Target: condoms Create an environment that supports the infected % of infected and Baseline: TBC Household and the affected affected individuals Target: survey who received Frequency: supportive counseling beginning, mid over the last 12 months and end of 5-year plan % of companies with Baseline: TBC Workplace ~ Reduce stigma and discrimination against non-discriminatory Target: survey PLWHA policies and practices Frequency: inrecruitment and beginning, mid benefits for employees and end of 5-year infected with HIV plan % of people surveyed Baseline: TBC Household expressing an accepting Target: survey attitude towards people beginning, mid with HIV and end of project Key Project Outputs Access to VCT improved Number o f public Baseline: TBC Facility survey (From outputs to facilities that are Target: Frequency: outcomes and staffed by trained beginning, mid objectives) counselors providing and end o f 5-year specialized HIV plan counseling and testing The national plan Access to treatment and Number of healthcare Baseline: 1 Facility survey receives full and care for HIV/AIDS facilities that deliver Target: 6 Frequency: sustained support of all improved palliative care, beginning, mid stakeholders treatment for and end o f 5-year opportunistic infections plan Current human resource and referral for HIV- shortages will be infected patients overcome and retention according to national of staff i s ensured guidelines 25 Number of health care Baseline: 1 Financial resources facilities providing Target: 6 earmarked for the plan HAARTaccording to are adequate national guidelines b) Project MonitoringIndicators - Monitoring indicators focus on programmatic reporting of input andprocess measuresto be usedby program managers as indicators of project performance. - Means of verification are service statistics andreports aggregatedfrom service delivery sites. - Core Indicators are drawn from the UNAIDSGuide to Monitoring andEvaluation (2000), the Caribbean HealthResearchCouncil "Caribbean Indicators andMeasurement Tools (CIMT) for the Evaluation of National AIDS Programmes" (2003), the U SAID: Handbook of Indicators for HIV/AIDS/STIprograms (2000), and the St. Vincent HIV/AIDS Strategic Plan 2004-2009. Process Measures for Prevention Process Indicators Activities Voluntary Counseling and Testing (VCT) I Reduce the incidence of HIV FromJanuary 2005, all VCT services meet national and regional- infections quality standards I Sexually Transmitted Infections IINumber of personscounseled in each delivery site by age group and gender and number o f positive cases referred @TI) ~ Improve the accessibility and STI services available in at least one Primary Health Care Center in control of STIs each district by the end of 2005 By 2009,50% increase among clients with one or more STIs who sought treatment for STIs within the previous six months Condoms Availability of condoms improved Number of male condoms distributed duringthe preceding 12 months divided by population aged 15-49 PMTCT Free PMTCT and PMTCT Plus B y December 2004, all pregnant women routinely counseled and services integrated into all public screenedfor HIV status and private antenatal services By December 2005, all HIV positive mothers-to-be provided with treatment and guidance Blood Safety 100% of blood units transfused have been screenedfor HIV according to WHO guidelines P L W H A Create an environment that By December 2005, all known PLWHA and their significant others supports the infected and the have access to peer support groups affected Elimination of stigma and By the end of 2008, at least 50% of all health care institutions 26 ProcessMeasuresfor Prevention ProcessIndicators Activities discrimination observing "PLWHA Friendly Health Care Institution" Policy ~~~ Orphans % HIV/AIDS orphans and vulnerable children receiving psychosocial support SupportGroups By 2006, at least one community and home basedcare program in operation ineach health district Trainingand CapacityBuilding By January 2006, at least one primary health care facility in each health district staffed with trained VCT counselors and offering free VCT services Number of doctors trained inHIV/AIDS InputMeasures NationalStrategicPlanInputIndicatorsandTargets IEC programs for general Average number of TV and radio spots with IEC messagesper population expanded week Education programs targeting From2004, all instruction in Life Skills and HIV and STI school-based and community-based prevention promote sexual responsibility among males and females youth expanded and addressgender issues Beginning in 2004, at least 3 teachers per school receive refresher training at least once annually to increase their capacity to address HIVIAIDS issues Parents empowered to B y 2008, 25% more parents expressing comfort with educating communicate with their children their children on HIV/AIDS/STI (both male and female) on B y 2008, 25% increase in youth expressing satisfaction with HIV/AIDS/STI issues parental communication on HIV/AIDS/STI Capacity of Civil Society to # of CSOs providing HIV/AIDS care and support activities respond to the needsof PLWHA # of sustainedprivate sector workplace programs strengthened STI and HIV/AIDS surveillance B y January 2005, systems and staffing of the surveillance unit are strengthened capable of undertaking comprehensive HIV/AIDS/STI surveillance Number of laboratory facilities performing ELISA HIV tests and linked to NSUthrough ITplatform Appropriate institutional and ByDecember 2005, three moreline ministries participate in management arrangementsfor the implementingthe National Strategic Plan national expanded response established National AIDS Secretariat fully staffed and operational by December 2004 Conduct specific HIV/AIDS/STI Base line data obtained from Seroprevalence studies and from research KABP studies undertaken on selected population groups by Seotember 2005 DocumentingandReportingOutcomesandImpact The previous Results Framework contains a list of key indicators that will be augmented by indicators included in the National HIV/AIDS Strategic Plan. Tools to document outcomes and impact will include: 27 (i) Behavior Surveillance Surveys (BSS)7and seroprevalencestudies: youth and high-riskgroups, STD patients, CSW, MSM;prison inmates; (ii)Knowledge, Attitudes, and Practices ( U P ) studies of selectedgroups and the general population regarding HIV infection and AIDS; (iii)workplace discrimination surveys; and (iv) key informant interviews. The Clinical Management InformationSystem (CMIS) described inthe next section will be the driving force behind the reporting of outcomes and impact. Researchactivities to be financed would address issues relating to the economic and social impact of HIV/AIDS, behavioral changes, ART clinical outcomes, and cost-effectivenessof interventions. ProgrammaticReportingof Input,Process,and Output Monitoring of ongoing activities and of progressbeing made i s an integral part of managing the process of delivering aplanned and supervisedflow of HIV/AIDS/STIprevention, treatment and care services. Programmatic reporting documents critical activities that are causally linked to positive project outcomes that must be monitored by the program manager on an ongoing basis. Prevention Activities: VCT: How many and where are positive HIV cases diagnosed?How many positive cases were counseled?STD:Where and how many STD cases are diagnosed and treated? Condoms:How many andwhere are condoms distributed?; PMTCT: new cases, cumulative cases, HIV treatment given and type of treatment, cost of treatment; BloodSafety:Number of donors screenedfor HIVIAIDSand number positive. Treatment and Care Activities: PLWHA:number of new cases, cumulative cases, AIDS treatment given and type of treatment, number of ART prescriptions, ART expenditures, opportunistic infections (01s) incidence rate, number of deaths, time elapsedbetween diagnosis and death, number receiving 01prophylaxis, number of hospital patient days; Orphans:number identified, total number identified, number enrolled, total number enrolled, number receiving support; Support Groups: number of groups, number of groups with trained counselors, average patientdgroup, number of patients enrolled by age and sex. Capacity BuildingActivities: Training: new and cumulative numbersfor professional staff, peers, volunteers; number of persoddays of training provided by target group, number of doctors trained inHIV/AIDS, number of patients seen by trained doctors. The CMIS will capture these data at the point of service. Health care delivery personnel will be trained to ensurethe reliability of data recorded for subsequent processing and reporting to management. The project will support strengthening the epidemiological and analytical capacity of MOHE to monitor the HIV/AIDSsituation and to evaluate the impact of the project, including technical assistanceat midterm review and at project completion. BaselineData. A country-wide survey has been carried to measurethe knowledge of and attitude towards HIV/AIDSof a random sample of 400 young people aged 10to 24 of which 60 percent were inschool and40 percent were out of school. Half of the respondents were male and half 'The BSS interventions would be programmedtargeting high-risk groups, including laboratory and seroprevalence surveillanceprotocols for VCT, CSW, MSMwith CAREC support. 28 female. Data were collected in November 2003 usingan open and closed interview instrument and validating the interview responsesthrough the use of three focus groups. A first draft of the results will be available end May 2004. This survey - financed by UNICEF andexecutedby the St. Vincent PlannedParenthoodAssociation - will provide some baseline data for assessing behavioral change inthe same age group during project execution. Other behavioral and epidemiological baseline data will be collected using behavioral and seroprevalence surveys during the first year of project implementation. HIV/AIDS/STI Clinical ManagementInformation Systemand Connectivity. To support the objectives in the GOSVG's HIV/AIDS Strategic Plan 2004-2009 for strengthening the surveillance andMonitoring and Evaluation systems, the project will fund the acquisition and implementation of a clinical management information system (CMIS) and required information technology (IT) platform for the mainpublic hospitals and for 18 VCT selectedhealth centers. The system will generateHIV/AIDS/STI demographic and clinical information for decision making at the point of service, through online electronic medical records (EMR)for case managementsupport addressing VCT, ANC, PMTCT, ART and STIs interventions. The proposed application will complement the Milton Cat0 Memorial Hospital initiative to develop the HospitalInformation Systemincludingthe Patient Administration System and Laboratory Information module within the CMIS, and will provide the IT platform to integrate current MOHE's surveillance databases and additional behavioral databases required to implement HIV-AIDS second generation surveillance. The CMIS will capture demographic, diagnostic' and other patient services andproceduresat the point of service, manage clinical records online (outpatient and inpatient), abstract data from clinical records for monitoring purposes, and report results from behavioral and risk factor surveys. With CAREC's technical assistanceto be provided under the CARICOM HIV-AIDS Regional Grant, the project will support the MOHE and the NationalPathology Laboratory at the Milton Cat0 Memorial Hospital inthe implementation of CAREC's laboratory information system(LABIS)ininterface with the selectedCMIS. The CMIS will also contribute to the M C M Hand other MOHE Hospitals and health centers future management, by generating apatient account and unique identification (ID) linked to the National Insurance Scheme. This would enable billingand reimbursement mechanisms basedon discharges and coded procedures (Diagnostic RelatedGroups ) and ICD9- CM9. The requirements of the system, to be selectedfrom applications available inthe market should: - protect the confidentiality of medical records through encrypted technology and provide electronic audit trail mechanisms; - improve the quality of the notification, surveillance and M&Einformationallowing enable validation and cross reference analysis from multiple databases; - contribute to reductions in underreporting, redundant testing and improved turn - around access to treating physicians and nurses through secured online real time time in diagnostic procedures; and provide enable clinical, behavioral, laboratory, diagnostic imagingand pharmaceutical information at the point of service. * Basedon the International Classification of Diseases lothrevision. InternationalClassification of Diseases gthRevision, Clinical Modification. 29 The HIV/AIDS/STICMIS should provide real-time laboratory and clinical informationfor case managementand to activate notificationand surveillance mechanisms, antenatal care, VCT and MTCT, and HIV/AIDS/STIearly diagnosis and treatment; patient registration and assigning a unique ID and patient demographics; risk factors; contact tracing and counseling; tuberculosis (TB)case managementassociatedto HIV; Web basedaccess for treating physician to online diagnostic and lab testing relative to the management of 01s and ART response; CD4 and viral load and applied history and date sensitive treatment; plan adherenceand non compliance alert as well as up-to-date informationon drug prescription, dispensation, online therapeutic protocols, adverseeffects advice, utilization, drug adversereaction and resistance; estimated date of HIV transmission; utilization of all care, treatment and support services resources:pharmacy", laboratory, x-ray and other specialty diagnostic interventions, counseling time and materials; diagnostic (ICD- 10) andprocedurescoding and insurance billing processes(ICD9-CM, CPT-4 1 or other codes adoptedby the MOHE and the National Insurance Scheme). The application should include interfaces for the electronic transfer of CD4 and Viral Load and other test data and reports generatedby laboratory and blood bank analyzers and for the integration of the HIV/AIDS/STI notificationdatabases with geo-referencedmappingtools. To protect patient's privacy rights as well as the integrity and confidentiality of the electronic medical records, the application should includeencrypting technology and double key facilities, restricting access to medical records to authorized personnel only. Epidemiological studies and surveillance processesshould be basedon coded data assuring anonymity and confidentiality o f epidemiological analysis and research. The system should be able to track quality o f care aspects interms of outcomes andcosts, casemanagement- inparticular, managementof treatment and adherenceto highly active antiretroviral therapy (HAART). The system will capture variables (indicators) which will provide measuresof cost effectiveness, efficacy, accessibility, responsiveness,reliability and equity of care to be compared with defined standards of care, treatment and support. The implementation of the CMIS will include: i)pilot testing phasefor the selection and acquisition of the CMIS from applications available in the market, and technical assistancefor the adaptation andimplementation in selectedoutpatient and inpatient care departmentsinthe Milton Cat0 Memorial Hospital (MCMH), the NationalLaboratory and Blood Bank, and Kingstown Health Center, the MOHE (Health Planning and Information; HIV/AIDSTechnical Unitand the Epidemiology Unit),andthe Community HealthServices and Nursing, the Central Stores and Pharmacy in the Environmental HealthBuilding; ii)expansion in the secondphaseto the five MOHE District Hospitals and 18 selectedVCT health centers and line ministries (see detailed list inAnnex Ito this Annex); iii)capture of data at the point of service relative to demographics, clinical records and behavioral and risk factor surveys to support real time notification, processing, and reporting in VCT, STI, antenatal and MTCT activities and ART; iv) online, real time access, web-based critical information for HIV-AIDS-STI prevention, treatment and secondgeneration surveillance, epidemiological analysis andresearchfor decision making; and iv) connectivity'2 andITplatform for selectedhealth centers, the M C M Hlaboratory and ~~~ lo Ininterfacewith the OECSPharmaceutical ProcurementService systemto be implementedinthe MOH&E's Central Medical Stores and PharmacyDepartment. I' Common Procedural Terminology Fourth Revision The connectivity for the MOHE Wide Area Network (WAN) and the health facilities' LAN (data, VoIP, and video) to be provided by the project, will complement the backboneand LANs being implemented and operatedby the MTSTI. Server roomswith controlled access and air-conditioning, will be requiredwithin the offices of the MOH&E, the MCMHand the Environmental Health Building. 30 blood bank, district hospitals, and central level MOHE, and Environmental Health Building, line ministries and NGOs. Training should be provided inthe differentproject phases to managers, health professionals and technicians, financial and administrative staff of the MOHE and respective health facilities inthe use of information technology, and in the respective mission critical applications, including the retrieval, geo-referencedstatistical andepidemiological analysis and the use of information in decision making. InformationTechnologv (IT) Platform. The project will complement the funding of the MOHE Pilot Project with the Ministry of Telecommunications, Science, Technology and Industry (MTSTI), for the implementation of MOHE's connectivity to the SVG's Back bone andWide Area Network (WAN) inKingstown, and the MOHE's communications network linkingselected St. Vincent andThe Grenadines health facilities. The MTSTIwill provide technical support, basic computer training and specialized I T certification of users and IT technicians neededfor the creation of IT Unitsinthe MOHE and MCMH to support users andday to day network administration. The proposed implementation should be coordinated with civil works included inthe project for health facilities selectedfor rehabilitation of VCT rooms, emergency, laboratory and bloodbank, and should be complemented with ergonomic nursingcounters and connections as well as the inclusion of embeddedconduits, dedicated electrical wiring and uninterrupted power supply (UPS) for 24 hour power supply. To ensure the sustainability of the ITplatform, the Health Planning and InformationUnitinthe MOHE will require the establishment of an IT Unitfor network and database administration and a help-desk to support users inall networked facilities. Specialized IT technical assistance, training and WAN connectivity support would be obtained from the MTSTI. For the implementation of the First Phase, the MCMH will also require the establishment of an IT unit. Agreements between the MOHE and the new M C M Hgovernance board to staff such unit would be necessary. To contribute to the development of the health sector and the MOHEcapacity to operatethe IT platform andto assist the MOHE, line ministries and other participating agencies inall phases of the CMIS implementation, the project will fundthe selection and recruitingof an IT specialist for the NAS. Proposedterms of reference were reviewed with the MOHE duringproject preparation. The HIV/AIDS/STI surveillance, M&Eand the CMIS will be implemented inthe selectedHealth Facilities andLineMinistries (See Annex Ito this Annex) providing decentralized data entry at the point of service andcentralized processing inthree nodes with a battery of servers installed at the MCMH, the Environmental HealthUnit and the IT Unit at the MOHE. Electronic data transfer with MOHE's Health Planning and InformationUnit will provide connectivity, online access to NAS, the Epidemiology and HIV/AIDS Technical Units, with full database redundancy and back up protection. SecuredWeb basedbrowsers through IPprotocols (virtual private network (VPN)) and encrypted technology for the protection of patient's confidentiality should be available to private physicians and labs to access the MOHE's HIV/AIDS/STI information system. The applications and acquisition of IT Platform should be modular, scalable and integrated in steps, according to the following recommended phases: 31 Preparation of Request for Proposals(RFP), short list and selection, and awarding of technical assistancefor the implementation of HIV/AIDS/STI clinical MIS from applications available in the market; inthe preparatory stage, technical specifications for the hardware and software to be acquired and respective biddingprocesseswill be defined according to the health facilities participating inthe Pilot Phase. Ten months parameterization and pilot testing in the Milton Cat0 Memorial Hospitaland Health Center including the National Lab. This pilot phasewill include the initiation of sensitization and training of the clinical and paramedic staff participating in the SecondPhase with the use of case studies with complete medical records of a sample of HIV/AIDS patients. The pilot will also include the implementation of the laboratory and bloodbank test processing module (LABIS)13 providedby CAREC. Once the modules are operational at the Kingstown hospital, configuration and connectivity with the main servers at the MOHE and the Environmental Health Building should be establishedthrough the MTSTIbackbone. Inparallel with the FirstPhase, the project will providetrainingfor the strengthening of the monitoring and evaluation capacity for program development and management, including UNAIDS support inthe implementation of data collection and analytical processesin all participating agencies. Line ministries will be providedwith workstations and technical assistancefrom UNAIDS and the NASR`echnical Unitto populate and operateUNAIDS/Country ResponseInformation System (CRIS) databases: Indicator database; Projecthesource tracking database; Researchinventory database. The SecondPhasewill be initiatedduringthe secondyear, with the implementation of the CMIS inDistrict Hospitals andHealthCenters, includingthe backbone links, testingand connectivity with the MTSTIbackbone. A tentative timetable has been developed, indicating the possible sequenceof the procurement processesby years one to three. Fullimplementation of the CMIS and the required ITplatform will be completed by year four. The technical specifications for the I T platformagreeableto the Bank should be compatible with the MTSTIand will be the basis for the definition of the final requirements in Hardware and Software to be procured under the project. The bidding documents for the purchaseand installation of the hardware, should include the provisionof the provider to install and configure the server's operational software (Microsoft Windows Server 2003 or equivalent with network administrator, servers manager, web page creation, structured query language (SQL) Server with on line analytical processing application or equivalent, with technological upgrade or software assurance for at least two years); network anti-virus and web firewall; multi-licenses for office applications and other geo-referencedmapping software; statistical packages; epidemiological modeling and forecasting applications; UPS system and electrical wiring; switches, panels, structured wiring or wireless as appropriate for voice over internet protocol (VoIP), data and 13CAREC's CariSurv -Lab InformationSystem2000"virtual laboratory" application (LABIS) includes specimenand patientregistration; test scheduling,barcode label printing and reporting of individual patientresults following electronic approval, running over a LAN with an SQL database. Embeddedis a specimeninventory management systemthat facilitates tracking of specimens in short- and long-term storage, and maintains the linkbetweenspecimen, patient andtest datafor archived specimens. 32 video, local area networks (LAN). Extended warranty for the repair and maintenance of the equipment for at least three years should be considered. 33 Figure 1:Organizational Data Flow 1. Reduce H NTransmission 2, Mitigatethe impactof HIV and AIDS 8 8 c0a IInformed by I m m m 8 m m m Develops National AIDS Council Annual Evaluation Reports Stakeholdersat national, district and local level mB Private Sector, Public Sector m m And Civil Society 8 s cca 8 34 t r E r? I I N r N c v - r ? --I--- - I + + --I- I *I - I l- t 7 Annex 4: DetailedProject Description St. Vincent And The Grenadines HIV/AIDS Prevention And ControlProject The project will support the Government of St. Vincent andThe Grenadinesto implement its national responseto the HIV/AIDSepidemic in all the key areas of a comprehensive response including prevention, treatment, care, and impact mitigation. The project will be implemented by bothpublic sector and civil society organizations and will include capacity building interventions to ensure adequate capacity to effectively implement, monitor and evaluate project interventions. Prevention. Project interventions in this area will include information, education and communication interventions, with an emphasis on behavior changecommunication for specific target groups and the generalpopulation; condom promotion; voluntary counseling and testing (VCT) andprevention of mother-to-child transmission of HIV/AIDSwith extension of services to the entire affected family (PMTCT-Plus); Treatment and care. The project will support the treatment and care of PLWHA including the use of antiretroviral drugs, treatment of opportunistic infections, treatment of sexually transmitted infections and support to home and community-based care and support services; Capacity buildingfor health care service provision. Support will be provided by the project to assist inthe training of health care workers, including laboratory service providers, to ensure provision of quality HIV/AIDS services by the health sector. The project will also support the acquisition of the necessaryequipment and supplies for appropriate management of PLWHA within the health sector. Capacity Buildingfor advocacy, policy formulation, program coordination, resource management. The project will support capacity buildinginterventions for civil society organizations, non-health sector project implementers and NAS, to ensuremultisectoral and coordinated project implementation. Strengthening of monitoring, evaluation and operationalresearch. The project will support the strengthening of national capacity to monitor and evaluate HIV/AIDS interventions. This support will include support for HIV/AIDSsurveillance (sentinel, population based andbehavior) and program managementmonitoringbasedon performance indicators; The project will be implementedover a period of five years and will be financed through an IDA and IBRDblend of grant, credit and loan with Government contribution for counterpart funds. The project will have four components as outlined below. Component 1. Scaling-up HIV/AIDS Response by Civil Society Organizations (US$0.98 million). Civil society organizations are more effective than public sector agencies inreaching certain vulnerable difficult-to-reach groups inthe community, such as sex workers and other hard-to-reach-groups. The civil society organizations also operatemostly at the community level where there are opportunities to interact directly with individuals and communities. While some civil society organizations may be well developed and ready to implement their respective HIV/AIDSprogram activities, others may needsubstantial capacity buildinginorder for them to be effective. This component will finance HIV/AIDSprevention, care and support activities ledby communities, Non Government Organizations (NGOs), faith-based organizations, women's 38 organizations, the private sector and other similar organizations. It will also support capacity building activities of civil society organizations to respond effectively to HIV/AIDS. The types of HIV/AIDSactivities to be supportedby this component will bedemand-driven and will vary depending on the proposals that will be presentedby the respective civil society organizations. Examples of activities by these organizations that will be eligible for project support include, but are not be limitedto: (a) delivery of community-based HIV/AIDS IEC/BCC; (b) condom distribution and/or social marketing; (c) home-basedcare of PLWHA; (d) community advocacy to reduce HIV/AIDS stigma and discrimination; (e) support activities for orphans and widows/widowers of HIV/AIDS; (f) support activities for people infected and affected by HIV/AIDSincluding income-generating activities; (g) community targeted activities for HIV/AIDSvulnerable groups, includingsex workers, out of school youth and young women; (h) training of civil society organizations on HIV/AIDS knowledge and communication; (i) training of leaders of civil society organizations on financial managementpractices relevant to the implementation of the HIV/AIDSproject; and 0) provisionof essential goods and supplies for NGOs to enablethem to effectively function while delivering HIV/AIDS prevention care and support services. Criteria for eligibility and proceduresfor the civil society organizations to access project funding will be specified inthe Operational Manual of the project. Inparticular, the operational manual will specify eligibility criteria for funding, the processfor application and approval of fundingand the reporting arrangements between the civil society organizations and the project coordinating team. Eligibility criteria will be flexible enough to allow greater participation of various categoriesof civil society organization inthe fight against HIV/AIDS in the country. The reporting arrangements for the civil society organizations will be simple enough to enable accountability without overburdening the limited capacity of particularly smaller organizations. Component 2. Scaling-up the Response by Line Ministries(US$1.60million). An effective and comprehensive responseto HIV/AIDS includes the responseof all sectorsas each sector has a uniquerole to play in the fight against HIV/AIDS. This component will support the response to HIV/AIDS by non-health sector line ministries. There are basic cross-cutting HIV/AIDSactivities which all ministries areexpectedto implement under their respective sectoral HIV/AIDSprograms and to be supported under this component. These include: (a) development and implementation of workplace HIV/AIDS policies; (b) IEC/BCC for HIV/AIDS and STDs; (b) condom distribution and promotion; (c) advocacy to reduce HIV/AIDS stigmatization and discrimination, particularly in the work place; and (d) establishment of a support group for HIV/AIDS (either as a single ministry or in collaboration with other ministries). There are also HIV/AIDS-related interventions that are specific to a particular ministry and each ministry i s responsible for identifying its specific HIV/AIDSprogram needs that will be supported by this component. For example, the ministry responsible for education has a specific target group (pupils, students and teachers) that requires relevant HIV/AIDS interventions. The ministry responsible for tourism requires a specific HIV/AIDS responsefor the tourist environment. The ministry responsible for the uniformed forces and prisons may wish to design HIVIAIDS interventions for the uniformed forces and for the prison population. All ministriesare expectedto be implementingtheir respective HIV/AIDS programs by the end of the third year of project implementation. However, three ministrieswill lead the way as of the first year of project implementation. They are (a) Education, Youths and Sports; (b) Tourism and Culture; and (c) Social Development 39 Ministries will appoint HIV/AIDS focal points (person or unit) who will lead the respective sector's HIV/AIDS response. A sectoralHIV/AIDS committee will be set up to support the focal point inorder to institutionalize the sectoralHIV/AIDSresponse. The focal point will coordinate the ministry's HIV/AIDSplanning, implementation, monitoring and evaluation. Focal points will be supported by the project to receive training to develop the skills required for them to effectively lead their respective sectoralHIV/AIDS response. Component 3: Strengthening the Health Sector Response to HIV/AIDS (US$3.48 million) This component will support strengtheningof health sector HIV/AIDS related servicesfor prevention, treatment, care and support. It will support the strengthening of existing primary health care (PHC) services to respond to HIV/AIDS. This will include capacity buildingto ensure that health care services are strengthened and staff members are adequately trained to respond to HIV/AIDS especially giventhe fast-changing knowledge and technology. Some of the areas of support within this component will include the following: a) Ensuring safety of blood supplies. The project will support MOHE the ministryto strengthen its blood supply mechanismsto ensure safety from HIV and other blood borne diseases. In particular, it will support the expansion of blood storage capacity and community campaigns to increasethe number of regular blood donors. b) Voluntary Counseling and Testing (VCT). Support will be providedto MOHE to develop an effective and confidential VCT system for the country. The project will support the provision of VCT services in all nine health districts of the country. It will support: refurbishment of 18 VCT rooms at selectedhealth facilities to provide for the appropriate privacy and confidentiality to clients; development, distribution andupdating of the VCT protocol; equipment, test kits and supplies; and, training on VCT. c) Sexually Transmitted Diseases (STDs). The project will support: strengthening of the existing STD servicesand inparticular, strengthening the syndromic approach to the managementof STDs; drugs; diagnostics; trainingof health workers; and, refurbishment of the examinationlcounseling room at the STD clinic. d) Provision and distribution of condoms. The use of condoms is one of the most cost effective HIVIAIDS interventions. The project will support the provision of condoms through the Government's health care network and for distribution by civil society organizations and non- health sector ministries. One million condoms will be procured in the first year and thereafter, one and a half million condoms will be procured each year. Condom supply and demandwill be monitored to ensure adequateand continuous supply across the country. e) Treatment, care and support of PLWHA. The project will support the services for treatment of opportunistic infections, STDs, anti-retroviral therapy; prevention of mother-to-child transmission of HIV/AIDS including the treatment of mothers with anti-retroviral drugs (PMTCT-PLUS); and support of nutritional interventions for PLWHA. The project will support: (i) Supply of pharmaceuticals, equipment and supplies for HIV/AIDSmanagement. The project will support the procurement, storage and distribution of pharmaceuticals, 40 equipment and supplies required for effective managementof HIV/AIDS. Inparticular, the project will support the ministry's effort to increasethe availability and choice of anti- retroviral drugs within the arsenal of pharmaceuticals for the managementof HIV/AIDS and drugs for management of opportunistic infections. (ii) projectwillsupportthestrengtheningofthelaboratorycapacitytoassistinthe The diagnosis, treatment and care of PLWHA. Inparticular, the project will support the training of staff, acquisition of materials and equipment required for laboratory use during the use of antiretroviral drugs for the managementof PLWHA. A CD4 count system, rapidtest kits, laboratory reagentsand a laboratory technologist to support the laboratory service, will all be provided by the project. (iii)Training of health care staff to respond to HIV/AIDS. There i s an expressed needfor training of various categoriesof health care workers on the treatment protocols for managementof HIV/AIDS. Training will also be provided health care workers to reduce stigma and discrimination of HIV/AIDS patients. (iv) Care and support initiatives including home-basedcare and nutritional support will be assistedby the project. f) HIWAIDSsurveillance andoperational research. While thereis ongoing HIV/AIDS surveillance by MOHE, there i s room for improvement of the surveillance system to ensure reliability of the data collected. The project will support the strengthening of the HIV/AIDS surveillance system and operational researchrelated to HIV/AIDS. Ante-natal surveillance will be strengthenedas it i s auseful source of estimating the population prevalence of HIV given that there i s almost 100percent ante-natalcare attendance in the country. Three behavioral surveys will be carried out. The project will support training, equipment, supplies and technical assistance under component 4. g) Information, Education and CommunicationBehavior Change Communication (IECBCC). It i s important for efforts in IECIBCC to be steppedup for the different population groups. Support to strengthen HIV/AIDS IECBCC through the MOHE will include: development and dissemination of IEC/BCC materials; installation of an electronic billboard; use of television, radio and newspapers. The MOHE will also provide technical support to the line ministries and civil society organizations. This support i s included under component 4 of the project. h) Promotion of safe workplace proceduresinthe health sector. The project will support MOHE in strengthening the implementation of its safe workplace proceduresto minimize occupational HIV infection among health care workers. Support inthis area will include trainingof health workers and the provisionof materials and supplies necessary for ensuring safe working environments inthe health sector. i)Medicalwastemanagement. TheprojectwillsupporttheGovernmentintheimplementationof its medical waste managementplan, as it relates to the disposal of medical waste created in the course of delivery of services to PLWHA. Inparticular, the project will support training of health care staff to keep up to date with the requirements for safe disposal of medical waste. 41 j)Policyformulation and technical support onHIV/AIDS.Theproject will supportpolicy formulation and strengthening of the role of MOHE inproviding technical guidance for managing HIV/AIDS to the non-health ministries and the civil society organizations. Component 4: Strengthening Institutional Capacity for ProgramManagement and Monitoring & Evaluation (US$2.55 million). This component will support the buildingof institutional capacity for program coordination and management. The Government has establishedthe NationalAIDS Council to coordinate the national response andensure an appropriate policy and legal environment. The Council i s co- chaired by the Prime Ministerand the Minister of Health andincludes key stakeholdersfrom the public andprivate sectors. The project will support the operations of this body. A National HIV/AIDS Secretariat (NAS) will provide operational support to NAC and coordinate the technical implementation aspects of the project. An already existingPCUin the MOFPD will assure proper financial and procurement management.The project will support the NAS and the PCU in its functions that include: (a) overall coordination and oversight of project implementation; (b) program monitoring and evaluation; (c) financial managementand procurement; and (d) HIV/AIDS related and programrelated training of staff of NAS and PCU. Project support will include consultant services, technical assistance, materials, furniture, and equipment for the operation of NAS. NAS will provide key program coordination and managementfunctions. Functions of the Secretariatthat cannot be providedin-house would be out-sourced. Strengtheningprogram monitoring and evaluation including information technology capabilities. The National HIV/AIDS Secretariat will be responsible for overall monitoring and evaluation of the program and of this project. Key areas to be supported include: (i) strengthening program monitoringcapacity; (ii) development and strengthening of the HIV/AIDS/STI case management; and, (iii)measuring the trend of the epidemic and surveillance system. The project will support training for managers; health professionals and technicians; financial and administrative staff of the M O Hand respective health facilities inthe use of information technology (including retrieval, geo-referencedand epidemiological analysis) and the use of information for decision making). It will also support connectivity and wide area network services and internet service provider (ISP); technical assistancefor development of a national plan and activities on surveillance, research, evaluation andinformation systems and training. The HIV/AIDS/STIsurveillance, monitoring and clinical case managementinformation system (MIS)will bedevelopedmodularlyto support HIV/AIDSProject components. Itwill capture demographic and service provision data at the point of service delivery, manage clinical records online (outpatient and inpatient), abstract data from clinical records for monitoring purposes, and report results from behavioral and risk factor surveys. Informationwill be providedfor real time decision making, and for notification, processing, and reporting, VCT, STI, PMTCT and ARV interventions. Resourcesfor hardware, software, staff, training and technical assistancewill be provided through this component of the project. 42 Annex 5: Project Costs St. Vincent And The Grenadines HIV/AIDS Prevention And Control Project Project Cost B y Component and/or Activity Local Foreign Total US $million US $million US $miIlion Component 1. Civil Society- Organizations Initiatives - 0.960 0.020 0.980 Component 2: Line Ministry Response 1.370 0.230 1.600 Component 3: Strengthening the Health Sector response 1.330 2.150 3.480 Component 4: Strengthening Institutional Capacity for 1.840 0.710 2.550 program management Total Baseline Cost 5.500 3.110 8.610 Price Contigencies 0.105 0.105 TotalProjectCosts' 5.500 3.215 8.715 F r o n t a dFee 0.035 0.035 TotalFinancingRequired 5.500 3.250 8.750 'Identifiable taxes and duties are US$m0.86,and the total project cost, net of taxes, i s US$m 7.89 . Therefore, the share of project cost net of taxes is 90 percent. 43 Annex 6: ImplementationArrangements St. Vincent And The Grenadines HIV/AIDS Prevention And ControlProject InstitutionalArrangements The project would be implemented through an institutional andmanagement structure that would permit the widest participation of public sector andprivate sector stakeholdersand allow incorporation of eventual future donors of the international community. Responsibility for determining the strategic content and the direction for implementing the project inSVGwould be vested inthe NationalAIDS Council (NAC). Cabinet grantedapproval for establishing the National AIDS Council on February 23,2004 to be co-chaired by the Hon. Prime Minister and the Minister of Health. This will provide strong visibility and accountability of the national response and the project to the Cabinet and to the broader public interest. The NAC will advise the GOSVG on HIV/AIDS policy, set project priorities, advise on budget parameters, advocate and promote the active involvement of all sectors and organizations in implementing HIV/AIDS managementactions, createpartnerships to broaden the national response to HIV/AIDS,mobilize resourcesinternationally and locally to support the efforts, andbe accountable to the public for the successfulexecution of the St. Vincent and The GrenadinesHIV/AIDS/STI Strategic Plan 2004- 2009. The NAC would be accountable for project results. The NAC would consist of representativesfrom the public and private sectors. The Council would have nine to thirteen members with approximately equal representation from Government and civil society and with initial but renewable appointments for two years. The NationalAIDS Council would: i) be fully accountable to Cabinet for project results; ii) include public andprivate sector stakeholder groups: representatives of line ministries and representativesof relevant private institutions such as NGOs, FBOs, CBOs, Chamber of Commerce, Manufacturing Associations, Hotel and Tourism Association, andhealth care providers; iii) advise the Cabinet on those policies and strategies that require Cabinet approval; iv) set the priorities for the project; V I advise on program and budget parameters; vi) prepare an annual report on the national response; vii) mobilize national and international resources for the fight against HIV/AIDS/STI; viii) mobilize multi-sector support for the national response; and ix) coordinate preparation and implementation of the work programs of the line ministries ensuring that each ministry has an appropriate work plan and budget. The Director of the National AIDS Secretariat will act as Secretary to the NAC and will: i) interface between the public and the Government on matters of HIV/AIDS/STI advocacy, ii) serve as a major point of contact between the Government and the international HIVIAIDS community. The day-to-day work of coordinating program implementation will be executed through the National AIDS Secretariat (NAS). The NAS i s the operating arm of the NAC and will 44 implementits decisions. The HIV/AIDS/STI Unitinthe MOHE will be expandedand strengthenedto assume the technical andcoordinating responsibilities for clinical care. The NAS will not be engaged in implementing the national responseas this will fall to the implementing agencies. The responsibilities of the NAS will be twofold: (i) providingtechnical support to the implementing agencies inplanning andpreparing the project's work plans and monitoringand evaluating results; and (ii)supporting the implementing agencies with efficient and transparent financial andprocurement managementservices. A Director for the NationalAIDS Secretariatwas appointed on April 5,2004 and will managethe HIV/AIDS/STITechnical Unit located inthe Ministry of Health & Environment andliaise with the PCU responsible for fiduciary matters located inthe Ministry of Finance, Planning and Development. The Director of the NAS reports to the Permanent Secretary of MOHE and coordinates the functions of the PCUthrough the Director of Planning within the MOFPD. The NASwill handle all technical mattersrelated to designing and implementing prevention, promotion, diagnosis, treatment, care and support activities and for coordinating all HIV/AIDS prevention and control work programs and plans to be executed by the three types of implementing agencies (described below) ensuringthat all proposed activities are inline with the National Strategic Plan. Program officers will staff NAS with capabilities inmonitoringand evaluation, information technology, development communications strategies, epidemiology, a coordinator for the line ministries and the CSOs and supportive administrative personnel. Such staff may be recruited through personal services contracts or secondedfrom other branchesof government service inorder to promote sustainability of the Unit. The NAS will receive support from technical departmentsin the MOHE inspecific substantive areas. It will aggregatethe results from the monitoringand evaluation processesof the national responsefor consideration and eventual decisions on changes inpolicies and operating procedures by the NAC. The pcUinthe MOFPD will handle all mattersrelating to financial managementand procurement processes. The core staff for this unit already exists in the MOFPD. The PCU would be responsible for financial managementtasks (keeping books of accounts for all project resourcesin accordance with GOSVGand WB regulations, disbursingfunds to implementers, requesting payments or reimbursements from the World Bank, preparing consolidated financial reports) and for procurement activities (procuring goods and services, bidding and contracting tasks) and is staffed by a financial managementspecialist, a procurement specialist and appropriate administrative support personnel. The Councilof the Country CoordinatingMechanism(CCM) will review and evaluate proposals for subprojects submitted by Civil Society Organizations that are to be funded under this project. The CCM was launchedinFebruary 2003 with broadrepresentationfrom all sectors of the St. Vincentian society. Its executive Council consists of the chairs of the six subgroups and their deputies. The full CCM meets bi-annually and its Council meetsmonthly. The Chairperson of the CCM is a respectedprivate sector executive and the six subgroups with their respective chairs and deputy chairs are Maternal and Child Health, Monitoring and Evaluation, Surveillance, Training, Care and Support, and Fundraising. After evaluating the demand driven civil society proposals, the Council will refer the recommended proposals to the NAS for approval and to the NAC for ratification. 45 The governance structure proposedby the Government is shown inFigure 2. ImplementingAgencies The proposed project would be implemented by three groups of implementingagencies under the coordination of the NAS.The Ministryof Healthand Environment would be the lead executing agency because of its past leadership role andthe technical expertise it commands in the matter. The MOHE will be directly responsible for implementing the health sector's prevention, care and mitigation interventions and through NAS it will support, coordinate and overseeprogram implementation by non-health ministriesand by civil society implementing units. HIV/AIDS Focal Points inLine Ministries: A number of national ministries and agenciesinthe public sector will assume responsibility for HIV/AIDS prevention and control. Line ministries will establish their own programs to promote behavior changes and contribute to the prevention of HIVtransmission among the populations andtarget groupsthat they normally serve. The first three line ministries to be included from the start of the project are the Ministry of Education, Youth and Sports, the Ministry of Tourism and Culture, and the Ministry of Social Development. Other line ministries will be invited tojoin forces and will gradually be included as part of the national HIV/AIDS program. The Ministry of Social Development consists of six units dealing with gender, family services, skills training, community development, local government and the Kingstown Town Board. Among its external clients are PLWHAsand orphans that receive a monthly subvention, juvenile delinquents, child abuse cases, domestic violence and spousal abuse cases, school drop outs in needof vocational and technical skills training, and local community groups. Populations potentially at riskfor the Ministryof Education, Youth and Sports are school age children, unattachedyouth, and out of school youth. The Ministry of Tourism andCulture's high riskpopulation groups are water sports and tour operators, taxi drivers and street vendors, and hotel and restaurant service workers. A focal point - an individual identified ineach participating Ministry - will coordinate and manage HIV/AIDS- related activities in their respective institutions, adapting the components of the national responseto the specific needsand characteristics of their constituencies and target populations. A sectoral HIV/AIDSCommittee will support and provide guidance to the focal point person. Line ministries will receive technical and financial support for developing and implementing work programs from the Technical Unit of the National AIDS Secretariat. A person in the Technical Unit will be assignedto work with line ministries. Civil Society Organizations: CSOs will be fully involved indesigning and implementing key project activities especially at the community level and working with highrisk population groups. Non-governmental (NGOs), faith-based (FBOs) and community-based organizations (CBOs), and other private sector entities will be invited to initiate new HIV/AIDSprevention and control activities or to extend and/or continue those that they are currently managing. A network of NGOs has beenestablishedwith its Articles of Incorporation and i s inthe process of being registered with the Registrar of Companies in the Court House as a legal entity representing most NGOs. SelectedNGOs may also be invited to perform specific functions such as IEC/BCC activities or support formulating and/or implementing work programs of line ministries. Depending on their comparative advantages, they would serve the needs of specific target groups at risk or in need of care. 46 A leading NGO is the St. Vincent PlannedParenthoodAssociation with a staff of six persons and an annual budget of US$53,000. The House of Hope is aFBO launched in 1999by the Anglican Church to care for HIV/AIDSpatients and i s now supervised by the Anglican, Methodist and Roman Catholic churches, the Salvation Army and the Christian Council. Bread of Life i s a smaller FBO managedby a Catholic Apostolate within the Carmelite Congregation to care for HIV infected orphans. An example of aCBO is the PenistonSports and Cultural Organization. Other CSOs are the St. Vincent Human Rights Association, the Baptist Church, Marion House, the National Youth Council, Impact 2000, East Dynamic Organization, RedCross, and the Association for Advancement of Troumaca. As inthe case of the line ministries, technical and financial support for program development and for program implementation will be provided by and through the National AIDS Secretariat. Many civil society organizations are relatively small, of recent origin and do not have the necessary fiduciary and managerial structure to enter into performance-basedcontracts with the NAS. CSOs will submit work programs to be financed under the proposedproject andapproved by the NAC. They will be held accountable for results and for transparencyin their administrative, financial andtechnical operations. Recognizing that these grassroots organizations however could play an important role in their respective communities, sustained efforts will be made to mentor, coach and support them. Larger well-established NGOs could serve as mentors to small emerging NGOs. A person in the Technical Unit of the NAS will be assignedto work directly with civil society organizations. 47 Figure2: InstitutionalArrangements Prime Minister Cabinet I National AIDS Council (NAC) I National AIDS SecretariatDirector Review CSO Sub- MOHE Technical Support Unit I I I Implementing Agencies $. $. f iMinistry of Health and the Non-HealthMinistries Civil Society Environment NGOs Education, Youth & Sports FBOS 1Central Level Units Tourism and Culture CBOs Hospitals & Health Centers Social Development Private Sector Other Ministries Trade Unions iLaboratories BloodBank I I 48 ImplementationArrangements for LineMinistries. Component 2 will support the response of the non-health sector ministries to HIV/AIDS. Cross- cutting HIV/AIDS activities that all ministries can implement are: (a) developing and implementing workplace HIV/AIDS policies; (b) IECBCC for HIVIAIDS and STDs; (c) condom promotion and distribution; (d) activities to reduce stigmatization anddiscrimination; and (e) establish support groups for persons infected with HIV/AIDS and for their families. Some HIV/AIDS-related interventions are specific to a ministry's external clients, for example, pupils, students and teachers, for the Ministry of Education, Youth and Sports; the hotel and restaurant industry for the Ministry of Tourism and Culture; PLWHAs and orphans that receive a monthly subvention, juvenile delinquents, child abuse cases, domestic violence, school drop outs inneedof skills training, andlocal community groups for the Ministry of Social Development. All ministries would be eligible to obtain funding for their HIV/AIDS activities under the project. To access fundinga ministry should have: Identifieda person (focal point) responsible for managing the HIVIAIDS activities within the ministry who would lead the HIV/AIDS response.The focal point would coordinate the ministry's HIV/AIDSplanning, implementation, monitoring and evaluation functions. Focal points would be supportedby the project to receive training to develop the skills to lead their respective sectoral HIV/AIDS responseeffectively. 0 Establishedan HIV/AIDS team to provide guidance to the HIVIAIDS focal point. A focal point person is a minimumrequirement but, where feasible, a sectoral HIV/AIDS committee or team should be set up to support and provide guidance to the focal point in order to institutionalize the HIV/AIDS response. 0 Developed an annual work plan for its proposed activities. The annual work plan should be inline with the priorities of the National HIVIAIDS Strategic Plan. It should indicate the fundingsources for proposed activities including: Ministry's own contribution through its budget; requestedfunding from this project, funding from any other donors and external agencies, and fundingfrom the private sector. While all relevant ministriesareexpectedto be funded under the project, the following ministries - and any other ministry that has met the above readiness criteria - are expected to prepare work plans for the first year of project implementation: (a) Education, Youth and Sports; (b) Tourism and Culture; and (c) Social Development. Annual work plans would be reviewed by the National HIV/AIDS Secretariat andto the National AIDS Council for approval. 49 SUBPROJECT CYCLE FOR LINEMINISTRIES (LM)on work planpreparationand Secretariat assist in designingandbudgeting activities PrepareAnnual work plan including Annually Line Ministry, Permanent financial and procurementplan Secretary Review Reviewwork plans andrecommend Annually NationalHIV/AIDS I approvalin accordance with Secretariat guidelines Approval I Approve work plans andauthorize I Annually I NationalAIDS Council ~~ NAS to sign MOUs Contracting SignMOUwith line ministry Annually NAS andLM Disbursefunds basedon MOU As needed NAS Implementation Report projectprogress Quarterly LM Supervision Reviewimplementationprogress Quarterly NationalAIDS Council Mid-termevaluationof line Mid2007 I NationalHN/AIDS I projectmid-termevaluation ministriesinitiativesas part of I I Secretariat I I ProiectComDletion ReDort I End2009 I LMandNAS Implementation Arrangements for Civil Society Initiatives. Civil society organizations (CSOs) will implement component 1through subprojects. CSOs include: NGOs (local and international), faith-based organizations, community groups, professional associations, trade unions, andprivate sector organizations. They will be eligible for funding and will apply for grants through subprojects. The NASmay also solicit particular CSOs to prepare proposalsfor undertaking specific activities. Private sector organizations will be requestedto provide co-financing and will follow procedures specified inthe operations manual including: Principles of operation: -The National HIVIAIDSSecretariat coordinates the activities of the CSOs to ensure full integration with the national HIV/AIDS program. -Theproject review, monitoringand accounting processwill be open andtransparent Interaction betweendifferent CSO's working together e.g. NGOs and CBOs will be encouraged and facilitated. 50 Eligibleapplicants: -Be an established group that is recognizedby the Government, registered through a relevant Government agency, or be a member of the National NGO network or have international recognition; -Have experience in community work or be endorsed by community leaders; and -Have a verifiable managementand accounting structure. If criteriacannotbemetthentheNASortheNationalNGONetworkmayinsomecases these helpattain eligibility or recommendtwinning arrangementswith an eligible group. ProceduralArrangements: CSOswill prepareproposals according to guidelines distributed by the NAS. The NAS or larger and well establishedNGOs would provide technical assistanceto CSOs inproposal preparation. CSOs will submit proposals for subprojects to the NAS. NAS will review the eligibility of CSOs andrefer sub-project proposals to the CCM Council for evaluating their cost and technical soundness. NAS will transmit the list of recommendedproposals to NAC for ratification. NAS will provide guidancefor the implementation of the sub-projects and monitor their implementation. CSOs will implement the approved subprojects and submit quarterly progressreports and a completion report at the end of the project. NAS inturn will keep the NAC informed of the progressmade by the CSOs. Eligibleactivities: IEChehaviorchangeactivities (drama, seminars andtalks), guidance to care- givers, provision of care and support to PLWHA, support to orphans, schemes for income generation to replace income, guidance on treatment for STD, opportunistic infections and ARV, voluntary testing and counseling. 51 SUBPROJECT CYCLE FOR CSOS Stage Activity Timine; ResponsibleParty Planning 1. Mobilize CSOs 2. Annually National HIV/AIDS and disseminate project Secretariat information Distribute application forms and Annua11y NationalHIV/AIDS provide TA for sub-project Secretariat DreDaration Prepare sub-projects and send Annually or bi-annually cso proposals to NAs Appraisal Review eligibility of applicants Annually or bi-annually NationalHIV/AIDS and refer sub-project proposals to Secretariat CCM Council for evaluation CCM Council to evaluate Annually or bi-annually CCM Council proposals and recommend approval in accordance with guidelines and budget Transmit list of recommended sub- Annually or bi-annually National HIV/AIDS projects to NAC for ratification Secretariat and financing Approval Approve eligible subprojects and Annually or bi-annually National AIDS authorize NAS to sign contracts Council with CSOs Contracting Sign contract with CSO specifying Annually or bi-annually National HIV/AIDS rightsand obligations and Secretariat and CSO including a financial/procurement plan Disburse funds accordingto As needed National HIV/AIDS signed contract Secretariat ImDlementation Report project progress Quarterly cso Supervision Review progress of Quarterly National AIDS implementation Council Mid-termevaluation of CSO Mid2007 National HIV/AIDS initiatives as part o f project mid- Secretariat term evaluation Project Completion Report End2009 National HIV/AIDS Secretariat 52 Annex 7: FinancialManagement and Disbursement Arrangements St. Vincent And The Grenadines HIV/AIDS PreventionAnd Control Project Summary Conclusionof FinancialManagement Assessment. On the basis of the assessments performed, the financial management team presentsthe following conclusions: (9 The PCU, currently located inthe Ministry of Finance, Planning and Development and responsible for managing the fiduciary aspectsof two World Bank projects (namely ERPand ERDMP), will be responsible for managing the fiduciary aspectsof the proposed project. (ii) Overall,thePCUalreadyhasinplaceanadequatefinancialmanagementsystemto manage the fiduciary aspects of World Bank projects, since it manages two World Bank projects. (iii) AssumingthePCUcarriesouttheproposedactionplanspresentedinthisassessment, especially the hiringof an Assistant Accountant, it would have inplace adequate financial managementarrangementsthat meet the Bank minimumfiduciary requirements to manage the specific financial activities of the proposed project. It has beenagreed(1) that the PCU will open a Special Account denominated inUSDina commercial bank acceptableto the World Bank; (2) that loanfunds will, at least initially, be disbursed to the Special Account on the basis of SOEs; (3) that each quarter, the PCU will prepare the Financial MonitoringReports (FMRs) to be submitted to the Bank (the FMRswill include a narrative outlining the major project achievements for the quarter, the project's sources anduses of funds, a detailed analysis of expenditures by sub-component, a physical progressreport, a procurement report and aprocurement table); and (4) that annual project financial statements will be audited in accordance with International Standards onAuditingissuedby the International FederationofAccountants (IFAC), by independent auditors and in accordance with terms of reference (TORS), both acceptable to the Bank. Annex 6 details the Implementing Arrangements consisting of the National AIDS Council, the National AIDS Secretariat and three implementingagencies. The Technical Director of the NAS has been appointed. The Secretariat would have two units: (a) a fiduciarv unit for all matters relating to financial managementand procurement processes(maintaining accounting and administrative records, processing disbursements, reviewing contracts and makingpayments for activities related to the project). This unit (the PCU) already exists and i s located inthe Ministry of Finance, Planning and Development and will be strengthenedwith the addition of a Procurement Assistant, an Accountant Assistant and an Administrative Assistant; and (b) a technical unit, located inthe MOHE, for all matters related to designing and implementing prevention, promotion, diagnosis, treatment, care and support activities and for coordinating inter- sectoral arrangements with HIV/AIDS units in line Ministries and CSOs. These additional persons (both in MOF and MOH) will be paid out of project proceeds and the positions will be advertised and selection procedures will be startedbefore loan effectiveness. The use of the existing PCU currently in the Ministry of Finance, Planning and Development to manage the fiduciary aspect of the project (both financial managementandprocurement activities) was recommendedfor two reasons: (i) the M O Hhas relatively little experience with managing fiduciary aspects of donor-funded projects, hence considerable work would be neededto meet the 53 minimumBank requirementsfor the financial managementof the proposedproject, and(ii) the PCUhas experience inmanaging the fiduciary aspects of Bank projects (through its involvement with the Emergency Recovery and Disaster Management projects). Therefore, this arrangement utilizes the existing resourcesand expertise inBank financed projects inSt. Vincent. The financial managementaspects of the proposedproject will be managedcentrally by the PCU, as detailed inthe flow of funds section below. Flow of Funds. The Flow of Funds, which would be confirmed duringnegotiations, calls for the loadcredit funds to be channeledto the project through a Special Account denominated in US Dollars to be establishedby the PCUina commercial bank. The PCU will also operate a Project Account for the purpose of receiving counterpart funds from the GOSFG, which will be maintained in a commercial bank. Inorder to facilitate local currency payments, the PCU will operate a local currency account (zero balanceaccount), which will receive transfer of funds from the Special Account to cover the portion of payments eligible for IBRDfinancing and from the Project Account to cover the portion of payments eligible for Government financing at the time of payment to suppliers. Figure 3: Flow of Funds 1 E AIloca Applications Request I Portion IBRD Financing Portion GOSKG 54 For the proposed project, the GOSVG, under capital projects, will provide counterpart funding. The Government still needs to make a decision with respect to which Ministry will be responsible for accounting for budget estimates. Two options have been discussed with the Director of Budget: (a) counterpart fundingwill beprovided under the Ministry of Health's overall budget and will be transferred into the Project Account maintained by the PCU or (b) counterpart funding will be provided under the Ministry of Finance's overall budget (it was reported that this option might be easier to implement administratively, given the fact that the PCU will be locatedinthe Ministry of Finance), but the results of project implementation will be accounted for under the Health sector umbrella. Inboth cases, each year, the technical unit in the MOHE, incoordination with the PCU, will compile annual work plans for the project and submit a budget proposal to the appropriate Ministry. While counterpart fundinghas not been a problem in SVG inthe past, confirmation was obtained that the proposedproject will be included in the 2004 and 2005 budget estimates. The PCU will execute all payment orders on behalf of the line ministries (including theMOHE) which, under the proposedproject, will receive financial support for specifically approved activities intheir annual work plans. Therefore, the PCU will carry out the procurement for services and/or goods in accordance with Bank procurement guidelines, and will make payments to vendors for specific eligible expenditures incurred by the line ministries, upon receiving requests from the line ministries. This arrangement will not require additional accounts for Bank funds, as all financial transactions will flow directly from the PCU's Special Account. The PCU will also disbursefunds to Community BasedOrganizations (CBOs), NGOs and FBOs to implement the demand-driven subcomponent component of the project. Indoing so, the PCU will utilize the disbursementprocedures applicable to community-driven development project, as explained inFiduciary Managementfor Community-Driven Development Project: A Reference Guide (May 2002), as it also applies to HIVIAIDSprojects. Disbursements to Civil Society Organizations will be basedon sub-project agreements. Sub-project agreements will require (i) a minimumstandardfor financial reporting and accountability and (ii) Bank's prior review and the clearance of the template used. Tranche payments to community groups will be treated as eligible expenditures for replenishment, as long as they are madein line with the provisions of the financing/subproject agreement. Reporting and accounting for the tranche payments will be submitted by each subproject to the PCU, ina form and content appropriate for the project (the report will include at leastprogress and completion reports, minute of community meetings, and a statement of expenditures). Second andthird tranche payments will only be made upon submission of satisfactory financial reports or appropriate supporting documents for their expenditures by the subproject to the PCU. Accounting and Reporting. The PCU will be responsible for producing the Financial Monitoring Reports (FMRs) on a quarterly basis to be submittedto the Bank, only for monitoring purposes. The FMRs will include a narrative outlining the major project achievements for the quarter, the project's sources and uses of funds, a detailed analysis of expenditures by sub- component, a physical progressreport, a procurement report and a procurement table. FMRs should be submittedto the Bank no later than 45 days after the end of the reportingperiod. The annual financial statementswill include the project's sources and uses o f funds, a detailed analysis of expenditure by sub-component, the schedule of SOEs presentedduringthe year and a 55 reconciliation of the Special Account. These reports will be prepared by the PCU and made available to the auditors after the end of the fiscal year. Audit Arrangements. Under the proposedproject, project financial statements would be audited annually. Annual project financial statements will be audited in accordance with International StandardsonAuditingissued by the InternationalFederation ofAccountants (IFAC), by independent auditors and in accordance with terms of reference (TORs), both acceptable to the Bank. Auditors should provide audit opinions on project financial statements, and a report on internal controls. The TORs should include the financial activities undertaken by implementing Ministries, and the civil society (NGOs, CBOs, FBOs, etc.). The project's annual audit report will be required to be submitted to the Bank no later than 4 months following the end of the fiscal year (or by April 30). DisbursementArrangements. To facilitate disbursement under this project, proceeds of the credit/loan would be disbursed following effectiveness to the U S Dollar denominated special account managed by the PCU. Disbursements will be made based on Statement of Expenditures (SOEs) submitted to the Bank on a monthly basis. BudgetingProcess An annual budget would be prepared by the technical unit, incoordination with the PCU, on the basis of a consolidated annual investment plans from other participating implementing agencies. Area I Action Expecteddate 1.Flow offunds 1.1PCUto open the project bank accounts: the SpecialAccount inUS BY Dollars inthe bank selected, and the Project Account inlocalcurrency in effectiveness the bank selected. 2. Staffing 2.1 SubmitTORSfor new financial management staff. Complied with 2.2 Submit CV of selected personfor the Accountant Assistant to the Bank Before for no objection. effectiveness 3. Accounting and internal control 3.1 Create the Chart of Account in the accounting system to reflect the By disbursement categories for the project andproject activities. 3.2 Create the Draft Financial ManagementProcedures including sections By III effectiveness describing payment procedures, -flow-of-funds, format of FMRs, negotiations disbursement procedures (based on SOEs), coordination with implementing ministries, procurementsection and chart of accounts. 3.3 FinalFinancial ManagementProcedures. BY effectiveness 3.4 Prepare and submit to the Bank for review and clearancethe template By for the format and contentof the sub-project agreements that will be used. effectiveness 4. External audit 4.1 Submit final audit TORs and short list of firms and submit to the Bank 1 By 56 1for Area / Action review andclearance. I negotiations I I Expecteddate I4.2 biddingDrocessandtheamointmentoftheauditors.. Once the Bankclears the TOR and short list of auditorfirms, proceed with II By effectiveness I 5. Reporting 5.1 Submit draft FMR Format. BY negotiations 5.2 Submit first FMR. 45 days after the endof the firstfull Supervision Plan. Given the complex natureof the project, during the first year of implementation, a FMSpecialist from the World Bank will needat leasttwo staff weeks for FM supervision, which would include three separatemissions and review of periodic financial reports. Insubsequentyears, the number of missions could bereducedto two missions a year. costs 147,000 51,000 51,00040% Unallocated 40,000 35,000 35,000 LoanFee 35,000 Total 3,500,000 1,250,000 1,250,000 57 Annex 8: Procurement St. Vincent And The GrenadinesHIV/AIDSPreventionAnd ControlProject A. ProcurementArrangements Procurement for the proposedproject will be carried out inaccordance with World Bank "Guidelines: Procurement Under IBRD Loans and IDA Credits",published inJanuary 1995 (revised January/August 1996, September 1997, January 1999, November 2003 and May 2004); and "Guidelines: Selectionand Employment of Consultantsby World Bank Borrowers" published inJanuary 1997(revised inSeptember 1999, January 1999, May 2002, and November 2003), and the provisions stipulated in the Loan Agreement. B. Procurement Responsibility: The Project Coordination Unit (PCU) that will be locatedin the Ministry of Finance, Planning, and Development [that presently managestwo WB's projects, i.e. the Emergency Recovery Project (ERP) and the Disaster Management and Emergency Project (DMERP)]will beresponsiblefor the fiduciary aspects ofthe project, while overall management, technical expertise and managementof processes and contracts will be providedby the MOHE through technical staff devoted to this project. To this end, the MOHEwill strengthenthe PCU by adding new staff, i.e. aprocurement assistant, an accounts assistant, and an administrative assistant. All procurement will be conducted by the PCU, which will serve as a procurement agent. An operations manual will include details of procurement responsibilities, flow of documentation, funds and procedures. The MOHEPCU has prepared a general procurement plan for the entire duration of the project and a detailed procurement plan for the first 18 months along with the annual work plan. The procurement planfor each year will be submitted by the PCU to the WB for approval, not later than September 30 of eachyear. The procurement plan will follow a standardformat which will list as a minimum(i) works, goods and services to be procured for the year, (ii)their value; (iii) methods of procurement; and (iv) the timetable for carrying out the the procurement. The procurement planmay be updated at any time, if required under paragraph 1of Appendix 1to the Bank's Guidelines. Procurement methods: The methodsto be usedfor procurement are described below, andthe estimated amounts for each method, are summarized inTable A. The threshold contract values for the use of eachmethod are fixed inTable B. C.l Procurementof Works: Works under this project will include refurbishment of STIclinics, HIV/AIDSresourcecentre, rehabilitation and/or building of new counseling rooms andother small rehabilitation works. Contracts above US$1,000,000 will be procured following International Competitive Bidding(ICB). Contracts above US$150,000 but below US$l,OOO,OOO will be procured following National Competitive Bidding (NCB) procedures, usingstandard biddingdocuments agreedinadvancewith the World Bank. Small works, estimated to cost less than US$150,000 equivalent per contract, may be procured on the basis of comparing at least three quotations received from qualified contractors inresponse to a written invitation, which will include a detailed description of the works, including basic specifications, the required completion date, a basic form of agreement acceptableto the Bank, and relevant drawings, where applicable. C.2 Procurementof Goods: Goods under this project will include ARVs and other pharmaceuticals [(STI, OIs, PMTCT], laboratory reagents, test kits, condoms, laboratory 58 equipment, office supplies and equipment, I T supplies, dissemination campaigns' equipment, supplies for subprojects. To the extent possible, contracts for goods [other than ""Specialized Medical Supplies and Laboratory Equipment""] will be grouped into bidding packagesof more than US$150,000 equivalent andprocured following ICB proceduresusingBank-issuedStandardBidding Documents (SBD). Contracts below US$150,000 but above US$25,000 may be procured under NCB, usingbiddingdocuments acceptableto the Bank. Contracts for goods [other than "Specialized Medical Supplies and Laboratory Equipment" and condoms], which are estimated to cost below US$25,000 per contract may be procured usingNational or International Shopping (NS) procedures. Procurement of Specialized Medical Supplies and Laboratory Equipment (e.g., test kits, reagents, viral load and CD4count machines) will be determined by the market situation of each product (i.e., the number of available qualified suppliers) and the nature of the medical supplies. Regardless of the contract value, they may be procured usinglimited international bidding, shoppingor single source (SS)procedures inaccordance with the provisions of paragraphs 3.2,3.5 and 3.7 of the Guidelines. For procurement of condoms, the following proceduresshould be followed: -through SS with Pharmaceutical Procurement Service (PPS) [see below], that will be required to follow competitive procedures acceptableto the Bank -or [in case the condoms are procured directly by MOHElPCU]: -for contracts amounts below US$150,000: IS -for contracts amounts above US$150,000: Limited International Bidding(LIB). Contracts with NGOs, FBO, CBOs [,i.e. Eligible Entities (EE)] will be awarded on a single source basis, irrespective of their amount, ifthe proposed project i s acceptedinaccordance with proceduresto be established in the Operation Manual and acceptableto the Bank For goods procured by NGOs, FBO, CBOs [Le. Eligible Entities] under subprojects, inthe case of contracts above US$lO,OOO, the EEwill be required to procure such goods under Shopping or NCB as above. C.3 Pharmaceutical Procurement Service (PPS) procurement procedures. SVGparticipates inthe central OECS drugprocurement organization (PPS) to obtain all drugs for the public sector health services. Drugs are typically procured in accordance with "National Formularies"(1ists of types and quantities of various name brand and/or generic drugs neededfor the year). These needs are pooled across the OECS countries and prices for the drugs are obtained through bids from regional wholesale suppliers that representdifferent manufacturers. Contracts are awarded on the basis of the lowest price for a specified quantity of drugs to be delivered to eachcountry throughout the year. A preliminary assessment of this system was conducted in 2003 to verify its conformity with World Bank guidelines for procuring drugs and medicines. Drugs would be included inits National Formularyand procured through the OECS system. Drugswould be procured from suppliers according to registered brand names, at prices that are being negotiated in various settings with manufacturers (St Lucia is currently participating in the 59 Caribbean initiative to negotiateprices of ARV drugs on a regional basis with manufacturers) and would be proposed to the World Bank (when loan/credit/grant proceeds are to be usedto finance the purchase) as "direct contracting". The PPS will act as aprocurement agent for the Borrower, who will be responsible for paying the PPS's administrative fees. The Bank will assess in advance to any approval of a such a procurement that proceduresand biddingdocuments are acceptable to the Bank. A preliminary capacity assessment of PPS [carried out in20037 has been attachedto the Procurement Capacity Assessment (PCA) of the Borrower and the proposed PCU. For procurement of specialized medical supplies and laboratory equipment [including condoms], PPSwill be required to follow the principles highlighted inthe square box above, which will also be respectedby the Borrower, should they decide to purchasedirectly any specialized medical supplies and laboratory equipment. C.4 Selectionof Consultants: Consulting serviceswill berequired as technical assistancefor prevention, care, support of HIV/AIDSand STIpatients, VCT, Epidemiology and Surveillance, policy/strategy on HIV/AIDS,managementinformation systems, andmonitoring and impact evaluation. Firms. Services from firms estimatedto cost over US$lOO,OOO would be procured usingQCBS. The short-list of consultantsfor these services, estimated to cost less than $50,000 equivalent per contract, may consist entirely of national consultants. Small and simple contracts estimated to cost US$lOO,OOO equivalent or less would be procured following other procurement methods such asCQ. . IT training and connectivity services, radio/TV spots and any other servicesfor dissemination campaigns will be procured on a SS basis. Contracts with NGOs, FBO, CBOs [Le. Eligible Entities (EE)] will be awarded on a SS basis, irrespective of their amount, if the proposed project is acceptedin accordancewith procedures to be established inthe Operation Manual and acceptable to the Bank. For servicesprocured by NGOs, FBO, CBOs [Eligible Entities] under subprojects, inthe case of contracts above US$lO,OOO, the EEwill be required to procure such services under CQ or IC as appropriate. Individuals[IC]. Other assignments where neither teams of personnel nor additional outside professional support are required would be performed by individual consultants selectedby comparison of qualifications of three candidates. Consultants would be hired inaccordance with the provisions of paragraphs5.1 through 5.4 of the Consultant Guidelines. Prior review will be applicable for assignmentsabove US$50,000. Below such threshold, the prior review will only cover the Terms of Reference (TOR) for the assignment. Training. The project will finance technical training ( managementof ARVs, OIs, STI, PMTCT, VCT and the syndrome approach for management for STIs), training for IT, capacity building, strengthening the line ministries' and Civil Society Groups' responseto HIV/AIDS and health waste management, training for laboratory workers. C.5 Operatingcosts. Sundries, office rental, utilities, and other operational costs would be financed on a declining basis and would be procured usingadministrative procedures acceptable to the Bank. The Bank will finance a total of US$0.3M, declining annually in accordancewith an agreedplan. 60 D. Prior Review: The proposedthresholdsfor prior review arebasedonthe procurement capacity assessmentof the MOHE and the PCU andare summarized inTable B. Arrangements for prior review of the procurement processesare described above under Procurement Methods. Inaddition to this prior review ofindividual procurement actions, the planandbudget for the PCU operating costs will be reviewed and approved by the Bank annually. ProcurementCapacityAssessment Report: A procurement capacity assessment (PCA) was carried out inMarch 2004 by the WB to evaluate the capacity of the MOHEas well as the proposed PCU to be located inthe MOFPD. The detailed report i s inthe Bank's files. While the MOHE staff lack the relevant experience inprocurement, the quality and quantity of the staff the existing PCU inthe MOFPD i s good and essential to positive procurement implementation and administration. The assessment determinesthat ingeneral sufficient qualified staff are available to carry out the normal procurement tasks that would be assignedto them. The existing staff have relevant knowledge of the disciplines and the capacity requiredfor carrying out the proposed procurement plan under the project. Due to the fact, however, that the PCUwould be required to manage a large volume of tenders at the same time, additional staff for procurement and implementation purposes i s proposed inthe Action Plan. E.l PCUStaffing. The existing PCUto bemovedto the MOFPD, which currently managestwo World Bank projects, namely the ERPand the DMERP,will be incharge of fiduciary management(financial managementand procurement services) for the project. Currently, the staff at the PCUincludes a Project Coordinator, a Financial Management Specialist, a Procurement Specialist and an Administrative Assistant. The team i s well versed inWorld Bank financial managementand procurement proceduresand has the capacity to implement World Bank projects. This arrangementwould take advantageof the existing capacity and expertise in Bank-financedprojects in SVG, inparticular with respect to financial management and procurement, which are two critical activities of any projects. The Bank has carried out the financial managementand procurement capacity assessments [completed on April 8,2004 by the PS for the Caribbean] and has identified areas inneedof strengthening for the PCU, including additional staffing requirements. The PCU will needto be strengthenedthrough the addition of an Accounts Assistant, a Procurement Assistant and an Administrative Assistant, for at least the first two years. These three additional persons will be paid out of loadcredidgrant proceeds. The positions will be advertised and selection procedureswill be started before loan effectiveness in order to have the contracts inplace by effectiveness. E.2 Riskassessment. The conclusions ofthe assessment show the country's weak procurement environment, lack of proper legislation for procurement, lack of skilledpersonnel inprocurement within the M O Hat international level; weaknesses in the national biddingprocessesand award of contracts andin general lack of internationally recognized standardrules. The risk assessment of procurement implementation for this project i s considered HIGH, irrespective of the present good performance of the PCU [currently in the Ministry of Finance and Planning, where the Chairman of the CTB i s also based].This assessment i s conditional to the present organization of the MOHE and i s strictly tied to implementation by the M O Hof the proposed action planbelow and can be improved to ``"average"" ifthe MOH and the PCU would demonstrate a good performance after the first 18 months and pending positive results of the first audit. 61 E.3 Action Plan: Inorder to minimize the highriskof implementation, the following plan has beenproposed Designation of a Technical Director within the MOHE to take any procurement decision on behalf of the MOHE andrepresentthe MOHE inthe contractual relation with all the suppliers /contractors/ consultants. Designation by the MOHE of a technical unit and devoted staff to assist the PCU in drafting technical specifications and TOR. Such technical staff to be integrated in any evaluation committees Hiringof afull time procurementexpert to assistthe PCU staff under coordination of the present Procurement Specialist of the PCU, who will be incharge of training the newly- recruitedperson, if needed. The expert should have procurement expertise also inhealth sector to support, among others, the processesof hiring individual consultants, procuring specialized goods, procuring small works and supervision of small works. Hiringof FMstaff and anassistantclerk. Training plan of all the PCU staff for the first 18 months of implementation. Establishment of a procurement filing system satisfactory to the Bank. Preparation by the MOHE/PCU of a detailed procurement planfor the first 18 months of implementation. Final planto be annexedto the Legal Agreement. Preparation of the operations manual [OM] with a specific chapter on procurement detailing all the procedures andchannels of responsibilities and flow of documentation. The plan will be approved by the Bank as a condition of effectiveness. Preparation by the PCUof draft standardbiddingdocuments for all processesbefore project effectiveness. For purchases [Specialized Medical Supplies and Laboratory Equipment ] that MOH intends to carry out through PPS, M O H should provide evidence in the PPof such purchasesand: confirmation by M O Hthat they would pay the administrative fees of PPS under their own budget; signing of a special M O Ubetween M O Hand PPS [if needed, in addition to the permanent agreementwith PPS]; commitment by PPS to follow procedures and use biddingdocuments acceptable to the Bank. M O U signed with Line Ministries by effectiveness, Eligibility and selection criteria for EE [Eligible Entities= Civil Society Organizations] defined by effectiveness. Procedures for assessmentof EE's capabilities to be defined by effectiveness and detailed in the OM. Specifications and TORSfor contracts to be signed duringthe first 18 months to be submitted by effectiveness. A launching seminar will be carried out following effectiveness of the Loan with participation of staff from the PCU, NGOs, FBOs, CBOs and Line Ministries. This seminar will be followed thereafter duringthe first year by another intensive workshop in procurement procedures and rules. The proposed schedule of supervision missions i s outlined below: F. Procurement Plan: A procurement planfor the first 18 months of the project hasbeen prepared. At the beginning of each calendar year [ or earlier, ifrequired under paragraph 1of Appendix 1to the Bank's Guidelines] the PCU will update the Procurement Plan with a detailed procurement schedule for the coming year. 62 G.Frequency of Procurement Supervision:. The project would receive a minimumof one full supervision mission to carry out post review of procurement actions, every six months during the first year and every 12 months afterwards. Basedon the overall risk assessment (HIGH) the post- review field analysis should cover a sample of not less than 1in5 contracts signed. A procurement audit should be carried out every year. Table A: Proiect Costs by Procurement Arrangements (US$x lo6) 6. OperatingCosts 0.00 0.00 0.50 0.20" 0.70 (0.00) (0.00) (0.30) (0.00) (0.30) Unallocated 0.20 0.20 (0.15) (0.15) Total 0.00 0.25 8.30 0.20" 8.75 (0.00) (0.20) (6.80) (0.00) (7.00) Note: N.B.F. =NonBank-financed(includes elements procured under parallel co-financing procedures, consultancies under trust funds, any reserved procurement, and any other miscellaneous items). Figures inparenthesis are the amounts to be financed by the Bank loan/IDA credit/Grant FootNotes: a/ Three quotations (Le.: Small works procured under lump-sum,fixed-price contracts awarded on the basis of quotations obtained from three (3) qualified domestic contractors in response to a written invitation .The award shall be made to the contractor who offers the lowest evaluated price quotation for the required work, and who has the experience and resources to complete the contract successfully. b/ Shopping (National and International) and LIB c/ Consultants Services. Details provided in Table A-1 * estimatedadministrative fee for PPS 63 Table A1:Training and Consultant Selection Arrangements (US$ thousandx lo6 1 OCBS = Oualitv- andCost-BasedSelection; LCS = Least-Cost Selection; CO = Selection Basedon Consultants' Oualifications: - Other = Selection of individual consultants(per Section V of ConsultantsGuidelines) Figuresinparenthesisare the amounts to be financedby the BankLoanJCreditIGrant. Table B: Prior Review Thresholds Thresholds for Procurement Methods and Prior Review [inUS equivalent x 000] Expenditure Contract Value Procurement ContractsSubjectto Categorv (Threshold) Method Prior Review 1. Works >1,000 ICB All 150-1,000 NCB >500 All 4 0 0 First <1 so 3 Quotations None 2. Goods* >150 ICB All 150>x>25 NCB None <25 Shopping None DC/SS with EE, that 2A. Subprojects will be requiredto [NGOs,FBOs,CBO >25 procure subcomponents Entities=EE]** s= Eligible through NCB or CQ or First andTOWSpecs IC [as appropriate] afterwards ** Selectionand DC/SS with EE, that approval procedures should procure to be detailed in the 25>x>10 subcomponents through Operations Manual Shopping or CQ or IC First and TOWSpecs [as appropriate] afterwards 64 DC/SS <1 I) First 2.B Special Goods*** l/Drugs and suppliesfor Irrespectiveof the Method determinedby First and Specs TB, 01,ARV: amount market's economy: afterwards DC/IS/LIB 2/ Condoms 4 5 0 Shopping First >150 LIB First 3/Test kits, reagents, viral load and CD4 count machines Irrespectiveof the Method determinedby First and Specs amount market's economy: afterwards DC14/IS/LIB OR Specialgoodsand supplies at points 1/2/13 above ** ** Irrespectiveof the SS with PPS, that will amount be required to follow All first year and Specs procedures and use afterwards biddingdocuments acceptable to the Bank 3. Services -3.A Firms 3.A.1 >loo QCBS All 3.A.2 50 Comparison All of 3 c v 4 0 [Chapter V of TOR only the Guidelines] l4DC: Direct Contracting 65 *with the exception of specializedmedical supplies and laboratoryequipment ***"Procurement of SpecializedMedical Suppliesand Laboratory Equipment(e.g., test kits, reagents, viral load and CD4 count machines) will be determinedby the market situationof each product (Le., the number of available qualified suppliers) and the natureof the medical supplies. Regardlessof the contract value, they may be procuredusing limited international bidding, shoppingor single source procedures in accordance with the for any purchasesdone by the MOHE-PCU and/or any other channeled through PPS . provisions of paragraphs 3.2, 3.5 and 3.7 of the Guidelines." .These principles and procedureswill be applicable ****All the purchases[SpecializedMedical Suppliesand Laboratory Equipment] carried out through PPS undercommitment by PPS to follow proceduresand use bidding documents acceptable to the Bank. OverallProcurementRiskAssessment: Average Low 66 Annex 9: Economicand FinancialAnalysis St. Vincent And The Grenadines HIV/AIDS PreventionAnd Control Project The HIV/AIDS prevalence in St. Vincent and The Grenadineswas estimated at 0.2 percent at the end of 2000. There was a four-fold increasein reporting of HIV/AIDScases duringthe period 1992-1999 as compared to the period 1984-1991. The majority of HIV/AIDS cases fall inthe 25- 44 years age group which accounts for 60 percent of seropositives and 65 percent of AIDS cases. The age group 15-24 years accounts for 19.7 percent of HIV/AIDS cases. The main mode of transmission i s heterosexual contact. There are a number of risk factors for HIV/AIDS in SVG: a significant proportion of the population falls within the group that i s most likely to get infected (the 15-44 years age group accountedfor 46 percent of the population). The age group under 15 years accounts for 37 percent of the population. Consequences of a spreadin the epidemic would impact this group significantly due to loss of parents andproviders. HIV/AIDS and poverty are mutually reinforcing. Poverty i s therefore, a highrisk factor for the spread of the epidemic in SVG where 35 percent of households and41.9 of the population live below the poverty line.15 Growth inreal GDP averaged3.2 percent per annum between 1997-1999 and was largely driven by expansion inconstruction, transportation, tourism, banking and insurance, electricity, water and communications sectors. Agriculture's contribution to GDPgrowth per annum, averaged 12 percent. The Government's medium-term economic strategy i s basedon private sector development and emphasizesdevelopment of basic, physical infrastructure, improving the social environment, and establishing fiscal and regulatory policy to support the development strategy. Also included in the strategy i s economic diversification, tourism, financial services, information technology, public sector reform and human resourcedevelopment. The SVGeconomy depends on the strong human capital basedeveloped through investment in social services includinghealth and education. The HIV/AIDSepidemic poses a great risk to this human capital base and to the country's growth rate especially given that the highest prevalence of HIV/AIDS is in the most economically productive age group(25-44 years) which would be affected trough a rise in morbidity and mortality from HIV/AIDS. Other impacts include loss inproductivity due to absenteeismfrom work for the sick and their family members; increase inimpoverishment of householdsas they lose heads of households; increase in health costs; decreasein savings and investment; loss of key qualified workers and managers; and, a rise inthe number of orphans and destitute children. Early intervention i s necessary to prevent the epidemic from escalating and reversingthe socioeconomic achievementsof the country. The natureof the HIVIAIDS epidemic demands a strong public responsefor a number of reasons: the communicable nature of HIV/AIDS;imperfect information on HIV transmission; HIV increasessusceptibility to other opportunistic infectious diseases including tuberculosis; some individuals (spouses, newborns, victims of rape, accident victims who need blood transfusions) cannot control their own risk to HIV infection. l5 The PovertyAssessment Report of 1996. 67 CostinganHIV/AIDS preventionandcontrolprogramfor the Caribbean16 An estimation of the cost of a comprehensiveHIV/AIDSpreventionprogram was conducted by a team of epidemiologists andeconomistsfrom the Caribbean for 23 Caribbean c~untries'~under various scenarios. The model structure was basedon a simulation model under development by the World Bank". ModelandMainAssumptions Interventions An exhaustive list of the principaltypical interventions supportedby HIV/AIDS programs around the world to prevent the transmission of the HIV virus and to mitigate the impact of HIV/AIDSon persons and communities was drawn. Indirectinterventions include surveillance, research, monitoring and evaluation, advocacy, and enhancing regional and national institutional capacity to carry out the programs. Preventive interventions include those activities that have strong spillover benefits to society as a whole inpreventing HIVinfections andthus reducing the spread of the disease: public awareness campaigns, programs aimed at preventing the spreadfrom high- risk groups such as prostitutes andintravenous drugusersinto the generalpopulation; screening to ensure safe blood supply; fostering behavior change; increasing access to condoms; and, preventing the transmission from infected mothers to their babies. The third set of interventions includes various aspectsof care and financial assistance for persons or relatives of persons living with HIV/AIDS including: palliative care (prevention of opportunistic infections, counseling, home-basedcare, anti-retroviral therapy) since there is no cure for AIDS; and, financial and material support to AIDS patients, their families and orphans. Unitcostsassumptions Unitcosts were then estimatedfor eachof these activities. The costs were for the most part taken from the simulation exerciseundertaken in Sub-SaharanAfricalgand from the consensusview of the Commission of experts2'. The information derives from the literature and from the direct experience of the team of experts with HIV/AIDS programs in developing world settings. Populationandepidemiologicalinformation Estimates for the model parameters were collected or extrapolated from the latest published sources or generatedby the experts who participated in the simulation exercise. The main variables usedby the model are: population, HIV prevalence, birthrates, access to health services, l6The following analysis is drawnfrom the World BankProjectAppraisal Document (Report 22184-LAC), for the Multi-Country HIV/AIDS Preventionand ControlProgram(APL), June 6,2001 (Annex 8). l7The countries were loosely grouped according their geographic, cultural and economic proximity. Group 1: Anguilla, Antigua & Barbuda, British Virgin Islands, Dominica, Grenada, Montserrat, St. Kitts, St. Lucia, St. Vincent. Group 2: Bahamas, Bermuda, Cayman, Turks & Caicos. Group 3: Haiti, DominicanRepublic. Group 4: NetherlandsAntilles, Aruba, Guyana, Suriname. Group 5: Barbados, Belize, Jamaica, Trinidad & Tobago. Group 6: Cuba Bonnel R., et al., 'The Cost of Scaling-Up HIV/AIDS Programs to a National Level for Sub-Saharan Africa,' Working Paper, World Bank, April 2000. 19See footnote 3. 20See footnote 1. 68 use of ante-natal care services, ante-natalcare HIV prevalence, percentageof sexually active population reporting non-regular partnerships, annual incidence of treatable STIs, proportion of STIs that are symptomatic, averageannual numberofcommercial sex acts/sex worker, prevalence of syphilis among women, cumulative number of orphans, HIV prevalence rates among high-risk groups (prisoners, MSM, CSW, military), migrant and tourist populations, and public spending per capita in health. Program coverageassumptions The final set of model inputs was the coverage assumptions. For nearly all the interventions contemplated, it was assumedthat 100percent of the relevant population was targeted (e.g., all CSW, all HIV-infected mothers, all youngsters in school, etc). There were two main departures from the universal coverage assumption: it was assumedthat only 20 percent of AIDS patients will benefit from home-basedcare, and that only 15 percent21of HIVpatients will benefit from HAART, the three- andfour-drug combinations against HIV. A 100-percentcoverage was deemedimprobable for these two interventions if only becausethe health system cannot reach all patients andbecausethe uptake of home-basedcare i s partly predicated on client behavior. The cost estimates derived from the model are extremely sensitive to the coverage assumptions. Note that the implicit assumptionhere is that scaling-up is achieved immediately, a more realistic costing scenario will involve gradual scaling-up over aperiod of a few years. Main Results Usingthe assumptions discussedinthe previous sections, the following results were derived: Table 1: Low Cost Package activities" Public 162.1 12% 162.1 23% 162.1 28% Awareness and Prevention Basic Care 362.2 26% 362.2 52% 362.2 63% HAART 828.1 59% 118.3 17% 0.0 0% Total 1,403.5 100% 693.7 100% 575.4LL 100% The cost of providing a comprehensive package of prevention and care activities for the relevant populations inthe Caribbean will therefore be prohibitively expensive, at approximately US$1.4 billion. Tables 2 and 3 below show how these costs will translate into per capita terms for a few countries andcompares the estimated HIV/AIDS program costs with current overall per capita spending on health. 21Inthe successfulBrazil program, only 15 percentof the infectedpopulation are onanti-retroviral access despite 100%access. 22Of which $358 million for Haiti and the DominicanRepublic, $67 million for Cuba and $150 millionfor the rest of the Caribbean. 69 Republic Guyana $45 $6 $22 $36 $81 Jamaica $149 $4 $15 $22 $40 Trinidad & $197 $4 $16 $23 $41 Tobago Implementing a comprehensive package of interventions (prevention, basic care, and HAART for 15 percent of the HIV-infectedpopulation at current prices) will increase current overall spending in health by 180percent in Guyana. If the cost of providing HAART falls to $1,000 per patient per year, then a comprehensive package of interventions (prevention and care includingHAART) will imply a 10percent increase in health spending in the Bahamasand a 183percent increase inHaiti. The HAART costs are overstated because efforts have since been made to reduce the cost o f anti-retroviral drugs. The costs of drugs for HAARThave beenreduced to an annual cost of $350 per capita and below due to the continued efforts underway to further lower the costs of drugs. This make it possible for countries that hitherto could not consider public provision of HAART to all patients who need them, to include them intheir programs as SVG has done. Potentialbenefits23from checkingthe spreadof HIV/AIDS inthe Caribbean The benefits traditionally associatedwith HIV/AIDS programs are: (i) they contribute to reducing that productivity losses due to HIV/AIDS-related disability and premature mortality; and (ii) that they contribute to reducing the need for expensive care. These measures ignore the demand for such programs from the general population to reduce the riskof getting the infection, creating a safer environment, and so on. The benefits calculated here do not include these possibly substantial `consumption' benefits. A studyz4by the University of West Indies estimated that economic lossesdue to HIV/AIDS could amount to between 1.5 percent and 5 percent of GDP inJamaica and Trinidad and Tobago by year 2005. The estimated GDP loss is driven by the number of HIV/AIDS cases and the average loss of income/output associatedwith those cases. The study forecasts the economic impact of HIV/AIDS by modeling the impact on: output, labor supply, employment, savings and investment, and spending on HIV/AIDS treatment. An increase in HIVIAIDS-relateddeaths and morbidity adversely affects labor supply causing wages to increase. Raising wages and decreasing labor supply translate into lower levels of employment. The increase in expenditure associated with increased HIV/AIDS incidence diverts funds away from productive savings, which in turn affects the levels of investment that can be achieved. Depressedlevels of labor and capital affect the levels of output from the various sectors and therefore overall GDP. ~~ 23 The benefits consideredin this section are exclusiveof extemalities. 24 `HIV/AIDS in the Caribbean: EconomicIssues- Impactand InvestmentResponse,' Working Paper. Health EconomicsUnit, Universityof West Indies,St. Augustine, 2000 and `Modeling the Macroeconomic Impactof HIV/AIDS inthe English-SpeakingCaribbean: the Caseof Trinidad andTobago and Jamaica,' Working Paper, CAREC/LIWI/PAHO/WHO, 2000. 70 Table 3: The macroeconomic impact of the HIV/AIDS epidemic inJamaica HIV/AIDS ExDenditure The same study suggests the lossesto the economies of the English-speaking Caribbean could reach a level around $2 billion per year. Inother words, stopping HIV/AIDS transmission for that region yields a benefit of $2 billion per year. The table below, adaptedfrom Jha et al. (2001)25summarizesranges of values from the literature relating to the cost-effectiveness of some o f the most frequent interventions in HIV/AIDS prevention and treatment. Table 4: Cost-effectiveness of different tvDes of interventions infection -Cost averted per $0.35-0.52 $9.45 $12.77-17.78 $10.51 $66.2 $720-$2,355 DALY saved Individual country programs will maximize the number of infections averted and the number of DALYssavedif they were to ensure that the most cost-effective interventions obtain sufficient attention and financing. Countries that propose to finance HAART should be particularly attentive to making sure that preventive interventions that are known to be cost-effective are not crowded out in the process. SVGhas selecteda comprehensive approach, which has funding for preventive interventions both for targeting high-riskas well as for reaching the general population inaddition to the proposedscaling-up oftreatment and care. With the combination of the Government's own budget and the proposedproject, SVGis better placed to provide a comprehensive package of interventions that include anti-retroviral treatment inthe mediumterm. SVGlike other countries inthe Caribbean has limitedresources for dealing with the HIV/AIDS epidemic. The country has therefore selected a range of internationally recognized cost-effective interventionsfor implementing its strategic HIV/AIDS planfor the period 25 Jha, P., et al. (2001) `The evidence base for interventionsto prevent HIV infection in low and middle- income countries.' Backgroundpaper of the Commission on Macroeconomics and Health, the World HealthOrganization. ''UNAIDS 26 UNAIDS: Brazil Program 71 2002-2006. They include STImanagement, interventions for highriskgroups, voluntary testing and counseling, prevention of mother-to-child transmission and antiretroviral treatment. The estimated cost of the project i s US$8.75 million. The incremental recurrent cost of the project i s expected to be met largely from the project. Increase in the recurrent costs, thereafter will arise from the additional staff dedicated to HIV/AIDS work and the cost of pharmaceuticals and maintenance for equipment to be purchased under the project. 72 Annex 10: SafeguardPolicyIssues St. Vincent And The GrenadinesHIV/AIDSPreventionAnd ControlProject BIOMEDICALWASTE MANAGEMENT I.Theproposedprojectwillgeneratesomebiomedicalhazardouswasteinthecourseofclinical managementof patients infected with the AIDS virus. The environmental impact of this must be considered. This project will use the National Biomedical Waste Management Plan preparedfor St. Vincent and The Grenadines in 2002 to address this problem. This report summarizesthe four tasks of the assessment: (1) an audit of waste managementpractices, (2) review of existing biomedical waste treatment technologies, (3) development of a national biomedical waste managementplan, and (4) a training progradimplementation and monitoring. The plani s under implementation under the management and supervision of the Ministry of Healthand Environment. Proposed small-scale remodeling of existingcounseling rooms supportedby the project are not expectedto have a negative impact on the environment but nonetheless guidelines will be incorporated in the project's operational manual for ensuring compliance with environmental safeguardsfor civil works supportedby the project. Introduction 2. InNovember 2002, a National Biomedical Waste Management Plan was completed for St. Vincent and The Grenadines. This plan i s a component of a larger World Bank-funded program to address the problem of solid and ship-generatedwastes with the goal of protecting the environment and enforcing the MARPOL 73/78 Convention. The program covers six members of the Organization of Eastern Caribbean States (OECS). Audits of the existing waste management practices were conducted duringOctober 2001 andJanuary 2002, which becamethe basis for an Interim BiomedicalWaste Management Plan. The interim plan was acceptedby the St Vincent and the Grenadines Central Water and SewerageAuthority in April, 2002. The Hospitals Services Coordinator was to arrangefor the implementation of the recommendations contained inthis plan. Elements of the Interim Plan have been incorporated into the National BiomedicalWaste Management Plan, which was presentedto stakeholders (government officials, health-care facility staff and solid waste managementpersonnel) for discussion and comment duringimplementation of the training component in September 2002. The plan was put together following consultations with the Natural ResourcesManagement Unit of OECS. This report representsa synthesis of the findings and recommendations of the plan. The plancan be found inthe files of the Ministry of Health andEnvironment and the project files for the proposed project at the World Bank. 3. The plan includes recommendations for definitions of the waste components, in-house managementprocedures, occupational health and safety guideline, training requirements for all staff involvedinprocessing biomedical waste and the responsibilities of personnel handling biomedical waste. 4. EstimatesOf BiomedicalWaste Generation. An estimation method basedon the size of the population was usedfor quantifying waste data. Data and assumptions usedfor calculations: Population: est. 120,000 Milton Cat0 Memorial Hospital: 204-bed hospital Several smaller facilities 73 Numerous health clinics throughout the island (public health clinics, labs, private practitioners, dental practices) Estimated biomedical wastegeneration rate: 5. To determine the appropriate size of technology for medical waste managementin St. Vincent, it is necessary to estimatethe amount of medical waste generated. While specific quantities and volumes are not presently known, the WHO utilizes an averageof .4kg/year per capita. Using these estimates, the amount of 48,000 kg/year (120,000 x .4kg) of waste i s generatedin St. Vincent and The Grenadines. 6. Treatment technologies are generally rated on a per hour or per day basis. Assumingthe treatment technology will be used5 days a week (261 weekdays per year), the following daily throughput rates are required: 184kgper day. Assuming4 hours of operation per day, the following hourly throughput rates are required: $45/ kgper hour (100lbsh). Hence, the treatment technology should be basedon this throughput rate. 7. ExistingLegalFramework and Practices. The assessment found no written policies on waste managementinSt. Vincent and The Grenadines. Among practices in use were: color coding when supplies of bags are available; limited signage used; sharps generally collected in cardboard containers that are not puncture resistant; and fluids from placenta waste disposed in the sewer. At the Milton Cat0 Memorial Hospital, placentas were buried on the grounds. This i s an acceptable practice as long as health-care workers are protectedfrom splashes from body fluids. In-house (hospital) transport of waste was performed usingan open trolley insteadof a dedicated, fully enclosed cart. Waste was burned at an incinerator on-site of the hospital. Other facilities engaged inopen burning,burial, or disposal with solid waste. All designated sharps containers on St. Vincent and The Grenadines were returned to Milton Cat0 Memorial Hospital for disposal. Other islands burned or buriedtheir waste usingcrude burningmethods or burial. Treated waste residues from the incinerator were disposed of behind the existing incinerator area. Employee training on waste management was informal and infection control committees were either dormant or inexistent. 8. Landfills. Arnos Vale is the old solid waste disposal area. Dumpingwas supervised. Regular garbage was leveled and compactedby a bulldozer and an earth cover was added at the end of the day. A new landfill is now open in Diamond. 9. Following the assessment of the level of waste generatedand the practices inplace for their disposal, the consultant made the following recommendations: 10. Legal Framework. St. Vincent and The Grenadines needs to develop a legal framework: legislation and regulations on managementof biomedical waste managementthat should include the following elements: a) Clear definitions of what constitutes biomedical waste and its categories; b) Cradle-to-grave approachto biomedical waste management (the managementof biomedical waste from the point of generation to the point of disposal as described inthis plan i.e., tracking of waste via a manifesdshipping paper to point of disposal); 74 c) Coordination with hazardous (non-biomedical) waste management laws, as well as other statutes dealing with health (including prevention of infectious diseases, hospital hygiene and infection control), sanitation, environment (air quality, water quality, land disposal), and occupational safety and health; d) Delineation of national andlocal government authorities which are responsible for implementation (Ministry of Health and Environment for St. Vincent and The Grenadines); e) Legal obligations of the biomedical waste generator; f) Provisions for record-keeping and reporting of pertinent informationrelative to the transport, treatment and final disposal of biomedical waste; g) Provisions for the institutionof fees for transport, treatment, and final disposal; and h) Provisions relatedto inspections to enforce the laws andregulations, penalties for non- compliance, and legal proceduresfor managing appeals of enforcement actions. i)Apolicydocumentwhichdiscussestherationaleforthelegislation,nationalgoals,keystepsto achieve these goals, and an assessment of costs should be developed to augment the statutes. In addition, a technical guideline should be preparedto clearly present the generators' regulatory responsibilities andmay include: Legal framework relating to the safe managementof biomedical waste; Responsibilities of public health and environmental authorities, heads of health-care establishments,directors of public or private agencies dealing with waste management and disposal, and small generators; Practical specifications related to biomedical waste minimization, segregation, handling, storage, and transport L i s t of approved treatment and disposal methods for each of the categories of biomedical waste; and Trainingrequirements. 11. Administrationand Responsibilities. Proper managementof biomedical waste depends on good administration and organization. At the national level, biomedical waste managementi s generally under the principal authority of the Ministry of Healthand Environment working closely with other relevant ministries. Policy commitment should be reflected inbudgetary allocations for staff and other resources to ensurecompliance with biomedical waste laws and regulations. 12. At the level of the health care facility, there should be a written policy on biomedical waste management. The policy should state the facility's objective of providing a system for managementof biomedical waste in order to protect patients, staff and the general public from hazardsassociatedwith the waste. It should provide an overview of responsibilities and outline the major proceduresfor biomedical waste management. 75 13. HospitalWaste Management Team. To institute this policy, a major facility such as Milton Cat0 Memorial Hospital should establish a waste managementteam to be chaired by the hospital administrator. This individual will also act as the designatedcontact with the regulatory authorities. The administrator should appoint one member of the team as the Waste Management Officer responsible for the day-to-day operation and monitoring of the waste management system. 14. Other HealthcareFacilitiesWaste ManagementTeams. All health-care facilities should have a person or group that would be responsiblefor the managementof biomedical waste, including the implementation of waste managementplans. Ideally, that person or group should be the infection control officer or infectioncontrol committee so that the managementof waste can be incorporated into policies, procedures, andprograms to minimize the risk of spreading infection inthe hospital thereby protecting patients, health-care workers, and the public. One of the first tasks of the committee or officer i s to post educational material on segregation (see sample poster in the Appendix) andto make sure that the health-care staff is familiar with the segregationprocedure 15. OccupationalSafety andHealthGuidelines. An effective occupational safety and health program related to biomedical waste management includes: - Risk assessment and designing hazard control measures; - Proper training on safe practices; - Provision of personnel protection equipment; - Immunizationand personal hygiene; - Special precautions for cleaning up spillage; - Post-exposureprophylactic treatment and medical surveillance; and - Continuous monitoring of workers' health and safety. 16. Waste Classification. There are many ways of classifying the different components of biomedical waste. Inlight of the types of waste produced inSt. Vincent, the following simple classification i s proposed: Table 1: I )medical Waste Categories Waste Description Examples Where Found Category Sharps Itemsthat couldcut Hypodermicneedles, syringes, NursingStations, or puncture suture needles, scalpel andother Laboratory, regardlessof whether blades, lancets, saws, knives, Accidentand they harbor brokenor unbrokenglass, vials, EmergencyRoom, infectiousagents tubes, pipettes,etc. Surgery, Maternity Ward, Clinics Cultures and Culturesand stocks Humanand animalcell cultures, Laboratory, Stocks of infectiousagents stocks of etiologic agents, Microbiology and associated discardedlive and attenuated biologicals vaccine or serum, culturedishes andother devices usedto transfer, inoculateor mix cell cultures HumanBlood, Free-flowingblood, Free-flowingbloodor blood PatientWards, BloodProducts, components or components, semen, vaginal Surgery, 76 and BodyFluids productsof blood, secretions, cerebrospinalfluid, Laboratory, and specific body synovialfluid, pleuralfluid, Accident and fluids pericardialfluid, peritoneal Emergency Room fluid, amniotic fluid, andbody fluids contaminatedwith blood Pathological Humanpathological Tissues, organs, anatomical Surgery, Pathology, Waste waste waste (recognizablebodyparts Autopsy except teeth) removedduring surgery, autopsyor other procedures Animal Waste Contaminatedanimal Animal carcasses, animalbody Veterinary waste parts, blood, body fluids, and Hospitalsand beddingknownto havebeen Clinics, Research exposedto infectiousagents Laboratories Selected Waste generatedby Swabs, excreta, soiled dressings, IsolationWard IsolationWaste patientswho are drainage sets, items saturatedor isolatedto prevent drippingwith humanblood, etc. the spreadof highly from patients infectedwith communicable highly communicable diseases diseases (see below) 17. Waste Minimization. Waste minimization i s the reduction, to the greatest extent possible, of waste that is destinedfor ultimate disposal, by means of reuse, recycling, and other programs. The combination of segregation (see next section) and waste minimization is an effective tool to lessen notjust the quantity of waste that must be treated as biohazardousbut the amount of regular garbage that goes to the landfill. Health-care facilities should initiate waste minimization programs following the guidelines and ideas listed below. The potential benefits of waste minimization are: environmental protection, enhancedoccupational safety and health, cost reductions, reducedliability, conformance with international conventions on sustainability and the protection of the regional environment, and improvedcommunity relations. 18. Waste MinimizationTechniques: The following i s the recommended hierarchy of waste minimization techniques inorder of decreasingpreference: a) Segregation-making sure waste items are inthe appropriate container. Staff training is essential to keep biomedical waste separatedfrom regular garbage. b) Source reduction - minimizing or eliminatingthe generation of waste at the source itself; source reduction should have a higher priority than recyclingor reuse. Users and waste managers should be aware of the waste generatedby the products they buy. Source reductionrequires the involvement of purchasing staff. Steps should be taken to reduce at the source biomedical waste as well as regular garbage. A cost-benefit analysis should be conducted to evaluate the use of reusable versus disposableproducts with the objective of reducing the volume of waste. Some specific sourcereduction techniques include: - Material elimination, changeor product substitution, e.g., substitutinga non-toxic biodegradable cleaner for a cleaner that generateshazardous waste; employing multiple-use (reusable) insteadof single-use (disposable) products; 77 - Technology or processchange, e.g., using non-mercury-containing devicesinstead of mercury thermometers; - Good operating practice, e.g., improvinginventory control to avoid expired product waste; covering disinfectingsolution trays to prevent evaporative losses; using the minimumformulation recommended for an application; - Preferential purchasing such as selecting vendors that minimize packaging waste; c) Resource recovery and recycling: recovery and reuse of materials from the waste stream. Some specific examples include: - Recyclingnewspapers,packaging material, office paper, glass, aluminum cans, construction debris, and other recyclables; - Purchasing products madeof post-consumerrecycled material such as recycledpaper Composting organic food waste; - Recovering silver from photographic chemicals inradiology; d) Treatment:treatment to remove andconcentratewaste, preferably inprocessrather than end- of-pipe treatment such as the use of filters and traps to remove mercury from wastewater; e) Proper Disposal - when all possible waste minimization options have been exhausted, the remaining waste should be disposedinthe method with the least environmental impact. 19. Waste Segregation. Biomedical waste should be separatedor segregatedfrom the general waste streamcreated in the routine operation of a health care facility. The segregation should occur at the point of generation to assurethat the components of biomedical waste are appropriately processed. Inaddition, this separationof the two waste streams may allow the facility to reduce its overall costs for the treatment anddisposal of biomedical waste andpermit the facility to effectively divert aportion of the materials for recycling. Inmany countries, the inclusion of biomedical waste with the general wastes will cause the entire waste streamto be designatedas potentially infectious requiring all waste to be treated. The most efficient means of segregatingbiomedical waste i s to provide separate, distinct containers at the points of generation throughout eachhealth care facility, e.g., hospitals, clinics, doctors and dentists offices. Marking, labeling of containers and color coding of plastic bags and containers are important elementsin the appropriate segregationof biomedical waste. 20. Waste Collection. As previously noted, biomedical waste should be segregatedat the point of generation in appropriately marked, color coded containers and/or bags that meet the specifications described below. 78 Table 2: Biomedical Waste Container Specifications TYPE OF SPECIFICATIONSFORCONTAINER OR BAG WASTE Sharps - Container shouldbepuncture-resistant, leakproofon the sides andbottom, durable, andclosable (closureshouldbe secure) -- Container should be labeledandcolor-coded Container shouldbe designedso that it is easily and safely determinedwhen the container is nearlyfull Non-sharpsbio- - Container shouldbe leakproof,rigid, durable, labeled, andcolor medicalwaste coded (solidsemi-solid) - Plastic bag should be leakproof;designedto prevent ripping, tearing, or burstingunder normaluse; labeled; and color coded. The plasticbagshouldbe placed insidea rigidcontainer Non-sharpsbio- medicalwaste -- Container shouldbe leakproofand durable Container shouldbedesigned suchthat it can betransported (liquid) without spillage 21. Handlingand Transport Within the Facility. Housekeeping staff or other personnel should collect all biomedical waste throughout the facility on a regular basis inorder to prevent the accumulation of the material inunsecuredlocations. Those designated with this task should be equipped with appropriate protection including gloves, gowns, masks, face shields, andor safety goggles or glasses. 22. Storage. An on-site storage area should be a specifically designatedlocationeither within or outside of the health care facility. It should be large enough to accommodatethe daily maximum volume of waste generatedand be situated at a locationphysically separatefrom food preparation and supply areas. The integrity of the packaging should be maintainedduring storage andto that end, care should be taken in arranging or orienting the waste packages while instorage to avoid spills. Stacking and piling of biomedical waste containers should be avoided. Wheeled carts or bins should not be overloaded duringthe time they are heldinstorage. Appropriate personnel protective equipment and spill responsesupplies should be available inthe storage room. 23. Transport Outsidethe Facility. Transport of untreated biomedical waste outside a health- care facility to a central point for treatment should be regulated by appropriate governmental agencies, the Ministry of Health and Environment, and possibly the Ministry of Public Works, Utilities, Transport, and Postsinrelation to vehicular transport. 24. Waste Treatment. a) Interim Plan. Until a long term treatment solution was to be implemented, an interim plan was considered. A long term approachwas also outlined. The single-chamber incinerator or open burningshould not be used in the hospitals and health centers. As an interim solution, the categoriesof waste should be treated in one of the following ways or using a combination of ways shown in the table below. Cultures should not be transported as untreated waste but should be treated on-site usinga small autoclave. 79 Table 3: InterimTreatment Methods 1 APPLICABLE METHOD NOTES WASTE All wastes except Packaging, Transport, and This interimmethod culturesand burialin SpecialLandfill should be usedby the large anatomicalparts Trenches generators(hospitals). (largebody parts) Sharps, blood- SmallOn-SiteBurial Pits This methodcouldbe used soaked material, in healthcenters. small tissues (e.g., skin tags), placenta waste Anatomicalparts Intermentat Burial Grounds This is the preferred methodfor bodyparts. This shouldbethe method usedfor culturesat the MiltonCat0Memorial Hospitallaboratory. Free-flowingblood Sanitary Sewer This methodapplies to all and body fluids healthfacilities with sanitary sewers. These methodscould be usedincombination. It was recommendedthat healthcenters bury blood- soakedmaterial, smalltissues, andplacentainsmall burialpitswhile transportingsharps for disposalto MiltonCato. This would reducethe amountof waste beingtransportedandavoid theproblemof storingputrescentwaste for extendedperiods. Long.Term Plan for Treatment. Liquidblood and body fluids should be discharged directly and carefully into the sanitary health-care facilities, bothpublic and private, and the treatment of the waste at a centralized waste treatment facility. The centralized facility would employ a state-of- the-art alternative treatment technology that would not have the adverse environmental and health impacts associatedwith incineration or open burningwhile enhancing the safety of landfill workers and waste pickers who will not have to deal with untreated waste. The centralized facility would handle the bulk of the biomedical waste stream for the foreseeable future. Biomedical waste generators that choose not to participate inthe collection and centralized treatment program would be required to show that they are able to treat their biomedical waste in some other manner that meets the treatment criteria and any applicable environmental and health regulations for: blood and body fluids; anatomical waste; sharps; and, other hazardous waste components. The appropriate technology for waste disposal will be selectedfrom options reviewed. The investment inthe technology will needto be planned, necessaryequipment purchased and installed in an appropriately selected site following installation guidelines provided for the technology. Training would need to be providedfor operators and engineering staff. Operators should also be trained inwaste handlingtechniques, occupational safety, use of personal protective equipment, record-keeping and contingency plans. 25. FinalDisposal. Ingeneral, treated biomedical waste, when made unrecognizable through shredding, can be mixed with regular garbage and transported for final disposal in a sanitary landfill. A sanitary landfills i s constructed with a clay or geomembrane liner such as highdensity polyethylene andprovidedwith a leachatecollection system. St. Vincent and The Grenadines has developed a landfill suitable for disposal of treated material. 80 26. Contingency Planning. As a general rule, all health-care facilities should develop contingency plans inthe event that biomedical waste i s spilled, a worker is injured, or the treatment technology i s down for repairs. 27. Employee Training and PublicEducation. Employee training and public education are key components of medical waste management. General employee training programs should include the following: - Overview and rationale of the health care facility's policy on waste managementand the objectives of the policy; - Roles andresponsibilities ofeach staff member inimplementing the policy; - Risksassociatedwith biomedical waste, the basic elementsof infection, and the importance of safe practices; - Waste classification; - Procedures for waste minimization; - Proceduresfor waste segregationincludinglabeling andcolor coding; - Overview of the fate of medical waste after collection: handling, storage, transport, treatment, and final disposal; - General cleaning, disinfections, andcontingency procedures for spills and accidents; and - Reporting proceduresfor accidental exposuresto infectious waste (needle-sticks, blood splashes, etc.) or improper collection, handling, or treatment practices. 28. For health care providers, the following additional precautions should be emphasized: - Special care has to be taken when dealing with sharps waste. Sharps containers should not be overfilled. Needles should not be manually removed from syringes; - No attempt should be made to remove items from abiomedical waste bag or container. Ifany waste item i s accidentally placed ina regular trash bag, the entire mixture should be treated as potentially infectious waste; and - Hazardous chemicals, such as mercury and formaldehyde, and pressurized containers such as aerosol cans, should not be mixed with potentially infectious waste. 29. Waste handlers and treatment technology operators should receive specialized instruction. In addition to the above topics, trainingprograms should also include: - Specific proceduresfor handling, includingidentifying the types of waste inbags and containers through their colors and labels; when to seal bags; how bags are sealed; how bags are pickedup and deposited; how bags should be carried; procedures for handling sharps containers; and ergonomic issues; - Specific proceduresfor storage (ifneeded) and transport of biomedical waste, includinghow to keep waste segregated, loading and unloading bags, and the proper use of carts; - Safepractices and use of protective equipment such as gloves andfootwear; - Emergency responseto spills and other accidents; - General operatingprinciples of the treatment technology; - Occupational safety, health, and environmental issuesrelated to the treatment technology; - Specific technical procedures for the operation and monitoring of the treatment technology, including the loading and unloading of waste, start-up and shut-down procedures, understanding equipment monitoring data, and the use of controls; 81 - Emergency responseto equipment alarms andfailures, includinghow to detect abnormal conditions and malfunctions; - Maintenance proceduresrelated to the treatment technology; and - Removal of residues from the treatment technology. 30. Budget for Implementation. The Ministry of Health and Environment i s implementing the BiomedicalWaste ManagementPlanand is inthe process of acquiring new incineration technology to dispose of medical waste in an environmentally acceptable manner. Fundingfor the technology i s available from existing resources andthe Government i s inthe process of selecting the appropriate type of incineration technology. It i s important to ensure that health care staff, incinerator operators and waste disposal handlers are adequatelytrained on issues regarding medical waste management. The project will finance an extensive training program of health care workers and staff handling bio-medical waste at an estimated of cost US$45,000 over the project life. Institutional Arrangements and Responsibilitiesfor Implementation and Supervision of Mitigation Activities Each of the participating agencies, with support from NAS, would be in charge of managing the implementation and supervision of the mitigation activities identified in this environmental assessment. 82 Annex 11:Project Preparationand Supervision St. Vincent And The Grenadines HIV/AIDS Prevention And ControlProject Planned Actual 01/08/2004 02/10/2004 ~ PCNreview Initial PIDto PIC 01/15/2004 03/25/2004 Initial ISDS to PIC 01/15/2004 03/22/2004 Appraisal 04/26/2004 05/03/2004 Negotiations 05/03/2004 05/20/2004 BoardRVP approval 06/04/2004 Planned date of effectiveness 10/30/2004 Planned date of mid-term review 03/30/2007 Planned closing date 06/30/2009 Bank staff and consultants who workedon the projectincluded: Name Title Unit Mary Mulusa TeamLeader LCSHH MarianaMontiel LegalCounsel LEGLA EdwardDaoud Sr. LoanOfficer LOAG John StephenOsika Sr. HealthSpecialist AFITR FabienneMroczka FinancialManagement Specialist LCOAA GuidoPaolucci Sr. Procurement Specialist LCOPR Willy DeGeyndt InstitutionalManagementSpecialist Consultant PatricioMarquez LeadHealthSpecialist LCSHH Albert0Gonima InformationTechnologySpecialist Consultant Yaa P.A. Oppong SocialAnthropologist PRMGE Samia Benhouzid LanguageProgramAssistant LCSHD Peer reviewers: Jonathan Brown (Operations Adviser, HDNGA)and Helen Saxenian, (Lead HealthEconomist, LCSHH). Bank funds expendedto date on project preparation: Bank resources: US$101,365.64 Trust funds: US$50,000.00 Total: US$151,365.64 Estimated Approval and Supervision costs: Remaining costs to approval: US$ US$4,000 Estimated annual supervision cost: US$ 140,000 Supervision strategy. The project involves a wide range of implementers in an environment with little experience of implementing Bank projects and with capacity constraints especially inthe area of human resources. The first two years of the project will require the range of skills usedin project design to provide support on each of the key components. Fiduciary aspectsinparticular will require regular contact between the Government and the Bank team. To initiate project implementation, a workshop will be heldincountry and will require not less than two formal supervision mission visits in the first year. Given the Bank's active involvement inthe region, short visits connected with missions to other countries will be useful inproviding proactive support to implementation. Regional training sessions for project and other implementers will be conducted. 83 Annex 12: Documents inthe ProjectFile St. Vincent And The Grenadines HIV/AIDS Prevention And Control Project A. Backgrounddocuments 1. St. Vincent and The Grenadines HIV/AIDS Strategic Plan2004-2009 2. Cost of the Five-YearHIV/AIDS/STI Strategic Plan2001-2006 3. Country HealthProfile 2002: Saint Vincent and Country Chapter from Healthin Americas, 2002 Edition; PAHO; WashingtonDC 4. Ministry of Health & the Environment,NationalHIV/AIDS Unit: OperationalPlan2004 5. HIV/AIDS in the Caribbean. IssuesandOptions. World Bank. 2001. 6. NationalBiomedicalWaste Management Plan, November 2002 7. St. Vincent and The Grenadines: CabinetMemo029/04 dated February23,2004 establishingthe NationalAIDS Council. 8. St. Vincent andThe Grenadines: NationalEconomicand SocialDevelopmentCouncilAct 2003 9. Evaluationof the HIV/AIDS SurveillanceSystems, St. Vincent andThe Grenadines, 22- 26 November, 1999, MOHE and CAREC/PAHO/WHO 10. The St. Vincent andThe GrenadinesHIV/AIDS NGO Networks: Strategic Plan2004- 2006 11. Assignment in St. Vincent and The Grenadines: Social MarketingApproaches to HIV/AIDS PreventionStrategies- "Another Way Forward" MOHE/ PAHO B. Project Documents 1. Draft ProjectOperations manual. 2. Health Care Waste ManagementPlan. C. BankAssessments 1. Financial management capacity assessment. 2. Procurement managementcapacity assessment. 84 Annex 13: Statement of Loansand Credits ST. VINCENT AND THE GRENADINESHIV/AIDS PREVENTION AND CONTROL Differencebetween expected andactual OriginalAmount in US$ Millions disbursements ProjectI D FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd PO69923 2002 VC DisasterManagement 3.00 2.91 0.00 0.00 0.00 5.97 3.40 0.00 PO76822 2002 St Vincent EmergencyRecoveryProject 0.96 2.24 0.00 0.00 0.00 1.91 0.72 0.00 Total: 3.96 5.15 0.00 0.00 0.00 7.88 4.12 0.00 ST. VINCENT AND THE GRENADINES STATEMENT OF IFC's Heldand DisbursedPortfolio InMillions ofUS Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Panic. Loan Equity Quasi Panic. Total portfolio: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Approvals PendingCommitment FY Approval Company Loan Equity Quasi Partic. Total pendingcommitment: 0.00 0.00 0.00 0.00 85 Annex 14: Country at a Glance ST. VINCENT AND THE GRENADINESHIV/AIDS PREVENTIONAND CONTROL Grenadines &Carib. income Development diamond' 1 2002 Population, mid-year(mfllions) 0.Q 527 2,411 Lifeexpectancy GNIpercapita (Atlas method, US$) 2,820 3280 1390 GNI(Atlas method, US$ bfll!ons) 0.33 1,727 3,352 I T Average annual growth, 1996-02 d Population (%A) 0 7 15 1.0 Laborforce (%A) 22 12 GNI Gross per pnmaty M o s t recent estimate (latest year available, 1996-02) capita enrollment Poverty (%ofpopulafionbelownatfonalPOverty/me) Urbanpopulation (%/.oftotalpopulatfon) 57 76 49 Life expectancyat birth (years) 73 71 69 Infantmortality (per lowlfvebirths) 17 27 30 Childmalnutntion (%of childrenunder5) 20 9 n Accessto improvedwater source Access to an improvedwatersource(%ofpopulatfon) 93 86 81 Illiteracy(%ofpopulationage 64 I1 D Gross pnmatyenrollment (%ofschool-age populatfon) xu) in - St. Vincent andthe Grenadines Male 01 111 Lowr-middle-income groUP ~ Female e8 110 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1982 1992 2001 2002 Economic ratios' GDP (US$ bfllfons) 009 023 0.35 0.36 Gross domestic investment/GDP 279 24.3 27.4 w o r t s of goods andservices/GDP 589 59.3 46.7 Trade Gross domestic savings/GDP -19 152 10.9 Gross nationalsavingsiGDP 201 10.6 Currentaccount balance/GDP -Q6 -104 Domestic interest payments/GDP 07 09 15 l2 savings investment Total debt/GDP 248 325 55.8 572 Total debt sefvice/eqmrts 31 48 7.9 Presentvalue of debt/GDP 44.7 Presentvalue of debt/exports 88.3 Indebtedness 1982-92 1992-02 2001 2002 2002-06 (averageannualgrowth) - GDP 60 1.7 02 0.7 St VfncentandtheGrenadfnes St.Vincent Grenadines GDP percapita 5.1 1.0 -0.6 0.0 __Lowr-mfddle-fncomegroup wr-middle-income STRUCTURE of the ECONOMY 1982 1992 2001 2002 Growth of investment and GDP (%) (%?of GDP) Agriculture 8.5 19.4 10.3 2o T lndustty 25.3 24.3 24.4 Manufacturing 10.9 9.5 5.4 XI Services 582 56.3 65.3 0 Private consumption 76.5 610 615 -K) Generalgovernmentconsumption 23A 23.8 27.5 Imports of goods andservices 88.7 66.4 63.1 -GDI -GDP 1982-92 1992-02 2001 2002 Growth of exports and imports (%) (averageannualgrohth) Agriculture 6.5 -11 -5.0 lndustcy 62 16 2.5 Manufacturing 3.9 -2.0 10 Services 6.1 4.6 -0.8 2 Private consumption 52 2.0 8.7 GeneralgovernmentconSUmptiOn 4.8 6.4 3.3 Gross domestic investment 6.3 4.5 -2.0 --Exports Imports of goods andservices 4.4 2.8 4.0 -Imports 86 St. Vincent and the Grenadines PRICES and GOVERNMENT FINANCE 1982 1992 2001 2002 1:l::h Inflation Domestic prices ( O h ) I (%change) Consumer prices 7.3 3.3 14 implicitGDP deflator 9.0 2.1 3.6 2.8 I Government finance (%of GDP, includescurrentgrants) Current revenue 25.7 23.8 -5 Current budget balance 2.8 4.1 I Overallsurplus/deficit -7.9 -0.5 -GDPdeflator -CPI I TRADE 1982 1992 2001 2002 (US$ millions) Export and import levels (US$ mill.) Total exports (fob) 70 43 Bananas 37 D ~ Eddoesanddasheens 3 2 200 Manufactures 22 21 150 Total imports (cif) 16 186 Food 27 48 100 Fuelandenergy 9 l7 50 I Capitalgoods 21 62 0 Export priceindex(1995=WO) XI9 96 97 9a 99 w Import priceindex(895=WO) XI0 exports olmports Terms of trade (895=WO) XI9 BALANCE of PAYMENTS 1982 1992 2001 2002 (US$millions) Current account balance t o GDP (%) Exportsof goods andservices 48 18 7 4 0 Imports of goods andservices 74 157 229 Resource balance -26 -38 -54 .m Net income -3 -7 -23 Net currenttransfers 18 t3 B .20 Current account balance -11 -24 -30 Financingitems (net) 7 35 Changesinnet reserves 4 -11 5 -40 Memo: Reservesincludinggold (US$ millions) 38 61 Conversion rate (DEC,local/US$) 2.7 2.7 2.7 2.7 EXTERNAL DEBT and RESOURCE FLOWS I 1982 1992 2001 2002 (US$millions) Composition of 2002 debt (US$ mill.) Total debt outstanding anddisbursed 21 76 8 5 206 18RD 0 0 0 0 IDA 0 8 8 x) G:32 Total debt service 2 6 14 14 IBRD 0 0 0 0 I IDA 0 0 0 0 0.67 Composition of net resourceflows Officialgrants 3 8 5 Official creditors 4 5 2 Privatecreditors -1 0 0 F 6 I Foreigndirect investment 2 14 36 Portfolio equity 0 0 0 E 31 World Bank program Commitments 0 0 0 5 Disbursements 0 0 1 2 A IBRD E - Bilaterd B IDA -- D Other multilateral - F-Privale Principalrepayments 0 0 0 0 IC-IMF G Short-term - 87