48943 PROPOSALTO RESTRUCTURE THE PAN-CARIBBEANPARTNERSHIP AGAINST HIV/AIDSPROJECT FORTHE CARIBBEAN COMMUNITY [IDA GRANT H077-0-6Rl DATA SHEET TEMPLATE FOR PROJECT PAPER Date: June 2, 2009 Team Leader: ShiyanChao Country: CARICOM Sector ManagerDirector:Keith E. Hansen ProjectName: HIVIAIDS Preventionand CountryDirector: Yvonne Tsikata Environmentalcategory:B Revisedestimateddisbursements (BankFYISDR m) FY 200415 200516 200617 200718 200819 2009110 Doesthe restructuredproject requireany exceptionsto Bankpolicies? oYes xNo Havethese beenapproved by Bank management? xoYes No I s approval for any policy exceptionsought from the Board? oYes xNo Revisedproject development objective/outcomes The proposedrevisedProjectDevelopmentObjective is to enhancethe Caribbeanregional responseto HIV/AIDS by: (a) supportingimprovementsinthe policy and legalenvironmentsfor addressingHIV/AIDS; (b) strengtheningthe knowledgebase on HIVIAIDS in the region; and (c) strengtheningthe capacityof selected regionalinstitutionsto providepublic goods and model tools to help CARICOMmember countries implementtheir nationalHIV/AIDS strategicplans. Doesthe restructuredprojecttrigger any new safeguard policies? No RevisedFinancingPlan(SDR Million) Source Total Recipient 0.23 IDA 6.10 Total 6.33 3 PROJECT PAPER PROPOSAL TO RESTRUCTURE THE PAN-CARIBBEANPARTNERSHIPAGAINST HIVIAIDSPROJECT FORTHE CARIBBEANCOMMUNITY [IDA GRANT H077-0-6Rl I. INTRODUCTION 1. This Project Paper seeks the approval of the Executive Directors to introduce the following changes to the Grant Agreement for the Pan-CaribbeanPartnershipAgainst HIV/AIDS Project (Project ID PO8072l),IDA Grant H077-0-6R, between the Caribbean Community (CARICOM) and the International Development Association. 2. The proposed restructuring would: (a) revise the Project Development Objective (PDO) statement to better reflect the outputs and outcomes that are achievable and attributable to the Project; (b) revise the results framework to align indicators with the revised Project Development Objective; (c) add a new subcomponentunder Part B of the Project, "Prevention of the Spread of HIV/AIDS", for the provision of mini-grants to support the subprojects carried out by youth organizations; (d) amend Part C of Schedule 2 to the Grant Agreement to reduce the work program for the Caribbean Epidemiology Center (CAREC) and add the Pan American Health Organization (PAHO) as the implementing entity in charge of some of the activities under this component; (e) allow for the utilization of the 2006 revision of the Procurement and Consultant Guidelines; (f) amend Schedule 1 to the Grant Agreement to: (i)include a new category of expenditures for mini-grants; (ii)reallocate resources among categories of expenditure to take account of the actual costs of project activities; (iii)allow the following expenditures to be financed from the proceeds of the Grant: "Goods" under Part B, "Prevention of the Spread of HIV/AIDS" and "Training" under Part A, "Advocacy and Policy Development" and Part B ofthe Project "Prevention of the Spread of HIV/AIDS"; and (iv) increase the financing percentage in Category 5, "Operating Expenses" to 100 percent, retroactive to February 26, 2007; and (g) extend the Grant's Closing Date to June 30,2010. 11. BACKGROUNDAND REASONSFORRESTRUCTURING A. HIVIAIDS in the Caribbean and the regionalresponse 3. The Caribbean region is the region most affected by HIV/AIDS after Sub-SaharanAfrica. The estimated adult prevalence of HlV in the Caribbean in 2007 was 1.1 percent. An estimated 230,000 people are living with HIV, of whom 20,000 were infected in 2007. The Pan-Caribbean Partnership against HIV/AIDS (PANCAP) was established in 2001 in responseto the realization that HIV/AIDS posed a.serious threat to the region. It was launched at the meeting of Heads of State and Government of the Caribbean Community and Common Market (CARICOM) countries. PANCAP is a regional partnership which operates under the aegis of CARICOM and is supported by a Project Coordination Unit (PCU) at the CARICOM Secretariat located in Georgetown, Guyana. 4. The SDR 6.1 million Grant for the PANCAP Project was approved on March 25, 2004, and became effective on October 15, 2004. This Project is part of the Caribbean Multi-Country HIV/AIDSPrevention and Control Horizontal APL (MAP) approved by the World Bank's Board in2001. 4 5. The Project brings together governments, regional institutions, the international community, the private sector, Civil Society Organizations (CSOs), and people living with HIV/AIDS (PLWHA) to enhance the response to the epidemic at national and regional levels. The Project's mandate includes the coordination, resource mobilization, advocacy and development o f regional public policies and support to the provision o f regional public goods. 6. The Project channels funds to specialized regional agencies' to carry out activities under the Caribbean Regional Strategic Framework (CRSF). PANCAP not only received grants from the World Bank, but also received funding from a number o f donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the European Union, a number o f bilateral donors (USAID, CIDA, DFID, and KfW), and UNagencies. B. Project Performance to Date 7. The Project experienced a very slow start due to a number o f constraints, mainly delays in signing Memoranda o fUnderstanding(MOUs) with implementing agencies and difficulties in disbursing funds to the CAREC. Most o f these constraints have been addressed through recommendations made by supervision missions, including the Project's Mid-Term Review. The Grant Agreement, dated April 28,2004, was amended on September 17, 2004 to clarify a number o f procurement provisions and to revise Section 3.04 which relates to Part C o f the Project: "Strengthening Regional Laboratory Services to Support the Expansion of Treatment and Care" executed by the Caribbean Epidemiology Center (CAREC). The Grant's Closing Date has been extended once from December 31,2007 to June 30,2009. 8. The Project has made progress so far, namely: (a) rehabilitatedand equippedthe regional tuberculosis laboratory and training o f laboratory staff from a number o f countries in the region; (b) trained PLWHA country networks inadvocacy and program management, sensitized CSOs on laws, ethics and human rights, and strengthened the CRN+ Regional Secretariat; (c) trained through the University o f the West Indies (UWI) with internships, a number o f national program staff, prepared educational materials for use inundergraduate programs, sensitized 250 students at the UWI on HN prevention and provided situation analysis o f response to HN/AIDS on two UWI campuses; (d) strengthened capacity for monitoring and evaluation through provision of technical assistance to the countries in the region by UNAIDS; (e) completed a number o f analytical studies; and (0 provided direct support to regional HN/AIDS related initiatives through CARICOM. 9. Overall, the notable achievements towards Project Development Objectives are: (a) development o f a regional governance structure; (b) development o f an information and communication framework and an advocacy campaign through the "Champions for Change" program that has reached out to involve political leaders, the media, religious leaders and private sector leaders in the fight against AIDS; (c) development o f tools for use by countries, including model workplace policies and an education sector and HIV/AIDS policy; (d) development of model programs that demonstrate effective ways o f reaching key vulnerable groups; (e) development o f the new Caribbean Regional Strategic Framework (2008-2012); and (f) strengthened capacities o f regional institutions (CAREC, CRN+, UWI, CCNAPC and CVC), enabling them to provide interventions targeted at specific vulnerable and at-risk groups and to helpcountries strengthen the implementation of national HN/AIDS strategic plans. 1At present, these agencies are: the Caribbean Epidemiology Center (CAREC), Caribbean Health Research Council (CHRC), CaribbeanNetwork of People Living with HIV/AIDS (CRN+), University of the West Indies (UWI), Caribbean Coalition of National AIDS Program Coordinators (CCNAPC), Caribbean Vulnerable CommunitiesNetwork (CVC) andthe CaribbeanCommunity (CARICOM) Secretariat. 5 10. PANCAP has won acclaim as a model o f regional cooperation (UNAIDS has recognized it as "International Best Practice"). It is an example of the emerging trend toward the consolidation o f regional entities in the Caribbean with a view to achieving greater impact and cost-effectiveness. 11. Notwithstanding the progress described above, project implementation has been slower than envisaged. As mentioned above, after initial delays, CARICOM and the implementation agencies have signed MoUs and most o f the earlier constraints in project execution have been addressed. The performance o f PANCAP and most o f the implementing agencies has improved considerably in the past year. The delay in reaching an agreement on how to disburse funds to CAREC, however, has continued to cause low disbursements. As o f January 2009, most o f the agencies involved had spent or committed a large share o f their allocated funds: the CARICOM Secretariat 86%, CRN+ 85%, and UWI 89%. However, CAREC has disbursed only 33% of its funds, due primarily to the fact that the agency requires the availability o f full funding before initiating any activity. Consequently, advances to CAREC from the project special account have usually taken an inordinate amount o f time to document. The slow documentation o f CAREC's advances, which represented about 75% o f the special account initial advance, adversely affected the timely replenishment of the special account, which in turn delayed project implementation. Dueto the delays under CAREC, the overall disbursement is only 55.7% (US$5.3 million of the grant as o f June 1, 2009). The initially dysfunctional flow o f funds arrangements have led to a financial management rating o f "unsatisfactory" in the current ISR, as well as a rating for achieving the Project Development Objectives o f "moderately unsatisfactory", and a rating for Implementation of "moderately satisfactory". However, despite these disbursement-related issues, based on the most recent information, the financial management systems o f the project are considered adequate to provide reasonable assurance that Grant proceeds are being utilized in accordance with the Grant Agreement. The unsatisfactory rating is not dictated by any serious fiduciary concerns. Due to the institutional changes, CAREC i s no longer implementing the Project. The future disbursement to PAHO will be based on a cooperation Agreement between CARICOM and PAHO providing for a blanket withdrawal mechanism. That would resolve the disbursement issues that CAREC faced before. Staff o f the Loan Department has programmed a special visit to the implementing agencies to assess the rate of progress and to help resolve any bottlenecks that might remain. C.Reasons for Project Restructuring 12. The main reasonsfor restructuringthe Project are as follows: (a) the original PDO was vague and ambitious and only reflected broader regional objectives o f the HIV/AIDS response as opposed to realistically stating achievable and measurable project objectives; (b) the original Results Framework did not have appropriate indicators to measure the Project's expected outputs and attributable outcomes, which are mainly related to capacity building at the regional level rather than changes in the AIDS epidemic at the individualcountry level; and (c) the CARICOM member states have recently decided to restructure the public health institutions inthe Caribbean region. As a result o f this restructuring, CAREC, along with four other agencies, will be consolidated into a new agency, the Caribbean Public Health Agency (CPHA) under CARICOM. The transition is planned to take place by the end of 2009. The new agency will not be part o f PAHO, where CAREC i s currently placed. As a result of the restructuring, CAREC will no longer implement some o f the planned 6 activities under Component C of the Project and some of these activities will be taken over by PAHO through its HIV CaribbeanOffice (PHCO). In. PROPOSEDCHANGES The restructuringwould involve changes in following areas: Amending the Project Development Objective. The original Project Development Objective (PDO) was to expand, consolidate and effectively coordinate regional support within the CARICOM's member countries in an effort to reduce the impact of HIV/AIDS on the human and economic development of the Caribbean region. The Project's Mid-Term Review concluded that the original PDO was vague and ambitious and only reflected broader regional objectives of the HIV/AIDS response as opposed to realistically stating achievable and measurable project objectives. Therefore, the proposed revised PDO would be to enhance the Caribbean regional response to HIV/AIDS by: (i)supporting improvements in the policy and legal environments for addressingHIV/AIDS; (ii)strengtheningthe knowledge base on HIV/AIDS in the region; and (iii)strengthening the capacity of selected regional institutions to provide public goods and model tools to help CARICOM's member countries* implement their national HIV/AIDS strategic plans. Changing Indicators in the Results Framework. The original project monitoring and evaluation indicators resemble outcome indicators for the national AIDS programs. This is overly ambitious, because this project is a capacity building project at the regional level and does not provide or control the service delivery at the country level that would be needed to change behavior or reduce HIV incidence rates. Thus, outcome indicators on behavior changehesults of HIV control that can be measured at the country level are not appropriate for monitoring achievements of this project. Based on the revised PDO, the results framework would therefore be amended to measure the results that are attributable to the Project. The revised PDO indicators are: (i)the new Regional AIDS strategy is developed and disseminated; (ii)a new regional coordination mechanism is established and functional; and (iii)regional products in policy and model programs being usedby countries. The revised Project Results Framework is presented in Annex 1 to this Project Paper as well as inthe revised OperationsManual. Adding a new subcomponent under Part B of the Project, "Prevention of the Spread of HIV/AIDS," for the provision of mini-grants to support subprojects carried out by youth organizations and community-based organizations to implement innovative interventions for HIV/AIDS prevention, care, and to address stigma and discrimination. The Mini-Grant Program (MGP) is a regional mechanism for creating an enabling environment for the reduction of HIV/AIDS among young people through a focus on youth leadership, mobilization and outreach. The MGP is designed by and for youth and implemented by youth through multiple youtldadult partnerships and networking arrangements operating at community, national, sub-regional and regional levels. The program is designed to equip young people aged 15-24 in disadvantaged communities with information and resources to provide service to peers and community. Key outputs include a strengthened leadership base of the CARICOM Youth Ambassador Program, 2Accordingto the Grant Agreement, the countries benefittingfrom the Project's regional activities are as follows: Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts and Nevis, Saint Lucia, St. Vincent and the Grenadines, Suriname, the Dominican Republic, Haiti, and Trinidadand Tobago. 7 National Youth Councils and other non-Government organizations. This program has been mainly supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). CARICOM has requested the Bank to support the scaling up of this program under this project. The funding mechanism, selection criteria and procedures have been developed and incorporatedto the Project's Operational Manual, Annex E. (4reflect Amending Part Cof Schedule 2 to reduce the workprogramfor CARECand to the addition of the Pan American Health Organization (PAHO) as the implementing entity in charge of some o f the activities under this component. As mentioned above, due to the restructuring o f CAREC, some activities described under Part C o f Schedule 2 would not be implemented and the scope o f Part C will be reduced. In addition, during the project extension period, PAHO will implement some activities under Part C o f the Project through its HIV Caribbean Office (PHCO). The detailed work plan for PAHO/PHCO is attached as Annex 3. A Cooperation Agreement between CARICOM and PAHO will be signed. Amended project descriptions are inI11(g) below. (e) The Project description has been amended to reflect the changes described in points (c) and (d) and to align the description consistent with the activities financed under the Project. The revised Project Description i s as follows: Under Component 1, Advocacy and Policy Development, the Project will: (i)support implementation of the regional strategy to raise awareness and knowledge o f the HIVIAIDS epidemic; (ii)support efforts to reduce stigma and discrimination (S&D) towards PLWHA and their families; and (iii)mobilize public support to address the epidemic at the regional level. Activities to be financed include studies on the interaction between tourism and HIV/AIDS; costing and monitoring o f HIV/AIDS programs; the Bahamas' experience in reducing HIV/AIDS; assessment o f legal frameworks and development o f model policies, guidelines and legislation to reduce S&D. Under Component 2, Prevention o f the Spread o f HIV/AIDS, the Project will support: (i) provision o f support to Member Countries for the preparation of studies and programs aimed at reducing the risk o f HIV infection among mobile populations; (ii)carrying out o f HIV preventive services at tertiary educational institutions; (iii)development and dissemination of materials concerning the prevention and control o f HIV/AIDS in the region; (iv) support for a regional condom social marketing program to promote safer sexual social practices among youth and other vulnerable groups; (v) provision o f support in connection with Member Countries' programs to promote corporate responsibility on HIV/AIDS prevention in multi-country enterprises, which programs shall include, inter alia, the development o f policies to be adopted at the workplace and a training program for the staff o f said enterprises; and (vi) provision o f mini-grants to support subprojects carried out by youth organizations and community-based organizations to implement innovative interventions for HIV/AIDS prevention and care and to address stigma and discrimination. Under Component 3, Strengthening Regional Laboratory Services to Supuort the Expansion o f Treatment and Care, the Project will carry out the following activities: 0 Through CAREC to strengthen regional laboratory services to improve the care and treatment o f HN/AIDS, other sexually transmitted infections and other opportunistic infections, such as tuberculosis, through, inter alia: (a) the renovation and expansion o f its existing small high security mycobacteriology laboratory; (b) the acquisition and utilization o f new 8 laboratory equipment and related supplies; (c) the design and carrying out o f a training program concerning new tuberculosis laboratory methods; and (d) the strengthening o f its biomedical waste management and disposal system and procedures. Through PAHO (using PHCO): (i)provision o f laboratory testing services through outsourcing and strengthening laboratory testing for HIV/AIDS and other sexually transmitted infections, and opportunistic infections, including tuberculosis; (ii)training o f staff on new tuberculosis laboratory methods systems and (iii)training on prevention and treatment for HIV/AIDS and other infectious diseases including tuberculosis control; and (iv) provision o f technical assistance in connection with the establishment o f a Caribbean laboratory network, the definition o f its modus operandi, and the strengthening o f its capacity. Under Component 4, Strennthening; the Regional Response Capacitv, the Project will support: (i)strengtheningPANCAP/CARICOM's capacity to coordinate the role of regional HIV/AIDS agenciedentities; (ii)increasing the institutional and operational capacity o f CRN+ to support country networks o f PLWHA; (iii)strengthening the UWI's Health Economics Unit to enhance capacity to undertake research and provide technical training to countries in the region through, inter alia, training and mentoring programs; strengthening the health economics undergraduate and graduate program, creating a pool o f experts for the countries to draw upon; short-term mentoring programs for staff o f eligible countries; expansion o f infrastructure facilities; and strengtheningthe UWI's own internal HIV/AIDS (UWIHARP) program to expand its outreach objectives; and (iv) supporting the UNAIDS objectives to expand country capabilities in monitoring the evolution o f the HIV/AIDS epidemic. The component also supports assessing drug registration and patent systems across countries and sponsoring HIV/AIDS care and treatment meetingsto facilitate cross-fertilization among countries. Allowing for the use o f the October 2006 revised World Bank Procurement and Consultant Guidelines, which allow for more flexibility in the use o f procurement methods and eligibility o f countries to participate inBank-funded procurement. Amending Schedule 1 o f the Grant Agreement. Schedule 1 would be amended to: (i)include a new category o f expenditures for the provision o f mini grants; (ii) reallocate resources among categories o f expenditure to take account o f the actual costs o f project activities; (iii)allow the following expenditures to be financed from the proceeds of the Grant: "Goods" under Part B, "Prevention of the Spread o f HN/AIDS"; and, "Training" under Part A, "Advocacy and Policy Development" and Part B o f the Project "Prevention o f the Spread o f HIV/AIDS"; and (iv) increase the financing percentage in Category 5, "Operating Expenses" to 100 percent, retroactive to February 26,2007, and Extending the Grant's Closing Date from June 30, 2009 to June 30, 2010. This would be the second extension o f the ClosingDate. With restructuring and a one-year extension, the project will be able to attain its revised objectives. Implementation problems have had more to do with institutional arrangements than with lack of commitment or technical shortcomings, and the restructuring will remedy these. Even with a one-year extension, the project will have had a total implementation period of just over six years from original Board approval. Additional time will 9 allow the Project to fully utilize the Grant and complete all the planned activities benefitingthe region. IV. ANALYSIS 14. Economic and Social Analysis. The proposed changes will not affect the economic, financial, technical and social aspects of the Project as appraised, The economic justification for investment in the PANCAP Regional HIV/AIDS Project outlined in the Project Appraisal Document (Report No. 27267 dated March 4, 2004) is still valid. The Caribbean i s still the region most affected by HIV/AIDS after sub-Saharan Africa, with an average HIV/AIDS prevalence o f 1.1 percent. The fact that HIV/AIDS is the main cause o f death o f 25 to 44 year old Caribbean nationals has important consequences for output, labor supply, employment, savings, investment, and household and Government expenditures on treatment. The ability to reduce new infections and prolong the lives o f those already infected is important for the economic and social development o f Caribbean countries. 15. PANCAP is a critical regional organization for HIV/AIDS prevention and treatment that plays an important role in dealing with the epidemic. PANCAP has led the development o f the Caribbean Regional Strategic Framework on HIV and AIDS 2008-2012 (CSRF) and i s playing a special role in building the capacity o f the Caribbean countries to implement the priorities outlined inthe CSRF and national plans. 16. EnvironmentalAssessment. The Project was assigned a Category "B" environmental rating and this rating will remain unchanged for the restructuring. As part o f project preparation in 2003, a biomedical waste management assessment was carried out to identify potential environmental impact from the handling o f biomedical wastes generated from laboratory testing o f blood samples by the CAREC regional laboratories. Resources were allocated for updating the manuals for handling and disposal o f biomedical waste generated by the laboratories; and for the purchase o f waste disposal equipment and staff training in the application o f appropriate standards to health care waste management. With support under the Project, CAREC revisedthe laboratory hazardous waste management policy and Standard Operating Procedures (SOPS). The revised policy outlines staff responsibilities in the management o f biomedical waste; different categories o f laboratory waste produced at CAREC; collection and segregation o f waste at the point of generation; and treatment of different types o f waste produced and safe disposal of the waste. The implementation o f the biomedical waste management plan has been monitored regularly during supervision missions. It was assessed as satisfactory during the Project's Mid- Term Review. Due to the restructuring o f CAREC, the project will focus on the establishment o f a regional Caribbean laboratory network, which will provide information on testing capacity in laboratories inthe region; thus, countries will be able to send samples to those laboratories during the period inwhich CAREC is intransition and therefore unable to provide testing services. 17. The Project envisaged civil works activities at two institutions: CAREC and the UWI at St. Augustine (Trinidad). At the CAREC site, the civil works involved the refurbishment o f the tuberculosis laboratory. These civil works have been completed and the laboratory is operational. No adverse environmental impacts resulted from the refurbishment o f the laboratory. The project will not support further civil works as CAREC will not be implementing further project activities, due to its absorption into the new Caribbean Public Health Agency (CPHA). 18. A teachinglearning facility for the UWI's Health Economics Unit (HEU) is being constructed at the UWI site, with significant co-financing from the Government o f Trinidad. The site that was selected for the construction is owned by the UWI and is within the perimeter o f the 10 University campus. It is the site of a previous structure that belonged to the University and was demolished. The site was cleared o f debris before this Project was designed. There are currently no occupants o f the site or any claims to the site, other than that of the UWI. The UWI campus at St. Augustine (Trinidad) has a stringent internal environmental code enforced by the University Administration. The HEU obtained the relevant construction clearance from the University Administration and the Local Government authorities prior to the construction o f the HEU building. 19. Reallocation of Funds. Project costs have been adjusted and funds reallocated to reflect the actual costs o f planned activities supported by the Project. Due to the organizational changes affecting CAREC, the Project will not continue to support the provision o f equipment to laboratories, and some finds originally allocated under Component C will be reallocated. Some funds will be used to support the establishment of a regional laboratory network. PAHO will help countries in the region to make arrangements for the laboratory work that CAREC will not be able to carry out duringits transition period. Giventhat PANCAPalso receives finding from the GFATM and bilateral donors, reallocation of funds is required to adjust for possible gaps in the parallel financing. 20. CARICOM has submitted time-bound action plans with monitorable indicators for the extension period. The Bank team has reviewed the plans and found them satisfactory. 21. Neither the Grant nor CARICOM (the Recipient) i s subject to an ongoing suspension o f disbursements. There are no outstanding audit reports. Overall, although the Project has experienced delays with regard to implementation and flow o f funds, PANCAP has been playing a critical role in coordinating the region's efforts in combating the AIDS epidemic, and currently, the implementation o f activities under the PANCAP secretariat is progressingwell. The Project is being restructured to ensure that the advances in project implementation continue and to formally correct the problems which have been contributing to the implementation delays and partial progress towards the PDOs. V. EXPECTEDOUTCOMES 22. It is expected that the proposed restructuring will: (a) improve the Project's focus on more realistic and achievable objectives, (b) improve monitoring and evaluation o f project performance based on relevant indicators, and (c) contribute to maximizing the effectiveness of Bank support to the region. The revised outcome indicators are discussed in Paragraph 13 (b) and presentedinAnnex 1. VI. BENEFITSAND RISKS 23. The Project adds value to the national HIV/AIDS programs by offering options for gaining economies o f scale through regional interventions that strengthen networks o f infrastructure and capacity o f regional institutions which provide regional public goods that countries individually could not afford. The Project has been supporting strengtheningo f regional reference laboratories; facilitating research and exchange o f information; training to improve skills and capacities o f countries; improved sharing o f knowledge and experience; supporting PANCAP and enabling it to strengthen collective bargaining (e.g., through the PANCAP process, the region was the first to negotiate for better AIDS drug prices). The Project has been supporting the regional agencies, including PANCAP, CRN+ and the UWI, which play a strong role in policy formulation and advocacy, to address major challenges, including stigma and discrimination which are major impediments to addressing the HIV/AIDS epidemic. The Project i s also helping to strengthen vulnerable and at-risk groups (youth, young adults at tertiary level 11 institutions, mobilizedpopulation,commercialsex workers, migrant workers) through improving the design and implementationof interventionsthat will continueto serve as models for country- level interventions and through research to help improve the knowledge base on these groups. Given the political visibility of the PANCAP framework, Caribbean countries have been increasingly using it as a platform for other issues. Achievement of the Project's objectives will contribute significantly to strengthening the regional and national capacity to address various issues beyondhealth. In sum, benefitswill be realized in: (i)stronger institutionaland technical capacity for regionalagencies; (ii)strengthenedcapacity for Caribbean member countriesthrough enhanced leadership, improved technical capacity resulting from training provided under the Project by the regional institutions, and availability of tools for addressing stigma and discrimination(e.g., modellegislation); (iii)greater knowledgeand understandingof the trends in the epidemic; and (iv) stronger regional advocacy and leadership capacity of key regional institutions. 24. The pace of implementation poses a moderate risk to achievement of the Project's DevelopmentObjectivesdue to possible delays in project executionby the beneficiaryagencies. Agencies have been slow to utilize and account for funds disbursed to them. This risk will be mitigatedby morefrequent site visits by the fiduciary staff of the PANCAPPCU. There is also a risk that the constructionwork at UWI could be delayed due to the possibility that the current global financial crisis may reduce the Government of Trinidad and Tobago's contributions to completing the building. CARICOM and UWI management teams are aware of this risk and have already explored different financing options. Finally, the issues in procurement and disbursement that affected the implementation under CAREC may continue to affect the new implementationagency, PAHO, and delay implementation.To resolvethe issue, CARICOM and PAHO will enter into a cooperationagreement, with the no-objectionof the Bank, providing for a blanket withdrawal mechanism in order to speed up the flow of funds and to ensure compliance with the Bank's fiduciary requirements. 12 Annex 1.RevisedPANCAP Results FrameworkandMonitoring Indicators CE Meansof - Verification/ Data Source Current Final status Project Development Objective: To enhance the Caribbean regionalresponseto HIV/AIDSby: (a) supportingimprovements (a- i) New Regional 1 RegionalStrategic inthe policy and legal AIDS strategy Framework environments for addressing developedand document, HIV/AIDS; disseminated. disseminationplan (a- ii) Draftmodel 15 & report, financial policy guidelines & records legislationto reduce stigma& discrimination developedand disseminatedto all participating countries. (b) expandingthe knowledge (b- i)# ofcountries 8 RCMreports base onthe cost & usingregionalpolicy consequences of HIV/AIDS documents and model intheregion programsas reported by country delegates to PANCAP at RCM meetings (b4 ) Project study 14 Study publications, reportson topics such policy documents, as HIV and poverty; dissemination HIV & tourism, and reports Costingand milestonesin HIVIAIDS, disseminatedto all participating CARICOM :ountries. (c) strengtheningthe capacity [c- i) regional 1 RCMquarterly o f selectedregional :oordination reports institutionsto helpcountries nechanism(RCM) implementtheir national :stablished and HIViAIDSstrategic plans. Functional. :c- ii)capacity o f six 6 Implementing -egionalinstitutions agency progress strengthenedand reports ;apable of increasing nandatedservice as 13 evidenced by achievements o f their workplans. Objectivesof each Intermediate Means of component outcome and output Verification/ indicators Data Sources 1. Advocacy and Policy # o fregional studies 7 Final study reports Development conducted with findings disseminated to inform policy development and advocacy # o f toolkits produced 6 Toolkits & disseminated documenting best practices to reduce stigma & discrimination at the country level # o f draft regional 1 report ,workshops model policies & and draft legislation legislation developed to reduce stigma & discrimination against PLWHAs & their families 2. Prevention of the Spread Regionalprogram 1 Regional framework of HIV/AIDS designed to provide and report HIV infection prevention services at tertiary educational institutions # o f workplace 2 Workshop reports HIV/AIDS prevention CEOhusiness leader workshops andor meetings conducted # of vulnerable 6 Quarterly population networks monitoring reports supported # o f HIV/AIDS 5 Quarterly prevention mini- monitoring reports grants implemented by CARICOM Youth Ambassadors (CYA) # o f healthcare 30 Workshop & providers trained to quarterly reports train other Droviders 14 how to serve M S M & CSW healthcare needs 3. StrengtheningRegional # o f regional 1 Quarterly Laboratory Services to laboratories monitoring Reports Support Scaling-Up renovated and Treatment & Care expanded # o f regional 2 Quarterly laboratories equipped monitoring reports Regional Lab 1 Quarterly Network established monitoring reports 4. Strengthening Regional # of UWI-HEU 1 Buildingsite review ResponseCapacity training facilities & quarterly reports expanded & equipment support provided Number of graduate 8 Quarterly students trained in monitoring Reports HIV-related health economics Number o f regional 10 R C M and A G M HIV/AIDS reports coordination meetings conducted # o f countries 4 Quarterly reports completing accreditation inthe Caribbean Initiative for the Elimination o f Vertical Transmission o fHIV & Syphilis # o f countries 0 0 5 Project reports receivingtechnical assistance on IT/M&E database and tools. # o f PLWHAs trained 0 Project reports on inadvocacy, project actual numbers & financial management, & marketing 15