Documentof The World Bank FOR OFFICIAL USEONLY ReportNo: 42719-JM PROJECTAPPRAISALDOCUMENT ONA PROPOSEDLOAN INTHEAMOUNT OFUS$10MILLION TO JAMAICA FOR A SECONDHIV/AIDS PROJECT April 9,2008 Sector ManagementUnitfor HumanDevelopment CaribbeanCountry ManagementUnit Latin America andCaribbeanRegion This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwisebe disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange RateEffective March 18, 2008) Currency Unit= JamaicaDollar (JMD) 1JMD =US$0.014 US$1= JMD71.14 FISCAL YEAR April 1 -- March 31 ABBREVIATIONS AND ACRONYMS AGD Auditor General'sDepartment AIDS Acquired ImmuneDeficiency Syndrome ANC Ante-Natal Clinic ARV Antiretroviral BCC Behavior Change Communication BSS Behavior Surveillance Survey CAS Country Assistance Strategy CAREC CaribbeanEpidemiology Center CBO Community-Based Organization CDC Center for DiseaseControl and Prevention CD4 Helper T-lymphocytes CHARES Center for HIV/AIDS Research, Education and Services CMO Chief Medical Officer COHSOD Council for Health and SocialDevelopment(Subcommittee of Cabinet) CQ Consultant Qualifications csos csw Civil Society Organizations Commercial Sex Worker DALY Disability Adjusted Life Year DOTS Directly ObservedTreatment, Short Course EC EuropeanCommunity FAA Financial Administration and Audit Act FBO Faith-Based Organization FY FiscalYear GDP Gross Domestic Product GFATM GlobalFund for AIDS, Tuberculosis and Malaria GOJ Government of Jamaica GTZ Deutsche Gesellschaftfur Technische Zusammenarbeit (GTZ) GmbH HAART Highly Active Antiretroviral Therapy HATS HIV/AIDS Tracking System HCL Health Corporation Limited HIS Health InformationSystem HIV HumanImmune-deficiency Virus IBRD International Bank for Reconstructionand Development ICB International Competitive Bidding IDB Inter-American Development Bank IEC Information, Education and Communication JAS JamaicaAIDS Support JICA Japan International Cooperation Agency JN+ JamaicaNetwork of HIV+ KAPB Knowledge, Attitude, Practices and Behavior LAC Latin American and Caribbean LIB Limited International Bidding M&E Monitoring andEvaluation FOROFFICIAL USE ONLY MDG MillenniumDevelopmentGoal MOWS Ministry of Financeandthe Public Service MOH Ministry of Health MSM MenHavingSex with Men NAC NationalAIDS Committee NCB NationalCompetitiveBidding NCC NationalContract Commission NGO Non-GovernmentalOrganization NHP NationalHIVIAIDS Program NNRTI Non-NucleosideReverseTranscriptaseInhibitors NPC NationalP l w gCouncil NPHL NationalPublicHealth Laboratory NSP NationalHIVIAIDS StrategicPlan 01 OpportunisticInfections PAC ParishAIDS Committee PAHO PanAmerican Health Organization PCU ProjectCoordinationUnit PEP Post-ExposureProphylaxis PIOJ PlanningInstitute of Jamaica PLWHA PeopleLiving with HIV/AIDS PMTCT Preventionof Mother-to-Child Transmission PSO PrivateSectorOrganization QCBS Quality andCost-BasedSelection RHA RegionalHealthAuthority RPR RapidPlasmaReagin SBD StandardBidding Documents SOE Statementof Expenditures STI SexuallyTransmittedInfection TB Tuberculosis UNAIDS Joint UnitedNationsProgramonHIV/AIDS UNGASS UnitedNationsGeneralAssembly Special SessiononHIV/AIDS USAID US.Agency for InternationalDevelopment VCT Voluntary CounselingandTesting VDRL Venereal Disease ResearchLaboratory WHO World HealthOrganization CountryDirector: Yvonne M.Tskita Sector Director EvangelineJavier SectorManager: KeithHansen Sector Leader ChingboonLee Task TeamLeader: Mary T. Mulusa This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not be otherwise disclosed without World Bank authorization. JAMAICA JAMAICA SECONDHIV/AIDS PROJECT PROJECTAPPRAISAL DOCUMENT LATINAMERICA AND CARIBBEAN LCSHH Date: April 9, 2008 TeamLeader: Mary T. Mulusa CountryDirector: Yvonne M.Tsikata Sectors: Health (80%); Other socialservices Sector Managermirector: KeithE.Hansen (20%) Themes: HIV/AIDS (P);Health system performance(S) ProjectID: P106622 Environmentalscreeningcategory: Partial Assessment LendingInstrument: Specific InvestmentLoan [XILoan [ 3 Credit [ ]Grant [ ] Guarantee [ ]Other: For Loans/Credits/Others: Total Bank financing (US$m.): 10.00 Proposedterms: The loanis a U.S. Dollar Variable SpreadLoan, with 5 years of grace period and 30 years repayment. FinancingPlan(US$m) Source 1 Local Foreign Total Borrower 1.54 0.00 1.54 InternationalBankfor Reconstructionand 6.00 4.00 10.00 Development FinancingGap 0.00 0.00 0.00 Total: 7.54 4.00 11.54 Borrower: Jamaica ResponsibleAgency: Ministry of Health Address: 2-4, King Street OceanaBuilding, Kingston, Jamaica, West Indies ContactPerson: KevinHarvey, SeniorMedical Officer Estimated Disbursements (Bank FY/US%m) FY 2008/09 2009/10 2010/11 2011/12 4nnual 2.00 2.50 3.50 2.00 2umulative 2.00 4.50 8.00 10.00 Does the project require any exceptions from Bank policies? [ ]Yes [XINO Ref. PAD 0.7 Have these been approved by Bank management? I s approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any criticalrisks rated "substantial" or "high"? Ref. PAD C.5 [XIYes []No u Does the project meet the Regional criteria for readinessfor implementation? Ref. PAD0.7 [XIYes [ No Y Project development objective Ref. PAD B.2, TechnicalAnnex 3 The project development objectives are to assist inthe implementation of the Government's NationalHIV/AIDS Programby supporting the: (i) deepening of prevention interventions targeted at high risk groups and the general population; (ii)increasing of access to treatment, care and support services for infected and affected individuals; and (iii) strengthening of program management and analysis to identify priorities for buildingthe capacity of the health sector to respond to the HIV/AIDS epidemic and other priority health problems. Project description [one-sentencesummary of each component] Ref. PAD B.3.4 Technical Annex 4 Component1:Prevention(US$3.34 million). This component will support scaling up of HIV/AIDS prevention interventions to halt and reversethe spreadof HIV/AIDS. Component2: Treatment,CareandSupport(US$ 1.81million). This component will provide financing to strengthenthe diagnostic capacity, enhance services (HIV/AIDS, sexually transmitted infections, tuberculosis and prevention of mother-to-child transmission of HIV)and support for those infected and affected by HIV/AIDS. Component3: StrengtheningInstitutionalCapacity(US$4.26 million). This component will support policy formulation for an enabling legal and regulatory environment, program managementand monitoring and evaluation. Component4: HealthSector DevelopmentSupport(US$2.10 million). This component will support: (a) strengthening of biomedical waste management and (b) capacity assessment for the health sector. Which safeguardpolicies are triggered, if any? Ref. PAD 0.6, TechnicalAnnex 10 OP4.01-Environmental Assessment. Significant, non-standard conditions, if any, for: Ref. PAD C.7 None Boardpresentation: May 8,2008 Start-up Date: September 1,2008 hankredit effectiveness: August 6,2008 Covenants applicable to project implementation The Borrower shall, not later than February 28 of each year during Project implementation, starting in year 2009, furnish to the Bank for its approval, an annual action plan, each said plan to include inter alia:@)the Project activities to be carried out by the Borrower, with the assistanceof the Implementing Agencies, as the case maybe, duringthe fiscal year following the receipt of the Bank's approval of the relevant plan; (ii) the updated Procurement Plan and estimated disbursements by Project activities for each said calendar year. CONTENTS Page I. STRATEGIC CONTEXT AND RATIONALE..................................................................... 1 A . Country and Sector Issues.................................................................................................. 1 B. Rationalefor BankInvolvement........................................................................................ 3 C. HigherLevel Objectives To Which The ProjectContributes............................................. 4 D. ComplementingOtherExternalSources of Funding......................................................... 4 I1. PROJECTDESCRIPTION.................................................................................................... 5 A. LendingInstrument............................................................................................................ 5 B. ProjectDevelopment Objectiveand Key Indicators.......................................................... 5 C. ProjectComponents........................................................................................................... 5 D. Lessons LearnedandReflectedinthe ProjectDesign....................................................... 8 E. Alternatives Consideredand Reasons for Rejection........................................................ 10 111. IMPLEMENTATION ...................................................................................................... 10 A. PartnershipArrangements................................................................................................ 10 B. Institutionaland ImplementationArrangements.............................................................. 10 C. Monitoring andEvaluationof OutcomesAXesults ............................................................ 12 D. Sustainability.................................................................................................................... 12 E. Critical RisksandPossibleControversialAspects for the ProposedProject...................13 F. Loadcredit Conditions andCovenants ........................................................................... 14 IV. APPRAISAL SUMMARY .............................................................................................. 14 A. Economic andFinancialAnalyses ................................................................................... 14 B. Technical.......................................................................................................................... 15 C. Fiduciary.......................................................................................................................... 16 D. Social................................................................................................................................ 17 E. Environment. EnvironmentalCategory B ....................................................................... 18 F. Safeguardpolicies............................................................................................................ 19 G. PolicyExceptionsand Readiness..................................................................................... 19 Annex 1: Country and Sector Background.................................................................................. 20 Annex 2: Major Related Projects ................................................................................................. 25 Annex 3: Results Framework and Monitoring............................................................................. 27 Annex 4: DetailedProject Description......................................................................................... 32 Annex 5: Project Costs................................................................................................................. 41 Annex 6: ImplementationArrangements ..................................................................................... 42 Annex 7: Financial Management and Disbursement Arrangements ........................................... 48 Annex 9: Economic and Financial Analysis ................................................................................ 61 Annex 11: Project Preparation and Supervision........................................................................... 73 Annex 13: Statement of Loans and Credits.................................................................................. 77 Annex 14: Country at a Glance.................................................................................................... 78 Annex 15: MAP IBRD 80 Jamaica: SecondHIV/AIDS Project I. STRATEGICCONTEXTANDRATIONALE A. Country andSector Issues 1. EconomicPerformance. Jamaicais the thirdlargest island inthe Caribbean with a population of 2.7 million. The country's economic performance' has improved steadily since 2001, with the highest GDP annual growth of 2.5% recorded inFY2006/07. The growth was due to an increaseinforeign and domestic private investment ledby tourism, mining and agriculture. The annual inflation rate dropped to 6.6% inEy 2006/07 from over 13.2% in FY2004/05. An estimated 14.3% of Jamaicans still live below the national poverty line. The 2006 Survey of Living Conditions identifies several factors linked to poverty: large households, female headedhouseholds, inequities in access to health and education services and low educational attainment. Despite improvements ineconomic performance, Jamaica continues to face many challenges: high debt, tight fiscal situation (though revenue collections have improved, they have not reached desired targets while expenditures have not been contained as planned). Crime and violence continue to pose challenges. Poor education outcomes affect the country' s competitiveness. 2. HealthStatus. Jamaicanhealth indicators compare favorably with LatinAmerican countries as well as middle income countries. The country i s still undergoing the epidemiological transition with a continued decline ininfectious diseases, maternal and infant mortality and childhooddiseases and a growth innon-communicable diseases. Leadingcauses of morbidity and mortality include: neoplasms(cancers), cardiovascular diseases, diabetes, injuries and HIV/AIDS. The age-group 15-49years has been hardesthit by AIDS and sexually transmitted infections. They are the secondleading cause of death among the 15-24year age- group. Despite achievementsinthe health sector, Jamaica i s still facing challenges to achieve the health MillenniumDevelopment Goals especially with respect to HIV/AIDS. 3. Statusof the HIV/AIDS Epidemic. Itis estimated that 25,000 (1.5%) of adults aged 15- 49 years are infected with HIV. The gender difference has been narrowing. The majority (65%) of reported AIDS cases fall within the 20-44 year old age group. The HIV epidemic inJamaica has features of both a generalized and concentrated epidemic. The prevalence varied across population groups with a highprevalence among female sex workers (9%) and sexually transmitted infections clinic attendees (4.6%) in2005; and between 20%-30% among men who have sex with men (MSM),and prisoners (3.3%) in2006. HIV infection i s also highamong substance abusers and people confirmedwith tuberculosis. Between 1982 and 2005, the cumulative number of known AIDS cases was 11,004 with 6,437 reported AIDS deaths. Better access to antiretroviral (ARV) drugs has helped to extend the lives of AIDS patients and decreasedthe mortality rate inthe past five years. By early 2007, just over 5,000 children under the age of 15 years hadbeen orphaned by HIV/AIDS. All 14parishes are affected by the HIV epidemic but the most urbanized parishes (Kingston, St. Andrew and St. James) have the highest cumulative number of AIDS cases. Heterosexualtransmission i s reported by 90% of persons with HIV. An intertwinedset of cultural, economic, social, and behavioral factors are driving 1CountryAssistanceStrategy for Jamaica, April, 2005 andthe CountryAssistanceStrategyProgress Report for Jamaica, July 19,2007. 1 the epidemic: risky behaviors such as multiplepartners (50% of men), participation in commercial and transactional sex and failure to use condoms with non-regular partners (30% of men and 40% of women), early sexual debut, gender inequity and gender roles, substance abuse, poverty, unemployment, population movement, stigma and discrimination which keep people from seeking prevention services. 4. NationalResponseto the Epidemic. Jamaica has confronted the HIV epidemic proactively for two decades, steeredby the Government-led NationalHIV/AIDS Program (NHP) since 1986 and the NationalAIDS Committee (NAC) established in 1988. The national response hasbeen guided by a series of medium-term HN/AIDS strategic plans, the latest of which was the 2002-2006 HIV/AIDSNational Strategic Plan (NSP). The Government has recently completed the new NSP (2007-2012). The new planreviews the NHPunder all the previous strategic plans, since 1986. The NHPhas covered prevention, treatment, care and support. Achievements include: implementation of a major behavior change communication programfor encouraging adoption of safer sexual practices; condom promotion and distribution; voluntary, counseling and testing (VCT) services which are now available all over the country and provider initiatedcounseling and testing; prevention of mother-to-child transmission (PMTCT) with 75% of HIV-infectedpregnant women and 85% of HIV-exposedinfants accessing anti-retroviral therapy in 2006 and a dramatic increaseinthe last two years; and expansion of managementof sexually transmitted infections, opportunistic infections and anti-retroviral therapy reaching 34% of those requiringtreatment. Inthe legalcontext, achievements include the approval of the NationalHIVIAIDS policy by Cabinet (2004) and Parliament (2005) and the Workplace policy approved by Cabinet in2007. The NHPhasbeen financed by the Government and external resources of which the largest three were the GlobalFundfor AIDS, Tuberculosis and Malaria (GRAM), the World Bank andthe UnitedStatesGovernment. Ithas beenclosely coordinated with all relevant regional institutions. 5. Challengesinthe NationalResponseto HIV/AIDS. Jamaica still faces a number of challenges. There are still inaccurate perceptions about HIV/AIDS;2risky behavior persists; and coverage of services is inadequate (in2006 only 34% of people needing antiretroviral treatment received it)3.Other needs include: capacity strengthening of the health care delivery system in the areas o f human resources (shortageof doctors, nurses, laboratory staff, social workers and counselors); diagnostic capacity (equipment and skil1s);strengthening technical managementof programs including the needto integrate HIV/AIDS services into the existing health and family planning services; strengthening institutionalsystems (management, monitoring and evaluation, procurement and financial management); and fostering an enabling environment that will reduce stigma and discrimination includinghomophobia and safeguardhuman rights. Finally, the Government has estimated that a substantial increaseinfunding i s neededto scale up the program to achieve universal access to HlV prevention, treatment and care for those who need it. 6. The NationalHIV/AIDS Strategic Plan (NSP), 2007-2012. Confrontingthe HIV/AIDS epidemic is still a highpriority for the Government which has recently updatedthe Only 36% of youngmenand40% of young women correctly identifiedways of preventingthe sexualtransmission of HIV accordingto the KnowledgeAttitudes PracticesandBehavior (KAPB) 2004 Survey. Furthermore, there are delays inseekingtreatmentandadherenceto treatment is a problem- a 2006 survey shows a 95 to 100%levelof adherenceinonly 55% of AIDS cases undertreatment, an 80% to 94% levelof adherencein 37%, andless than 80% in 8% of AIDS cases underARV. 2 NSPfor the period2007-2012. The NSPreviewed and assessedthe overall performance of the national HIV/AIDS program since its inception. It summarized the achievementsand challenges of the previous strategic plan and mediumterm plans for HIV/AIDS. The new NSP was developed through a participatory consultative process that involvedcivil society, the private sector, people living with HIV/AIDS (PLWHA), youth, representativesof marginalized groups, service providers, community leaders and policymakers and was peer-reviewed by the UNAIDS team (AIDS Strategy and Action Plan) basedat the Bank. It i s due to be approved by Cabinet. It outlines the vision, goal, and guidingprinciples for the national responseto the epidemic. The estimated cost of the NationalHIVETIProgram for the period 2007 to 2012 i s US$201.2 million. Available current and planned resources are US$65.7 million. The Government will continue to seek additional funding from external partners to fill the financing gap of 67%. It will inthe meantime, allocate the funds available to the highest priority interventions that will contribute more directly and efficaciously to reducing the spread of HIV and mitigating its impact. 7. The NSPidentifies four priority areas: (a) ImprovedAccess to Quality Prevention Services; (b) Comprehensive Treatment Care and Support Services that include: screening and diagnostic services, voluntary counseling and testing (VCT), PMTCT, antiretroviral treatment with a focus on strengthening adherenceto treatment, managementof sexually transmitted infections, opportunistic infections including tuberculosis, post exposureprophylaxis, psychological and social support; (c) EnablingEnvironment and HumanRights: fostering an environment that protects human rights and empowers people to make healthy decisions; and (d) Empowerment and Governanceincluding institutionalization of financing and management arrangements for the program, operationalizing the "Three Ones" principle4, and expanding the involvement of all stakeholdersinthe public sector, civil society and private sector. B. Rationalefor Bank Involvement 8. Jamaica is committed to sustaining its responseto the epidemic and needs support from external partners to help finance its NSP. The Bank funding will complement the Government's own funding and that of other key external funding agencies, principle among which i s the GFATM. Itwill buildon support providedunder the ongoing Bank-funded pr~ject.~The project contributed to the Government's program by supporting: prevention programs targeting high-risk groups and the general population; strengthening of treatment, care and support; and strengthening of the country's multi-sectoral capacity to respond to the epidemic. This new project will provide funding for key areas of prevention, treatment and care interventions not covered by the funding from the GFATMand complement initiatives supported by bilateral donors and UNagencies. Inparticular, the Bank funding will strengtheninstitutional, program managementcapacity and health care delivery system and provideinstitutionalstrengthening for the multi-sectoral responseto the epidemic through enhancing the role of non-health line ministries, Civil Society Organizations (CSOs) that reachparticular vulnerable and/or highrisk groups, and the private sector. 4One national coordinating authority for HIV/AIDS,one national framework and one monitoring and evaluation system. The JamaicaHIV/AIDS Preventionand Control Project due to close on May 31,2008. 3 9. Bank support is also critical for sustaining managementand delivery of the national HIVIAIDS program. Inparticular, the ongoing Bank-financed project, scheduledto close on May 31,2008, funded criticalpositions at the NationalHIVISTIControl Program (NHP) inthe regions and in selectedline ministries due to previous budget constraints that limited establishment of new positions. The Government has initiated action to absorb the staff positions over a four-year period, starting with the new fiscal year inApril, 2008. The new project will help with the transition by initially paying for some of the positions. 10. The Bank also brings to bear the accumulated technical experience inthe Caribbean and the rest of the world inimplementation of HIV/AIDSprojects as well as lessons drawn from assessments of the projects (including the multi-agency review of the Caribbean HIV/AIDS program ledby the Bank in2005). Ithas a comparative advantage inensuring a multi-sectoral responsethrough project funding and its overall cross-sectoral country dialogue and its role as a convener of donor and multi-lateralagencies. The Bank also contributes to strengthening implementation through its support for strengthening country systems for improved governance and accountability, transparent fiduciary management, monitoring and evaluation. C. HigherLevel ObjectivesTo WhichThe ProjectContributes 11. Supportfor CAS Objectives. The ProgressReport (datedJuly 19,2007) of the CAS for FYO6-09 states that the broad thrust of the CAS remains relevant. The project i s consistent with the Country Assistance Strategy (CAS) for Jamaica dated April, 2005 covering the period FY 2006-09. The CAS i s aligned with the Government's Medium-term Socio-Economic Policy Framework (2004-2009). The MTEFreaffirms the Government's commitment to achieving the MillenniumDevelopment Goals (MDGs). The CAS i s based on three mutuallyreinforcing pillars: (i)accelerating inclusive economic growth; (ii) improving human development and opportunity; and (iii) crime prevention and reduction. One of the goals under Pillar Two, to" improve access to prevention, treatment, care and support services for people living with HIVIAIDS (PLWHA)" addresses one of the MDG's, "halting andreversing the spreadof HIV/AIDS by 2015". D. ComplementingOtherExternalSourcesofFunding 12. The two principal external financing sources are the GFATMand the World Bank. UnitedNations (UN)agencies and bilateral donors6are also providing support to the Government's HIV/AIDS program. Fundingfrom the GFATMand the Bank will be applied ina complementary manner. A significant share of funding from GFATMi s dedicated to anti- retroviraldrugs (60%). There are differences inthe focus of support to the key priority areas funded, notably, inthe case of provision of ARV drugs, biomedical waste management, support to key non-health public sector ministries, and strengthening the capacity of the health services delivery system. Harmonizingthe financing of activities of these two sources will be an ongoing process during project implementation inorder to avoid duplication. The Project Coordination Unit(PCU) preparesthe annualwork planfor the NHPfunded bythe World Bank, GFATMand other external partners. It also prepares the procurement plans and financial statements for both the World Bank and the GFATM, makingit a de facto pooled funds approach. Ongoing They include:UNESCO, UNAIDS, PAHO(WHO), UNICEF, UNFPA, L O , USAID,EC andJICA (seeAnnex 2). 4 collaboration and exchangeof informationbetween the Bank and the GFATMwill continue and whenever possiblejoint annual reviews will be organized, though this may pose a logistical challenge inJamaica and the general Caribbean setting. 11. PROJECTDESCRIPTION A. LendingInstrument 13. The lending instrument proposed for the project will be a Specific Investment Loan (SIL) of US$10million with co-financing of US$ 1.54 million from the Government. B. ProjectDevelopmentObjectiveandKey Indicators 14. The project development objectives are to assist inthe implementation of the Government's NationalHIV/AIDS Programby supporting the: (i) deepening of prevention interventions targeted at high-riskgroups and the general population; (ii) increasing of access to treatment, care and support services for infected and affected individuals; and (iii)strengthening of program managementand analysis to identify priorities for buildingthe capacity of the health sector to respond to the HIV/AIDS epidemic and other priority health problems. 15. Intermediate indicators will monitor the progress in achieving prevention and treatment targets and the availability of timely inputs that contribute to achievement of the project impact and outcomes (see Annex 3) in support of the goal of the national program as specified inthe NationalHIV/AIDS Strategic Plan 2007-2012 -- to halt and begin to reversethe spreadof HIVIAIDS as well as STIs by providinguniversal access to prevention, care andtreatment. C. ProjectComponents 16. Component1:Prevention(US$3.34 million). Preventioninterventions are ahigh priority of the NHP and needto be scaledup dramatically to halt and reversethe spread of the epidemic. Various implementing entities will intensifyprevention activities: the Ministry of Health and the Regional HealthAuthorities, four non-health line ministries, CSOs and the private sector. 17. SubcomDonent l(a): Prevention Activities by the Ministry of Health (MOH) and the Regional HealthAuthorities (US$2.99 million). This subcomponent will strengthenthe capacity of MOHand the Regional HealthAuthorities (RHAs) to providetechnical guidance for the national responseto HIV/AIDS and to deliver HIV/AIDS related services for prevention through the health care system. Activities financed will include: (a) Supportfor behavior change communication (BCC)interventions targeting at-risk groups (CSWs,MSMs, in and out of school youth, prison inmates, drug users) and the general population. The activities aim at dissemination of information for adoption of safer sexualpractices. Fundingwill be providedfor development of BCC materials, mass media campaigns, peer education, and outreach; (b) Expansion of STImanagementand blood safety for preventing HIV transmission; (c) Expansion of VCT services for preventing of HIV transmission, scaling up treatment and care and expansion of PMTCT Services. These will include innovative approachesfor hard to reach and 5 vulnerable populations, including walk-in and mobile VCT services, and expand provider initiatedcounseling and testing. Fundingwill cover training, test kits reagents and supplies, laboratory support, mentioned inComponent 2, and minor refurbishment of VCT rooms; and (d) Promotionof increasedcondom use. Support will be providedfor procurement and distribution of condoms and lubricants that will not be financed through the GFATM. Female condoms will be donatedby UNFPA. 18. Subcomponent 1(b): Prevention Activities by the Non-HealthLine Ministries (US$0.30 million). Strengthening prevention requires scaling up the contributionof the non-health line ministries to make the national responsetruly multi-sectoral. Four key line ministries have been identifiedbecause they can reach important segments of vulnerable and/or at risk population groups through their official mandates: (a) Education7; (b) Labour and Social Security; (c) Tourism; and (d) National Security. These ministries implemented some HIV/AIDSprevention activities under the first project. They will receive technical support and funding to scale up their activities more strategically basedon mediumterm plans. This subcomponent will finance: annual work programs of three of the four line ministries that include implementing workplace HIV/AIDS policies, BCC, condom distribution and promotion, and advocacy to reduce HIV/AIDS stigmatization and discrimination; and, co-finance staffing costs of the focal points of the non-health line ministries. The national programwill finance training, technical and material support for focal points, program officers and their respective ministerialHIV/AIDS Committees. 19. Subcomponent 1(c): Prevention Activities by Civil Society Organizations and the Private Sector (US$0.05 million). This project will finance training and the position of the Civil Society Organizations (CSOs) Coordinator inthe PCUwho will provide capacity buildingfor CSOs. The GFATMwill bethe mainfinancing sourcefor CSOs through demand-driven "subprojects" that will target interventions for: (a) Youth, including sexuality education, risk assessment, behavior modeling, and leadership training; (b) Commercial Sex Workers (CSWs), includingbetter access to counseling and health care, skills development for alternative income generation, referralto agencies such as housing and drug addiction/prevention and support for increasedinvolvement of club operators and the tourism services inrisk reduction interventions including increased condom use; (c) MSMsby continuing training of trainers on risk reduction among the MSMs, referral to STI/HIV test and treatment along with adherenceand positive prevention; (d) Adult Males (19-39 years), including scaling up existing experiencesinreachingkargeting male dominated occupations such as taxi and bus drivers, the police force and auto-mechanics for risk reduction interventions. The project will also provide works skills training for economically vulnerable populations to assistthem inentering thejob market. The GFATMhas allocated US$5 million to fund CSOs which will allow a dramatic scaling up of the response. This support will encouragecommunity-based activities to strengthenprevention work inrural and inurban areas and work with orphaned and HIV/AIDS affected children. The NHPhas developed an organizational structure with standardoperating proceduresfor engaging CSOs and the private sector. Selection criteria are detailed inthe Project Operations Manual and include fiduciary and administrative procedures, demonstratedconsultation and participatory processes to mobilize and empower target communities, and a systemfor provision of technical support to the CSOs. 'The GFATMwill bethe principal funding source for the Ministry of Education and will alsofinance the position of a Program Officer inthe Ministryof Labor in charge of implementingworkplace policies. 6 20. Component 2: Treatment, Care and Support (US$1.81 million). This component will provide financing to support the efforts to enhancethe following services: (a) Laboratory Diagnostic Services. Refurbishing and equipping the TB Laboratory and the provision of reagents and supplies to support scaling up diagnosis and treatment of TB patients and the detection of HIV inthis group; (b) Training for staff inthe use of new equipment; (c) Refurbishing of select Treatment Sites as well as the procurement of drugs (not funded through the GFATM), nutritional supplements, substitution infant feeding formula, contraceptive methods and reagents and testing supplies for diagnosing and monitoring HIV; (d) Refurbishing of Regional Laboratories to facilitate decentralization of laboratory services; (e) Training of staff, and health care workers incomprehensive managementof HIV/STI/TB,PMTCT, counseling and testing, Public HealthManagement and BCC and, (f) Curriculum development to support training activities. 21. Component 3: Strengthening InstitutionalCapacity for Legislative Reform, Policy Formulation, ProgramManagement, Monitoring and Evaluation (US$4.26 million). SubcomDonent3 (a): Policy Formulationfor an EnablingLegal and Regulatory Environment and Human Rights(US$0.41 million). The new NSPemphasizesthe need for a supportive legal and regulatory environment. The project will provide technical assistance in support of the changes to the legislative framework that have been recommendedby the legislative review including updating of the Public Health Act to deal with new health challenges such as HIV/AIDS and advocacy for further legislative and policy reformto address stigma and discrimination. 22. Subcomponent 3 (b): Program Management (US$3.30 million). This subcomponent will continue to support the coordination and management of the Government's NationalHIV/AIDS Program. The project will co-finance staff costs for the technical andfiduciary functions of the PCU andthe RHAsin supportingthe coordination and managementof the Borrower's NHP. This includes reviewing work programs from line ministries and proposals from civil society implementing agencies, monitoring and evaluating program progress, and training staff of the PCU, Line Ministries, and CSOs infiduciary functions. 23. Subcomponent 3 (c): Monitoring andEvaluation (US$0.54 million). The M&EUnitof the NHPPCUinthe M O H i s implementing a comprehensive monitoring system. The objectives of the M&E systemare to provide continuous feedback to monitor the trends inthe epidemic and to enhancethe delivery of HIV services. The NHPwill emphasize: (a) staffing, training and building the capacity of the M&EUnit; (b) an informationtechnology (IT) platformthat will: (i) integrate the multiple sources of information and implementing partners; and (ii) complete the procurement of equipment, maintaining the software, training staff and rolling out the Laboratory Information Systemto the regions; (c) technical assistance, equipment and training to strengthen the M&E systemand the decision-making process; (d) harmonizing the information flow from multiple data sources for impact, outcomes, outputs, and inputs; i.e., biologicalHNsurveillance; behavioral HIV surveillance; (e) conducting surveys, surveillance and researchktudies on special populations to informthe national response; (f) integrating the five national and sub-national HIV databases to enableevaluating the impact of the nationalprogram; and (g) buildlocalM&E capacity. Most of the indicators for monitoring this project are drawn from the national 7 indicators agreedby all partners and usedfor reporting to the UnitedNations Special Sessionon HIV/AIDS (UNGASS). 24. Component 4: Health Sector Development Support (US$2.10 million). Subcomponent 4 (a) BiomedicalWaste Management (US$2.0 million). The project will support upgrading and improvedmanagementof the biomedicalwaste management system. This will include: upgrading medical waste treatment facilities; waste disposal supplies and materials in all health regions for enabling proper segregationpractices. Interim storage facilities to support the regional collection and alternative treatment systems will be financed by the Government through the NationalHealthFund. The project will also finance capacity building activities: develop and disseminate medical waste managementtraining material; train healthcare workers inmedical waste managementandpost exposureprophylaxis, includingregional `Training of Trainers' workshops; sharebestpractices; and, train staff for operation and maintenanceof new equipment. Finally, the project will finance preparation of facility specific waste management plan, including the creation of a systemto support health care facilities inthe documentation of infectious waste generation on a continuous basis. 25. Subcomponent 4 (b). Diagnostic Capacity Assessment of the Health Sector KJS$O.lO million). The 2004 national report preparedby the Planning Institute of Jamaica (PIOJ) noted that Jamaica i s behind in attaining some of the MDG2015 target values. Critical challenges to the capacity of the health sector to deliver quality services are the lack of adequatenumbers of staff inall professional categories, an underfinancedpublic sector, crowded hospitals and underusedhealth centers, periodic shortages of medical supplies, and pockets of violence in certain communities impeding access to health services and constraining the movement of health personnel. This component will finance a comprehensive assessment of the obstacles that limit the capacity of the health sector to deliver quality health care efficiently to those needing it most. The investment and operational cost of the actions identifiedinthe assessment will be calculated and options proposed for financing the cost from national and external sources. D. LessonsLearnedand Reflectedinthe Project Design 26. There are a number of lessons learned from implementing the ongoing Bank-financed Jamaica HIV/AIDS Prevention and ControlProject, as well as from other Bank and donor- financed projects throughout the Caribbean'. (a) The ongoing project had a slow start mainly due to unclear financial management and procurement procedures. Inparticular, differences between country and Bank procurement guidelines took time to resolve. These problems were subsequently addressedthrough a proactive process involving close coordination between the Bank and the project. With the experience gained by the M O Hteam, this project will take advantage of greater flexibilities in Bank procedures. The Government continues to review its own proceduresespecially for procurement. (b) Other challengesexperiencedrelate to slow involvement of non-healthline ministries, CSOs and the private sector inexecution of priority interventions especially for prevention. This * TheBankled a multi-agency reviewof the CaribbeanHIV/AIDS Programin 2005. 8 project will builduponthe lessons from the first project to strengthenthe procedures and technical guidance to these critical stakeholdersto ensure their greater participation especially in reaching at-risk and vulnerable groups. (c) Overall institutional and implementation arrangements are critical for a multi-sectoral responseinline with the NSP. Execution of the previous project and other Government HIV/AIDSefforts underscoredthe importance of the "Three Ones". Thisproject will support the strengthening of the NationalAIDS Committee as the "one coordinating national body" to enable it to providethe policy guidance. The project will also support execution of the NSP, "the one national strategic plan" with one "M&E plan". (d) Prevention. The number one issueposited bythe NSPis increasing prevention activities and improving strategic focus. This i s consistent with the experience in other Caribbean countries and globally. Activities that lead to behavior change needto be more skillfully designed and intensified to respond to the complex socio-economic factors that are driving the epidemic such as multiple partners, commercial and transactional sex and poverty. This project will contribute through a two pronged strategy: targeting interventions at highrisk groups and implementing non-targeted activities for the general population. (e) Stigma and discrimination inJamaica, as inmost Caribbean countries, i s still a major impediment to the responseto the epidemic as it prevents people from seeking care and caregivers from giving appropriate care. The project will provide technical assistancethrough support to efforts to foster an enabling environment through BCC as well as legal andregulatory reforms and policy advocacy. (0The fight againstHIV/AIDSrequires amulti-sector responsewith buy-infromleadership in Government, key non-health line ministries, the private sector, and participation of a cross- cutting range of stakeholders: CSOs, the private sector, community level, household level, religious groups, professional groups and PLWHA. The project will greatly scale up the role and capacity of non-health line ministries, CSOs, and the private sector which were activities under the first project that were not developed pro-actively. (g) The health systemstill requires considerable strengthening to enable it to cope with the increaseddemands for prevention, treatment and care brought on by the HIV/AIDS epidemic: improvingphysical facilities, diagnostic capacity, and increasing the number and skills of staff. Basedon the experience of the first project, this project will refurbish treatment sites and train health workers as indicated under Component 2 and finance a comprehensive assessment to identify and solve the most urgent bottlenecks in service delivery. (h) The fight against HIV/AIDS is expensive andJamaicaneeds additional resourcesto sustain the momentum it has built. Along with this, it i s critical for the NHP to be institutionalized through the establishment of staff positions on the regular public payroll. The Government will needto continue to keep HIV/AIDS as a priority inits expenditure plans as it has done inthe past to ensure that the HIV/AIDS responsei s sustained. 9 (i) itisimportanttonotethatthereisnoproven"production function" inrespondingto Finally, HIV/AIDS inacomplex epidemic such as the one inJamaica. Researchwill be important to continue to identify those areas that contribute the most to addressingthe epidemic. The project will support M&Eto ensurethat the Government continuously adjusts the programto the changing nature of the epidemic. E. AlternativesConsideredandReasonsfor Rejection 27. The first alternative considered was to have no follow-on project. The Bank-funded Jamaica HIV/AIDS Prevention and ControlProject i s scheduledto close on May 31,2008. The CAS stresses the threat of HIV/AIDSto the country's development prospects. This alternative was rejected. The second alternative considered was to combine a health sector intervention and a repeaterproject into one operation. This alternative was rejected because the broader needs of the health sector will be better addressedin a separatehealth sector programand will require diagnostic work that will take some time to complete. The Government was anxious to avoid a gap infinancing of the HIV/AIDS response and requestedthat preparation of the follow-on project be expedited. A third alternative would have beento usethe option of additional financing. This option was rejected as it would have restricted the implementation periodto three years and the Government team and the Bank task teamjudged a four year period more appropriate. The selectedalternative will be a specific investment loan that will buildupon the successfulimplementation of the first HIV/AIDS Project. 111. IMPLEMENTATION A. PartnershipArrangements 28. The Jamaica NSP i s funded by the Government and anumber of external agencies. The GFATMand the Bank provide the most significant levels of funding. Other partners, especially the United Nations Agencies and bilateraldonors also provide technical support and some fundingfor specific interventions. All the agencies provide their funding through the NHP. The project will not have specific co-financing from any other partner. The expandedHIV/AIDS theme group provides a regular forum for coordination. Inaddition, partnerships have been strengthenedaroundkey thematic areas. Section IB, above describes how the two main external financing sources (Bank and GFATM) will complement each other as well as the contributions being made by the other bilateraland multilateraldevelopment partners. The project design supportsthe strengthening of partnership between the key stakeholders:the MOH, non-health line ministries, civil society organizations, the private sector, and external funding agencies. Partnershipswith the GFATM, bilateral donors and UNagencies will include: implementation basedon one annual work plan of the NHP; regular informationexchangehpdates, harmonized technical assistanceon specific thematic areas e.g. education and coordinated implementation reviews/supervision missions whenever possible, though this may presentlogistical challenges. B. Institutionaland ImplementationArrangements 29. InstitutionalArrangements. The following institutions will bekey to the successful implementation of the project: The Councilfor Health and Social Development (COHSOD) 10 reporting to the Cabinet will be responsible for setting policy, overall coordination, and monitoring and evaluating the performance of the national HIV/AIDS program. The Ministry of Health (MOH) will be the Executing Agency through The Project Coordination Unit (PCU)of the NationalHIV/STIProgram. The PCU will coordinate activities and providetechnical and fiduciary support to the implementing entities. Executionof project activities will be handledby divisions of the MOH, the four Regional HealthAuthorities, four non-health line ministries, CSOs and the private sector. 30. ImplementationArrangements. The project will be coordinatedbythe PCUwithin the NationalHIV/STIProgram (NHP) of MOH. The PCUconsists of an experienced team of professionals that have coordinated the technical and fiduciary activities of the first HIVIAIDS project. The staff hasbeen trained inWorld Bank procedures, has performed satisfactorily under the first project and i s expectedto continue performing well under the follow on project. The Unitis headedbya Senior MedicalOfficer, who managesacore staff that includes the coordinators for the project components and subcomponents, an M&Eofficer, a financial manager and a procurement manager and their supporting administrative staff. The fiduciary unitalso managesthe grant funds fromthe GFATM. Most of the PCUstaff hasbeenpaidout of donor funds, including the first World Bank loan. The processto convert some of these positions into permanent establishment posts has been initiatedwith the intended outcome of creating an institutionalized and sustainablecore group of professionals to coordinate and support the implementation of the national HIV/AIDSProgram. 31. ImplementingEntities. Four types of entities will implement project activities: The MOHthrough its centralized departments andthe four decentralized RHAs;Four key non-health line ministries: Education, Tourism, Entertainment and Culture, Labour and Social Security, and NationalSecurity, Civil Society entities including the NGO sector with Community Based Organizations (CBOs), churches and other FaithBased Organizations (FBOs); and the private sector through the Jamaica Business Council, privatecompanies and the media. 32. The implementation strategy is detailed inthe Project Operations Manual and is summarized inAnnex 6. Implementation of project activities will be precededby the elaboration of annual work plans for the public sector entities and by proposals for the civil society entities. The Government Ministries will prepare annual work plans which are aligned with the Government annual budgets. CSOs will be funded through a demand-driven process basedon the systemthat has been put inplace under the ongoing Bank-financed project. A consolidated annual work plan will be preparedby the PCU and reflected inthe MOH's annual budget for submission to the Ministryof Finance and the Public Service (MOFPS). The work plan will include the MOH's own work plan, plans of other Line Ministries and a budget line for subprojects of civil society groups and the private sector. Annex 6 contains a fuller description of the institutionaland implementation arrangements includingeligibility criteria, selection procedures and funding mechanismsfor civil society and the private sector. The Project Operations Manualwill contain a detailed description of implementation strategies for line ministries, CSOs and the private sector. 33. FinancialManagementandProcurementArrangements. The PCUfinanced under the first HIV/AIDS project is familiar with the Bank procedures. It will be responsible for 11 financial managementand procurement. Latest financial managementand procurement procedures will be applied now that there is more capacity within the PCU and within the public administration ingeneral. Detailed guidelines on the financial and procurement management including accountability and transparencyprovisions are contained inAnnexes 7 and 8. C. Monitoring and Evaluation of Outcomeshtesults 34. A fulltime M&Eofficer with a supporting staff within the PCUwill be responsible for: (i)maintaining the overall M&Eplanincluding manuals, implementation procedures, tools, data flowcharts and a budget; (ii) strengthening the monitoring systems to ensure sound output and process monitoring; and (iii) validating data by randomsampling recording and aggregating processes and by examining large variations inhistoricaltrends. 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 general population, workplace surveys of a random sample of companies, and health facility surveys and specific research. Baseline markers and targets will be established for measuring progress. Outcome/impact indicators are listed inAnnex 3. Most of the indicators are drawn from the country's national M&Eplan and are the basis for the country's regular reporting to UNGASS. 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 and to show variations that occur. Input and process indicators are listed inAnnex 3. D. Sustainability 35. The following factors will contribute to program sustainability after project completion: (a) An enabling policy and legalenvironment with strong political support and leadership for dealing with HIV/AIDS; (b) Government's willingness and ability to sustainpublic awarenessof HIV/AIDS issues; (c) Implementation sustainability: development of broad ownership and a strong institutional coordination mechanismfor the expandedresponseto the pandemic and the involvement of other key stakeholders (line ministries, NGOs, FBOs, localcommunities, etc.); (d) Converting some of the PCUpositions into permanent establishment posts to create an institutionalized and sustainablecore group of professionals to coordinate and support the implementation of the national HIV/AIDS Program; (e) Financial sustainability will include Government budget allocations to finance the national HIV/AIDSprogram and continued support from external sources especially the GlobalFund; and. (f) Allocatingresourcesavailable for HIV/AIDSto the highestpriority interventions. 12 E. Critical Risksand Possible Controversial Aspectsfor the Proposed Project Descriptionofrisk Mtiptionmeasures Project design + Expenditures duringthe first + The new project defines ex ante four project for non-health line key non-health ministries that will ministries and for CSOs accounted develop their strategy, annual work for only 8% of total project plans and budgets. CSOs will be expenditures. s funded by the GFATMgrant. The M project will provide technical support to ensure the participation by the business + The first project has been sector and CSO community through criticized for its centralized demand-driven subprojects and approach and has been perceived disbursements against approved plans outside the MOH as a MOH and contracts. project rather than a multi-sectoral + The four decentralized Regional project. Health Authorities will be responsible for execution of most o f the project activities. Stigma and + The country's legal framework + A strong emphasis on IECBCC will Discrimination remains inadequate. However, mitigate the level of stigma and and Human several reforms have been discrimination. Rights launched over the past years. + Under the Project's third component, Major achievements include the the project will provide technical National HIV/AIDS Policy assistancefor reviewing for drafting a approved by Cabinet (2004) & new Public Health Act that will include Parliament (2005) and the National the rights of people living with HIV/AIDS Workplace Policy S S HIV/AIDS and other vulnerable submitted in 2003 to and approved populations, including children affected + by Cabinet inMarch 2007. by HIV/AIDS, giving them full An Amendment to the Public equality and dignity under the law, Health Act based on a review of without stigma or discrimination. existing legislation and for the purpose of repealing outdated legislation is beingdrafted. Implementation The first HIV/AIDS project invested + The Government has already initiated capacity inthe skills development of aproject a process of institutionalizing the sustainability unitto coordinate thenational programby establishing the requisite response. The challenge is to retain posts and other activities inthe this staff. S Government's establishment in a M phased manner over the medium-term to ensure sustainability of the national program. Financial Untilnow a significant shareof + Continuing efforts to secure external sustainability the Jamaica HIV/AIDS program fundingfor sustainingthe program. has been financed mostly with external funds. The GOJ may not s s be able to assume full financial responsibility utilizing its own resources for the national 13 Mitigation measures this project. I Financial + The Regional Health Authorities + A complete financial management management may not have robust financial assessmentof the financial management management and accounting capacity at the RHA level has been practices, specifically, conducted. Strengthening o f the RHA maintenance of appropriation M financial management will be included in M accounts, financial reporting and the project. internal auditing. Procurement + Compliance with both Bank and + The Government has indicated that it national procurement procedures will review its own procurement could potentially delay project thresholds within the next fiscal year to implementation. S address some o f the current bottlenecks. M The Bank team will guide the Government team intaking advantage of flexibilities in Bank procurement procedures Social and + The current HIV/AIDS project i s environmental management program may not be supporting the installation of a biomedical safeguards upgraded fully to cope with the waste plant to serve the south-east region current challenges. (accounts for 60% of the medical waste generated on the island). The medical S waste management plan has been updated inpreparation for this project and an M action plan has been agreed with priority actions identified for financing. Despite these actions, additional investments will still be needed by the Government to fully address the needs of the country. OverallRisk: M RiskRating-H(HighRisk), S (Substantial Risk), M (Moderate Risk), N(Negligible or Low Risk). F. Loadcredit Conditions and Covenants Conditionsof effectiveness: NIA Conditionsof disbursement: NIA IV. APPRAISAL SUMMARY A. Economic and FinancialAnalyses 36. There are compelling argumentsfor public intervention to addressHIVIAIDS inJamaica. BecauseHIV/AIDS is a communicable diseasewhich inflicts negative externalities on society, a 14 purely private responsei s unlikely to be optimum socially. Information regarding HIV transmission i s imperfect; HIV makes people vulnerable to other infectious diseases including tuberculosis; some individuals (spouses, newborns) cannot control their own risk to HIV infection, which are all reasonsfor intervention. Prevention/early intervention i s necessaryto reduce the health costs of treatment and mitigation inlatter years. Jamaica faces macroeconomic challenges including a high debt stock. Resources available to combat HIV/AIDS are limited and needto be focused on the most cost-effective interventions. 37. Jamaicahas selected a range of internationally recognized cost-effective interventions for implementing its strategic HIV/AIDS plan for the period 2007 to 2012. They include interventions for high-risk groups as well as the general population; voluntary testing and counseling, prevention of mother-to-child transmission, STImanagement and antiretroviral treatment. The expandedprogram covering antiretroviral drugs (not available inthe last Bank- financed project) was madepossible through Jamaica's successful application for grant funds from the GFATM. Inthe thirdroundof the GFATM, Jamaica securedUS$23.3 million. These funds together with the Bank loan of US$15 million (later reduced to US$10.6 million) enabled the Government to expand its program. With the new HIV/AIDS strategic plan, the Government has selected the priority interventions for a comprehensive approach including prevention, treatment, care and support. Funding available includes the US$6.9 million balance from the thirdround grant andUS$44.2 million recently approved under round7 of GFATM(2009- 2013). The availability of the grant over the next five years reduces the recurrent cost implication arising from the Bank financed project which i s designedto complement the GFATMgrant. The Government will provide US$1.55 million to cover the incrementalcapital and recurrent costs. The Government has also initiated a process of increasing budgetary allocations to the MOHfor staff costs and other related expensesin abidto initiate medium-term sustainability of the responseto the HIV/AIDS epidemic. B. Technical 38. The Government continues to sustainits commitment to confronting the HIV epidemic with the new multi-sector NSP 2007-2012. The plan was peer reviewed by the UNAIDS/World Bank AIDS Strategic and Action Plans (ASAP) team and was found to be technically sound. The plan identifies the factors that are driving the epidemic: risky behaviors (multiple sex partners, early initiation of sex, involvement intransactional sex, non-use of condoms, low perception of personal risk and commercial sex); economic conditions (including highlevels of unemployment and poverty); illegal drug trade; tourism and movement of people; and, social culturalfactors especially stigma and discrimination (including a high level of homophobia that drive those most-at-risk underground); gender dimensions that influence prevention options, e.g., women are often at risk becausethey are unable to negotiate condom use. Services for prevention, treatment, care and support have not reacheduniversal coverage. The NSPbuilds uponthe prior NHP (2002-2006) and all the earlier mediumterm strategic plans. Itreflects lessons learned inJamaica and globally on what constitutes an appropriate responseto the HIV/AIDS epidemic. 39. The NSPselected strategies aim to: decreasestigma and discrimination resulting in increasedacceptability and uptake of services; strengthenthe multi-sectoral approach through partnerships which will include improvement of capacity of all stakeholders, resulting in 15 increasedquantity, quality, availability and access to services; and establish a strong evidence- basedapproachthat complies with local, regional and international guidelines to informthe local responsecoupled with a strengthenedM&E systemto pave way for an efficient and sustainable responseto HIV. Other guiding principles include: equity, e.g., no person shall be denied access to prevention knowledge, skills and services or treatment, care and support services on the basis of their real or perceivedHIV status, sexual orientation, gender, age, disability, religion, socio- economic status, etc.; participation of PLWHA, promotion and protection of human rights, transparency and accountability, and application of the ILO principles on HIV/AIDS and the world of work. 40. The most cost-effective interventions have been selectedto addressthe strategies of the plan which have been summarized infour priority areas: prevention; treatment, care and support; enabling environment and human rights; and, empowerment and governance. Specifically, the project will contribute to the Government's program inthe priority areas of enhancing coverage and quality of appropriate HIV prevention interventions targeting those at high-risk as well as the general population; strengthening diagnosis and treatment; reducing stigma and discrimination associatedwith the disease and promoting and protecting the rights of infected persons; and improvingthe collection and use of reliable data to guide and monitor programimplementation and to evaluatethe impact of the program. C. Fiduciary 41. FinancialManagement. A financial managementassessment hasbeen carried out (see Annex 7 for details). The financial managementaspects of the first project were well managed. The fiduciary arrangements,both financial managementand procurement under the project, will be provided by the PCU located within the NationalHIV/STIProgram (NHP), a division of MOH. The overall financial managementresponsibility under the Project will be coordinated and exercisedby the Administrative Unitheadedby the Finance and Administrative Officer assistedby three Finance Officers and two Accounting Assistants. MOWS will issue warrants covering the budget for the project during the year inquestion. Expenditures incurredthat will be financed out of the World Bank loan proceedswill be funded out of the designated account to be opened at a commercial bank. The account under the project will be managedby the PCU. The RegionalHealthAuthorities will maintain individual accountsthat will be replenished periodicallyfrom the PCU's account. Expenditures by the non-health line ministries, CSOs and the private sector will be funded out the PCU's account. 42. The budget estimates for 2008/2009 include provisions for boththe on-going project and the proposed project. The eligible items included inthe budget of the proposed project will be retroactively financed from April 1, 2008 for an amount of US$1.3 million. Counterpart funding by the Government will beprovidedfor some items under the proposed loan. 43. Procurement. Procurement for the proposed project will be carried out inaccordance with the World Bank's `Guidelines: Procurement Under IBRDLoans and IDA Credits' dated May, 2004 revised October 1,2006; and `Guidelines: Selection and Employment of Consultants by World Bank Borrowers' dated May 2004 revised October 1, 2006, and the provisions stipulated inthe LegalAgreement. For each contract to be financed by the Loan, the different procurement methodsor consultant selection methods, the need for pre-qualification, estimated 16 costs, prior review requirements, and timeframe are agreedbetween the Borrower and the Bank inthe Procurement Plan. The Procurement Plan will beupdated at least annually or as required to reflect the actual project implementation needs and improvements ininstitutionalcapacity. Procurement procedures and StandardBiddingDocuments (SBDs) to be usedfor each procurement method, as well as modelcontracts for works and goods procured, are presentedin the project operations manual. 44. An assessment of the capacity of the implementing agenciesto undertake procurement was carried out by the Bank inJanuary 2008. The assessment reviewed the organizational structure for implementing the project andthe interaction between the project staff responsible for procurement and the national procurement authorities. The mission focused on the capacity of NHP incontracts managementusingbothWorld Bank and Government procedures. The main findings and recommendations of the assessment are summarized inannex 8. 45. Thejoint Country Financialand Procurement Assessment (CFAMCPAR) carried out by the World Bank and Inter American Development Bank in2005 and approved in 2006 identified a number of weaknessesinthe Jamaican procurement system. Improvements are neededto render the systemmore transparent. Issuesidentified inthe combined CFAA and CPAR report pertaining to procurement statistics, supplier's registration, procurement performance and monitoring and capacity are still actual and relevant. The discrepanciesbetween the national procurement systemthresholds and the World Bank thresholds for projects inJamaica also impact negatively on the procurement processes and timeframe. 46. Based on the procurement assessment, the following corrective measureshave been agreedto improve procurement processes. The operations manualhas beenupdated. It includes a specific chapter on procurement, detailing all the procedures and channels of responsibilities and flow of documentation. Regular submission to the Bank of aProcurement Plan beginning with the first plan to cover the first eighteen months of the project. Training inprocurement provided by the Bank to the PCU including regional staff as soon as the loan i s approved with further training to be provided duringthe first year of implementation as part of capacity building. HiringaProcurement Specialist with acceptable qualifications andexperience to assist the South East Regional Health authority. Inaddition to the above action plan, the procurement thresholds and methodshavebeenset to mitigate the procurement risk. The overall project risk for procurement i s moderate. D. Social 47. Individualbehavior to a large extent i s shapedby society at large. Annex 4-2 presents a detailed social assessment based on a literature review and field visits. InJamaica, the early socialization of male and female children, into specific gender roles, sets them up for behaviors and decision-making that puts them at highrisk for HIV/AIDS and sexually transmitted diseases. Outside the home, market forces support a diet for sexually explicit media and internet messages that glamorize unprotected sex, multiple sex partnerships and early sexual initiation. Musical 17 artists - inparticular dance hall disc jockeys - also glamorize multiple sexual partnerships and expressinnuendos of violence towards men who have sex with men. The result i s male adolescentsbeing lured into risk-takingattitudes andbehaviors, which promote "manhood" such as having many partners, and engaging inunprotected and early sex. Female adolescents on the other hand are also bombardedby the pressureto engage inearly sex and find less societal resistanceto actions such as engaging intransactional sex with older men. Life skills messages supporting responsible behaviors such as delaying sex and using condoms if sexually active are too few to compete with adult entertainment which i s within the reach of most adolescents. 48. Poverty, cultural factors and vulnerabilities compromise the ability of women to make safe choices. Some engage incommercial sex work or inmultiple partnership relationships. Social and culturalnorms also affect access to risk-reduction interventions for MSMthrough societal intolerance for this sexual practice. Inaddition, some religious denominations advocate against access to condoms, especially to minors and yet are not adequatelyengagedin interventions focused on the benefits of the delayed sex messageto minors and others. Laws criminalizecertain behaviors which fosters stigma and discrimination. Non-accepting attitudes and stigma and discrimination of people living with HIV affect the quality of services provided. There i s a need to focus on the needsof specific groups: youth in school (10-14), out of school adults, CSWs, MSM, adult males (19-39), and PLWHAs. The project will support interventions for these groups and will strengthenthe capacity of BCC teams and NGOs as well to ensurethat services to the general population addressthe social constraints. E. Environment. EnvironmentalCategoryB 49. SafeguardAssessments. The safeguardpolicy, Environmental Assessment (OP/BP/GP 4.01) i s applicable to this project as some additional biomedicalwaste couldbe generatedby activities supported by the project. The Government has a bio-medical waste management systeminplace. A number of investments inequipment and staff training have been financed under the ongoing Bank financed project. The assessment of the systemhas been updated and specific areas for strengthening biomedical waste have been identified. Most project activities are not expectedto generateadverse environmental effects. Some medical waste i s expected to be generatedduring the administration of HIV tests and inthe managementof treatment for PLWHA. Inrelation to construction, there will also be small-scale rehabilitation of existing health care facilities to ensure appropriate provision of HIV/AIDS services. Measuresthat the Government will take to mitigate potential environmental effects are detailed inAnnex 10. The project will support the Government inimplementing those measures. Of particular importance i s the need to ensure that health care workers are adequately trained on medical waste management. The project will provide support for: standardizing waste managementprocedures inallhealthcarefacilities; strengthening capacity inhealthcarewaste management, including training for health care workers inproper waste managementand post exposureprophylaxis; and upgrading of regional medical waste collection systems and treatment facilities with specialized medical waste collection vehicles and alternative technology. 50. Onthe management of environmental risks of small-scale construction works, the project's coordination unit will incorporate the required Bank environmental guidelines inthe project's operations manual and standardbiddingdocuments for civil works. 18 F. Safeguard policies Safeguard PoliciesTriggered by the Project Yes No Environmental Assessment (OPBP/GP 4.01) [XI [I NaturalHabitats (OPBP 4.04) [I [XI Pest Management (OP 4.09) [I [XI Cultural Property (OPN 11.03, beingrevised as OP 4.11) [I [XI InvoluntaryResettlement (OPBP 4.12) [I [XI Indigenous Peoples (OD 4.20, beingrevised as OP 4.10) [I [XI Forests (OPBP 4.36) [I [XI Safety of Dams (OP/BP 4.37) [I [XI Projects inDisputed Areas (OP/BP/GP 7.60) [I [XI Projects on International Waterways (OPBP/GP 7.50) [I [XI G. Policy Exceptions and Readiness 51. No policy exceptions are sought. The Bank has assessedthe Government as beingready to implement the proposed new project. The Government i s committed to dealing with HIVIAIDSandhasrecently completed anew NationalHIV/AIDS Strategic Plan2007-2012. The plan was preparedin a participatory and consultative processinvolving all key stakeholders within the Government, Civil Society at the community level, and external donors/partners. This plan builds on the achievementsof the previous plan which covered the period2002-2006. The institutionalmechanismsfor the national programare inplace with overallpolicy direction providedby the Cabinet through the COHSOD. The NationalHIVETIProgram within the MOHcoordinates the program. The project will be executedby the PCUwithin the NHP. The PCUhas a core of qualified and experienced staff that has managedthe previous Bank-funded project and other donor projects notable among them, a grant from the GFATM. The Government counterpart team has ledthe preparation of the project and all key departments within the implementing agency (MOH), the MOFPS and the PIOJhave beenkey partners in design of the project. The procedures for execution of the project are inplace and are outlined in the Operations Manual (updated from the previous Bank financed project's manual). They specify financial and procurement procedures. The PCU and MOHhave been assessed and found to have the capacity to managethe project. Necessary capacity buildinghas been planned for different project stakeholders. A procurement plan to cover the first 18 months has been prepared. Provisions havebeen madein the budget for the loan and for counterpart funds for the first fiscal year. The MOHhas an experienced M&Eunit and systeminplace with the capacity to conduct the M&Erequirements for the NHP. Monitoring and results framework has been finalized for the project. It i s aligned with the Government's overall M&Eframework and includes baseline and target values. 19 Annex 1: Country and Sector Background Jamaica SecondHIV/AIDS Project 52. Country Assistance Strategy. The project i s consistent with the Country Assistance Strategy (CAS) for Jamaica dated April, 2005 covering the period FY 2006-09. The CAS is aligned with the Government's Medium-term Socio-Economic Policy Framework (2004-2009). The MTEFreaffirms the Government's commitment to achieving the Millennium Development Goals (MDGs). The CAS i s basedon three mutually reinforcing pillars: (i) accelerating inclusive economic growth; (ii) improving human development and opportunity; and (iii) crime prevention and reduction. One of the goals under Pillar Two, "to improve access to prevention, treatment, care and support services for people living with HIV/AIDS (PLWHA)" addresses one of the MDG's "halting and reversing the spreadof HIV/AIDS by 2015". 53. The CAS Progress Report (July 19,2007) for FY06-09 states that the broad thrust of the CAS remains relevant. The country's economic performance has improved duringthe CAS periodwith a GDP growth of 2.5% inFY06/07. However, the economy's performance i s likely to be impacted by lower exports of two major exports (sugar and bananas) as well as shocks from natural disasters (hurricane Ivanin2004 i s estimated to have causeddamage worth 8% of GDP). The country i s still dealing with a number of challenges: highdebt, tight fiscal situation, poverty, crime and violence and poor educational outcomes. Achieving the health MDGswill also continue to be a challenge especially with respectto HIV/AIDS. Poverty, social vulnerability, gender and HIV/AIDS fuel each other inan intricately linked vicious cycle. 54. The Jamaica Health Sector. Jamaican health indicators compare favorably with Latin American countries as well as middle income countries. The country is still undergoing the epidemiological transition with a continued decline ininfectious diseases, maternal and infant mortality and childhood diseases, and a growth innon-communicable diseases. Leadingcauses of morbidity and mortality include: neoplasms (cancers), cardiovascular diseases, diabetes, injuries and HIV/AIDS. The age-group 15-49 years has been hit hardestby AIDS and sexually transmitted infections. They are the secondleading cause of death among the 15-24year age- group. Despite achievementsinthe health sector, Jamaica i s still facing challenges and i s unlikely to achieve the health MillenniumDevelopment Goals especially with respectto HIV/AIDS. 55. In 1997the HealthServicesAct establishedfour RHAswhich deliver services through a network of primary, secondary, and tertiary care facilities consisting of 24 hospitals and 316 health centers. Aproximately 38% of the population utilizes the public sector for ambulatory care, 57% use the private sector, and 5% useboth sectors. Due to increasedhealth care costs, more people from middle and upper income groups are accessingthe public health systems, especially for more costly health care needs like those related to HIV/AIDS. Public sector hospitals provide more than 95% of hospital basedcare on the island. The private sector dominates pharmaceutical and diagnostic services and provides about half of the ambulatory care. 20 56. Key constraints inthe health sector include: low fundingg; shortage of health personnel inmanykey categoriesincludingphysicians, nurses," pharmacists,radiographers, community mental health workers, health educators and public health inspectors due to emigration of professionals outside the country and to the localprivate sector and dissatisfaction with working conditions; financialburdenon families paying out of pocket for private medical care; old and crowded physical facilities and violence impeding access to health services and constraining the movement of health personnel. A national report prepared by the PIOJnoted that, according to U.N.targets,Jamaicaisunlikelyto meetthe childmortalityreduction, the maternalhealthgoals and the target for HIV/AIDS." 57. Statusof the HIV/AIDSEpidemicinJamaica. Jamaicahas apopulation of 2.7 million with 1.4 million inthe 15-49 years age-group. Itis estimated that 1.5% of this age-group is infected with the HIV virus equally divided between men and women. Heterosexual transmission i s reported by 90% of persons with HIV. There are however, more females infected inthe 10to 29 age group. The majority (65%) of reported AIDS cases fall within the 20-44-year old age group. The prevalence varies across different population groups: 9% among female sex workers in2005,4.6% among people attending sexually transmitted infections clinics in2005, 3.3% among prisoners (2006), and 4.6% among substance abusers. All parishes are affected by the HIV epidemic but the most urbanized parishes -- Kingston, St. Andrew and St. James -- have the highest cumulative number of AIDS cases. Between 1982 and 2005, the cumulative number of known AIDS cases was 11,004 with 6,437 reported AIDS deaths. Better access to antiretroviral (ARV) drugs seems to have extended the lives of the AIDS patients and decreased the mortality rate inthe past five years. By early 2007, just over 5,000 children under the age of 15 years hadbeen orphanedby HIV/AIDS. UNICEFestimates that 5,125 children in2003 lost one or bothparents to HIV/AIDS. 58. FactorsDrivingthe Epidemic. An intertwinedset of cultural, economic, social, and behavioral factors are driving the epidemic: early initiation of sexual activity, limited life-skills and sex education, multiple sex partners, gender inequity and gender roles, men having sex with men and homophobia, insufficientcondom use, substance abuse: crackkocaine and alcohol, poverty and unemployment, commercial and transactional sex, population movement, and stigma and discrimination. A knowledge, attitudes, practices, and behavior (KABP) survey in2004 showed a persistenceof riskybehaviors: multiple partners (50% of men), participation in transactional sex (20% of men and women), failure to usecondoms with non-regular partners (30% of men and 40% of women). Riskybehavior i s also evident among adolescents: drop in the median age of first sex for males and females, multiple partners, and low reported use of condoms. The risky behavior may be due to myths about HIV and low perception of personal risk:only 36% of young menand40% of young women were ableto correctly identify ways of preventing HIV and reject major misconceptions about HIV. A 2005 survey of in-school Public sector health expenditures account for 2.4% of GDPor US$90 per capita. An additional 5.1% of GDP or US$190per capita is spent inthe private sector. Most of the private expenditures are out of pocket payments to service providers and for pharmaceuticals. loVacancy rates for registered nurses increased from 17%in 2003 to 26% in 2004 and those for enrolled assistant nurses and public health nurses increased by 12% and 13%, respectively 11Planning Institute of Jamaica. Millennium Development Goals, Jamaica. April 2004. 21 adolescents (10-15 years) reported that 12% of those surveyed admitted to being sexually active and of those 56% had two or more partners and 48% reportedno condom use at last sex. 59. National Responseto the Epidemic. Jamaica has confronted the HIVepidemic proactively for two decades, steeredby the Government-led NHP since 1986 and the National AIDS Committee (NAC) establishedin 1988. The national responsehas also beenguided by earlier medium-term strategic plans and the NationalHIV/AIDS Policy approved by Parliament in2005. The responsehasbeenmulti-sectoral andhasincluded: prevention, treatment, care and support. Ithasbeen financed by the Government and external partners of whom the largest three were the Global Fund, the World Bank and the United States Government. The Jamaicanational responsehasbeenclosely coordinated with all relevant regional institutions. 60. Achievements include: establishment of VCT services inall major health centers with over 95% of relevant staff trained inVCT protocols and arapid expansion of PMTCT of HIV with 90% screeningof public sector antenatal clinic attendees. An estimated 75% of HIV infected pregnant women and 85% of HIV-exposedinfants were accessing anti-retroviral treatment in2005. Eighteen antiretroviral treatment sites were established and more than 2,500 HIV positive people were on treatment betweenin2006 (a dramatic increasein2 years). Expansion of the management of sexually transmitted infections i s resulting in a significant decline inthe incidence of some STIs, such as syphilis and congenital syphilis. There has also been an expansion of opportunistic infections treatment. Monitoring andEvaluation(M&E)has been strengthenedwith the establishment of an M&EUnitin2004. Inthe legal environment, achievements include the approval of the NationalHIV/AIDS policy by Cabinet (2004) and Parliament (2005) and the Workplace policy approved by Cabinet in2007. 61. Challengesinthe National Responseto HIV/AIDS. Despite the achievementsto date, the epidemic seems to have stabilized but has not been reversed. There are still challenges ahead. Behavior change aimed at reducing risky behavior has not progressedas expected.There are still inaccurate perceptions about HIV/AIDS12and initiationof sexual activity at earlier ages. The KAPB in2004 recorded a decline inthe median age at first sex to 15.7 years inmales and 17.2 years for girls (down from 16.4 years for boys and 18.2 for girls in 1996). About 54% of the infected do not know their status as they do not access testing services. Only 3,600 or 34% people who need antiretroviral treatment were accessingthe treatment in 2006; two-thirds of people needing treatment seek medical attention at a late stage of the diseasewhen the efficacy of treatment and the level of recovery attained may be limited; a 2006 survey shows a 95 to 100% level of adherenceinonly 55% of AIDS cases under treatment, an 80 to 94% level of adherencein 37%, and less than 80% in 8% of AIDS cases under ARV. The health system requires strengthening to handle the needs posedby the HIV/AIDS epidemic. This includes: diagnostic, laboratory and staff capacity (shortageof doctors, nurses, social workers and counselors), and institutional procedures which impede execution of planned activities due to lengthy delays inprocurement. There i s also need to integrate HIV/AIDS services into the existing health and family planning services; an enabling environment for the response to the epidemic that includes attention to social and culturalnorms and to the political environment and ~ ~~ 12Only 36% of young men and40% of young women correctly identifyingthe ways of preventing the sexual transmission of HIV (KAPB survey). 22 sensitive issues surrounding vulnerable groups; stigma and discrimination and protection of human rights; poor customer service within the health sector and its interpretation as HIV-related stigma and discrimination; and mitigate homophobia and religious intolerance of certain preferencesand behaviors. 62. TheNationalHIV/AIDS StrategicPlan(NSP),2007-2012.13 The Government of Jamaica has developed anew multi-sector National Strategic Plan, 2007-2012 through a participatory consultative process that involvedcivil society, the private sector, PLWHA, youth, representativesof marginalized groups, service providers, community leaders and policymakers. The plan outlines the vision, goal and guiding principles. It lays out the priorities and the cost and identifies the key issues: social vulnerability and policy, gender equity and roles, civil society ownership, initiative, capacity, empowering youth, reducing stigma and affirming rights involving PLWHA and promoting disclosure, and effective coordination. The estimated cost of the NationalHIV//STIProgramfor the period 2007 to 2012 i s US$201.2 million. Available current and planned resources are US$65.7 million. Unmet resource needs are calculated at about US$ 135.5 million. This represents a financing gap of 67.3%. The four priority areas of intervention are listedbelow. 63. Prevention. This priority area will increaseefforts to changehigh-riskbehaviors; address infrastructural obstacles that threaten the quality of and access to prevention services; researchto improveunderstanding of specific population groups and design more response interventions; capacity buildingfor outreach workers and peer educators; and engaging different players inthe public and private sector for the multi-sector responseto reachkey vulnerable groups and the general population. 64. TreatmentCareand Support. The NSPoutlines acomprehensive set of health services to address HIV/AIDS: enhanced screening and diagnostic services; voluntary counseling and testing; PMTCT services; access to antiretroviral treatment with a focus on strengthening adherenceto treatment; managementof sexually transmitted infections, opportunistic infections including tuberculoses, and post exposureprophylaxis; and psychological and social support. 65. EnablingEnvironmentandHumanRights. The strategy supports fostering an environment that protects human rights and empowers people to make healthy decisions and includes updating of legislation; implementation of workplace and sector-specific policies and programs to safeguardprivacy and confidentiality and address stigma and discrimination; improving access to condoms and contraceptives through affirmation of reproductive health rights; and public education, advocacy and training inHIV/AIDS issuesfor managementand employeesof the insurance sub-sector. 66. Empowermentand Governance. The planpriorities include institutionalizingkey positions inthe NHP within the public sector; inclusionof dedicated provisions for HIV/AIDS within the recurrent budget; operationalizing the "Three Ones" principles: one national coordination authority, one national HIV/AIDS plan and one monitoring and evaluation plan; improving the procurement managementsystem; fostering greater harmonization and l3The NSP was peerreviewedby the UNAIDS/WorldBankAIDS Strategic andAction Plans(ASAP)teambased at the WorldBank's GlobalHIV/AIDSProgram(HDNGA). 23 collaboration among stakeholders including the CCM of the Global Fundand the NAC; strengthening the capacity of public and private sector and NGOs; and working with religious leadersto promote greater tolerance and acceptanceof PLWHA. 24 Annex 2: Major RelatedProjects Jamaica SecondHIV/AIDS Project 67. The WorldBank i s supporting the JamaicaHIV/AIDS program through a loanof US$10.6 million due to close on May 31, 2008. The Bank project's objectives were to: support the NationalHIV/AIDS Strategic Plan (2002-2006) to curb the spread of the HIV epidemic through expansion of programs targeted at highrisk groups as well as the general population; strengthening of treatment, care and support for PLWHA; and strengthening Jamaica's multi- sectoral capacity to respond to the epidemic. The World Bank i s also collaborating with UNESCO and UNICEFto strengthen the education sector response. 68. The GlobalFundfor AIDS TuberculosisandMalaria(GFATM). Jamaicawas awarded US$23 million grant money by the GFATMfor the period 2004-2009 under Round3 and US$44.2 million inRound7 (2009-2013). This funding will focus on expanding supplying ARVs, treatment, support to the education sector; targeted intervention among those most at-risk; mass media education campaigns; condom promotion, anti-stigma campaigns, and policies to affirm human rights. 69. The EuropeanCommunity(EC). The EC funded aregionalproject14in2000to support eight regional cooperation projects for HIV/AIDS inthe Caribbean that also benefited Jamaica. It supported: increased skilledpersonnel; PMTCT; the network of PLWHAs;reduced high-risk behavior and increasedinformation on the course, consequences and costs of the epidemic. Inaddition, the EC supported the project, "Addressing HIV inJamaica: a holistic response (750,000.00 - 2005-2008). The programcovers areas with highconcentrations of HN: the inner city community of MandelaTerrace inKingston, Montego Bay, Ocho Rios, Mandeville inthe parishof Manchester,andSpring VillageinruralSt Catherineparish. 70. UNFPA. UNFPAprogram aims to promote sexual andreproductive health and rights, gender equality and equity, by integrating population-related factors into development strategies and plans. Ithas two sub-programs: sexual and reproductive health and population development. UNFPAprograms are integratedinto national programs: reproductive health, includingfamily planning and sexualhealth, service delivery including provision of male and female condoms, information, education and communication (IEC). Inaddition, UNFPA has ajoint project with the European Union (EU)/UNFPAprograminReproductive Healthwhich aims to: increase the capacity to deliver comprehensive, integrated SRH services and improvedaccess and reproductive health behaviors by the population, particularly vulnerable or neglected target groups. 71. UNICEF. The UNICEFCountry Program2007-2011for Jamaica aims to contribute to realization of children's rights to survival, development, protection and participation through the nurturingof an enabling andprotective environment. Itwill address the mainthreatsto childhood, viz, violence, HIV/AIDS, and natural disasters, and promote opportunities for child development. Support for HIV/AIDS includes: access to and quality of services, including ARV l4"Strengthening the institutionalresponseto HIV/AIDS/STIinthe Caribbean" (SIRASC). 25 services, for pregnant women before and after delivery, ARV prophylaxis for infants and ARVs for children, care support and protection for orphans. 72. ILO. The ILOhasbeenimplementing a4-year programfrom 2004 which covers: strengthening the tripartite relationship: the private sector, trade unions, and employers. It works through the Ministry of Labour and Social Security. The programincludes: work place programs, the voluntary compliance program focus on small and medium scale enterprises; and gender related issues. This program i s envisagedto end in 2008 and may have no follow on project. 73. UNAIDS. UNAIDS supports strengthenedcoordination and managementauthority; the development and implementation of an enabling legislative and policy framework with a gender- centered and child-centered focus; and support to increasing access to prevention, treatment, care and support and impact mitigation services. The UNAIDSi s also implementing aproject for people with disabilities and an economic empowerment project. 74. JapanInternationalCooperationAgency (JICA). Japancooperateswith the Caribbean under the "New Framework for Japan-CARICOM Cooperation for the 21St Century" as well as the annual Japan-CARICOM consultation. Technical cooperation inhealth covers prevention, control of chronic non-communicable diseases and the HIV/AIDS Prevention Education Program. An important element of the program is human capacity building: Japanese volunteers have providedtechnical support inmonitoring and evaluation and for prevention education training of human resources. 75. PAHO. PAHOprovides technical support for the HIV/AIDS strategic planpreparation, strengthening quality control for laboratories and testing; research includingbehavior change; support to the Caribbean Food and Nutrition Institute on nutritional aspectsfor PLWHA; tuberculosis management; education; study on NGOs; and strengthening monitoring and evaluation (education, management, analysis and systems development). PAHO also provides support through the country programwith CAREC. 76. UNESCO. UNESCOis implementing atwo year plancovering policy, planning and capacity building. A strategy has been preparedfor confronting HIV/AIDS. It will provide for mainstreaming HIV/AIDS training ina systematic manner, e.g., continuous education of teachers; health and family life education. Capacity buildingcovers the 6 regional education offices. A specific partnership for strengthening HIV/AIDS inthe education sector includes UNESCO, World Bank and UNICEF. 77. USAID. USAID support envisagedover the next few years, will promote public private partnerships and finances activities at the community level. Its annual budget over the next five years i s estimated at US$1.2 million. 26 Annex 3: ResultsFramework and Monitoring Jamaica Second HIV/AIDS Project PDOs: The project development objectives are to assistinthe implementation of the Government's National HIV/AIDS Programby supporting the: (i) deepening prevention interventions targeted at highrisk groups and the general population; (ii) increasing of access to treatment, care and support services for infected and affected individuals; and (iii) strengthening of program management and analysis to identify priorities for building the capacity of the health sector to respond to the HIV/AIDS epidemic and other priority health problems. 1. % of CSWs who 9%(2005) <7% <7% Every 2 -3 years; NHP/M&E Monitor progress in are HIV infected Unit meetingtargets o f NSP 2. % of M S Mwho are 25-30%est. <25% Every 2 -3 years; NHP/M&E AND BCC strategies; HIVinfected 15 Unit 3. Numberof men, 3,000 6,500 7,500 Annually, Treatment site Adjust programbased women & children with (2007) reports, Regional Surveillance upon the findings; advanced HIV receiving Officers Expand access to antiretroviral combination qualityHIVpreventive therapy according to and care services; national guidelines Revise policies and 4. Number of institutions 55 (2006) 80 Annually, NHP/M&E Unit strategy based on adopting policies to evidence address HIV Results Indicators for Eack Zomponent Component One : Prevent nActivities Subcomponent 1.a: Prevention Activities by the Ministry of Health and the Regional Health Authorities. Subcomponent 1.b: Prevention activities by the non-health Line Ministries. Subcomponent 1.c: Preventi activities b Zivil Socie rOrganizat ns. 5. % of most-at-risk csw:43% CSW 50% Every 2 years, Survey Systematic collection populations (MSM, CSW) (2005) Reports, NHP/M&E of outcome data for who receivedHIV testing MSM TBD improving access, inthe last 12months and (June2008) utilization and quality who know the results of services' delivery; 6. % o f young people Baseline Males KAPB every 3-4 year; NHP assess performance o f aged 15-24 reporting the Project I 80% M&EUnit service delivery use of a condom the last Men: 76 Female partners, to identify time they had sex with a Women 75% barriers and propose non-regular sexual 66%for the solutions to meet partneP 15-49age- group project objectives; (2001) Assess effectiveness of, and improve BCC l5 Data on M S M indicators will be available inJune 2008 after discussion with stakeholder meeting scheduled for May 2008. 27 7. % of female sex 92% (2005) >92% >92% Behavioral surveillance; every interventions targeting workers reporting the use 2 years. highly vulnerable of a condomwith last groups; Revise client programs and activities 8. % of men reporting the TBD (June, 10% M S MBehavioral surveillance based on evidence; use of condom the last time 2008) above conducted every 2 years. Assess line ministries they had anal sex with a baseline Specific surveys (KAPB); and civil society male partner NHP M&EUnit organizations' capacity 9. % of young women Males Males to deliver HIV and men aged 15 - 24 who 36.2% 70%; preventive services; both correctly identify Females Females and develop a ways of preventingthe 40.0% 80% strengthening agenda sexual transmission of HIV (2004) to buildtheir capacities and who reject major and quality of services misconceptions about HIV delivery; Expand transmission services to hard-to- 10.Number of persons 115,825 200,000 400.000 Every 2 years; Lab reports; reach groups and receiving counseling and (2006) NHPM&EUnit monitor adoption o f testing for HIV HIVprotective 11. Number of NGOs TBD (June Annually, NHP/PCU behaviors providing HIV/AIDS 2008) prevention, treatment, care and support according to national guidelineslstandards Component Two: Treatml It, Care and upport 12. % of adults & children 75% (2006) 90% Annually, Treatment site Expandaccess of with HIV still alive 12 reports; quality care services months after initiation of Treatment database from through monitoring ART EMR and evaluating 13.% of HIVpositive 4 0 % 100% Monthly, Treatment Site utilization of services, pregnant women receiving (2002) reports; Regional Surveillance with special attention a complete course of ARV 47% (2004) Officer/ HNcoordinators to the most vulnerable prophylaxis to reduce the 74% (2005) groups; Assess number riskofMTCT ofcases observed and 14. % of ANC clients that 96.3% 100% Monthly, Treatment Site treated by type of are counseled and tested (2005) reports; Regional Surveillance health facility, health for HIV (Project Iphrased Same as Officer/ HIV coordinators workers and target as "Proportion of Ante- End-of- population; Natal Care attendees Project 1 Asses medical and receiving M T C T value cultural barriers to interventions")" Baseline Project 1 access services and 15%(2001) device feasible solutions, including 15. % of infants born to 10%(2006) Annually, Regional community level 09p HIV-infected mothers, 25% (2000) HIV/AIDS Monthly Report; activities who are HIV-infected Regional Surveillance Officers & HIV Coordinators 16. Ratio of current school 0.99(2005) Every 5 years attendance among MultipleIndicator Cluster orphans to that among non- Surveys (MICS) l6 Indicator No. 6 was also a Project ICore Indicator; and target by end Project Iwas men: 85% and women 75%. l7 Indicator No. 13 Project ICore Indicator; and target by end o f Project I was 80%, which was achieved. 28 orphans IUNICEF 17. Number o f institutions I I Strengthen safeguards that have adopted a health at the clinical level care waste management I l l system Component Three: Strengthening Institutional Capacity for Policy Formulation, Program Management, and Monitoring and Evaluation Subcomponent 3.a: Policy Formulation for an Enabling Legal and Regulatory Environment and HumanRights. Subcomponent 3.b: ProgramManagement. To support the coordination and management of the Government's National HIV/AIDS Program Subcomponent 3.c: Monitori and Evaluation. 18. Number and percent of 70% Annually Assess the political reportedcases of HN- National HIV related environment and how related discrimination I Discrimination Reporting and implementing partners receiving redressby setting Redress System are including non- 19. Number of institutions 55 (2007) 80 Workplace Survey Report discrimination adopting policies to (25 private, 5 public); practices into their address HIV/AIDS Ministry of Labor/M&E Unit programs; 20. Number of individuals 350 Annually instakeholder Reports (M&Emonthly Assess participation of organizations trainedin report) all implementing M&Eandlor surveillance partners and how are and/or HMIS collaborating towards 21. Number of 100% Annually; Desk review common goals; mplementingpartners NHPM&EUnit Assess the .eporting on NSPindicators implementation of the 22. Completion of Ongoing Systems NHPprogress reports; As M&Esystem at the computerization for: I completed completed national and sub- NPHL; National Blood and NHP M&E Unit national levels with the Transfusion Services; populating assistanceof national surveillance system. data and international stakeholders; Recurrent collection of informationfor decision makingto manage the program based on quality data 23. Alternative NHP progress reports; As treatment technology for completed biomedical waste Upgraded biomedical management established in waste treatment to the Western Health Region mitigate potential environmental effects 24. Environmental NHP progress reports; As and protect health care management and completed workers monitoringplans for each plant dealing with Biomedical Waste developed and being implemented 29 Data Sourcesfor ResultsFramework and Monitoring 78. The NHPM&EUnitof the MOHis responsible for developingandimplementingthe program's M&Eframework. The Surveillance Unit,underthe MOH's HealthPromotionandProtectionDivision, is inchargeof alldisease surveillance activities, which includesHIV. The unitis staffedby a surveillance officer full time incharge of the HIV component. The four Regions and fourteenParisheshaveforty Contact Investigators,who are workingfull-time for the HIV ProgramandM&Eactivities. Inaddition, the Adherence Councilorsand Socialworkers are co-responsible for collectingandreportinginformation. 79. Routine Data Sources: (a) Sentinel Surveillanceof ANC and STIClinic Attendees. Tests are done at the health centre level. Positive rapidtests are then sent for testing by the ELISA method at a regional laboratory, or the NationalPublic Health Laboratory. The frequency of data collection and reporting i s typically between April and September, and i s collected every two years. (b) HIV/AIDS TrackinnSystem(HATS). HATS i s an ongoing HIV surveillance system based on confidential case reporting, which includes demographic information, mode of transmission, risk factors, and stage of infection. The M&EUnitreceives case reports from health services, public and private, on newly diagnosedHIV/AIDS cases. Inaddition, the surveillance officer basedat the NationalHIV/AIDSProgram actively visits hospitals, private practitioners, and hospices, death registries, among others, to identify and complete HIV/AIDS case reports. These case reports are entered into the HATS database, which i s routinely searchedfor double entries and revised periodicallybasedon updates from the surveillance officer or contact investigators. The database is usedto obtain national HIV prevalence estimates and other national statistics. Data are collected and entered inan on-going basis, and standardreports are generatedquarterly. (c) HealthInformationSystem(HIS). The Jamaican HIS consists of six stand-alone databases, out of which, two are still under development. The databases are directly managedby the Planning and Evaluation Department of the MOHand consist of data collected from: Hospitals - the Hospital Monthly Statistical Report (HMSR) databasethat reports on workload information within the hospital system; Medical Records Case Abstract (MRCA) databasethat stores patient demographics and information on diagnostic procedures, and discharge diagnoses; Patient Administration System (PAS) that stores patient demographics and information on admission, diagnostic procedures, and discharge; and Health Centers: Monthly Clinical Summary Report (MCSR) database that stores aggregateinformation on services including antenatal, postnatal, child health, Family Planning, etc.; Combined Immunizationdatabase; and Community Mental Health database. (d) Threshold 2lmodel. The T21 models the HIV epidemic inthe country basedon some of the rates shown above and other demographic information. The products are the projection models of the epidemic and the effects on the economy, the influence of program interventions, etc. The T21 software needs to be calibrated with realprevalence data on the general population and special groups; Le., MSM, CSWs and drug-usersto reduce overestimation of effects on the program interventions. 30 80. Non-routine DataSources: (a) National Knowledge,Attitudes, Behavior andPractices (KABP) Survevs. The NHPconducts National KABP population-based surveys to obtain information related to the prevention and transmission of HIV and other STIs. These surveys providenational leveloutcome indicators. The sampling methodology i s by clusters, usingEnumeration Districts (EDs). The EDsare selectedwith probabilityproportionate to their size. Itis a stratified multi-staged sample with quota control for gender. The target groups are male and female 15-24 years, and 25-49 years. The rural/urban composition of this sample i s generally representative of the country. The NHPconducts a Nationalpopulation-based survey every 3-4 years. (b) SecondGeneration Surveillanceof MSMandCSW. These surveys providenational indicators and prevalence rates of high risk groups such as youth, MSMand CSW. The youth data i s collected through the Healthy Lifestyles surveys that focus on school-based and population-based samples of 10-15 year olds and 15-19 year olds. The MSMand CSW surveys are modifications of the Priorities for Local Aids Control Efforts (PLACE) methodology. Biological samples are also collected for HIV testing for MSMand CSW. These studies will be conducted every two to three years, depending on availability of funding. (c) The M&EUnithas gained access to additional data sources or will implement other data collection activities that include: (i) Health facility survey; (ii) Workplace survey; (iii) MICS (Multiple Indicator Cluster Survey); (iv) NationalHIV/AIDS database secondary data analysis; and (v) NationalHIV/AIDS M&E 10Years Report of HIV/AIDS/STIin Jamaica to be developed. ResultsFrameworkand Monitoring 81. The Jamaica M&E systemis described inthe M&EPlan and the M&EOperations Manual. The M&EPlan describes the overall M&E system and components and the M&E Operations Manual provides specific national guidance on procedures, protocols, policies, roles, responsibilities, timelines and other implementation factors described inthe M&EPlan. The objectives are: to track the implementation of the NHP activities and establish whether the program goals have been achieved; to increasethe understanding of trends inHIV/AIDS prevalence and explain the changes over time to allow for appropriate responseto the epidemic; and to strengthenthe capacity of the NHP, regions, parishes and NGOs, CSOs and the private sector to collect and useHIV/AIDS data. 82. The NHPwill collect project indicators annually, biennially and every five years. Project indicators will be collected through various components of the system, which are interrelated and coordinated among implementing partners, and supportive assistanceof a Monitoring and Evaluation ReferenceGroup (MERG). Outcome indicators will be collected at the family level and of hard-to-reach groups. The role of the NHPwill be to oversee the overall design and sample selection; monitor and ensurethe quality of the data collected and enteredinto a database; and to carry out an overall analysis, triangulating informationfrom the different sources. Public and private sectors will feedback the informationto local communities and stakeholders. 31 Annex 4: Detailed Project Description Jamaica Second HIV/AIDS Project 83. Component 1: Prevention Activities (US$3.34 million). (a) Subcomponent 1.(a): Prevention Activities by the MOH and the Regional Health Authorities (US$ 2.99 million). Studies show high levels of knowledge on modes of transmission of HIV and coverage of services for vulnerable populations has increased. Nevertheless, the desired level of behavior change has not been achieved. Results from the KABP (2004) indicate: a decline inmedian age of first sex, persisting inaccurate perceptions and myths about HIV transmission, increased commercial sex -- 6% of males 15-24 and 15% of males 25-49 engaged incommercial sex in 2004 increasedfrom 2% and 1.2% respectively in2000 (KAPB 2000, 2004 surveys) and accepting attitudes towards PLWHA remain low (less than 6% of persons 15-49 have no discriminatory attitudes towards those living with HIV--KABP,2004). 84. The NHP aims to reduce individualvulnerability to HIV transmission through interventions targeted at most at risk and vulnerable groups (youth, MSM,CSW, prison inmates, drug abusers, PLWHA) as well as the general population by continued implementation of the behavior changecommunication strategy (BCC) initiatedin 1988 and whose objectives include: increasing awarenessabout HIV/AIDS among the general population; increasedknowledge and skills and practice specific to abstinence, condom use, partner reduction; and to increase appropriate risk perception. This subcomponent will strengthen the capacity of the MOH and of the RHAsto provide technical guidance for the national responseto HIV/AIDS and to deliver HIV/AIDSrelatedservices for prevention through the health care system. Support will include staffing, training, materials development, operational support for outreach efforts and studies. 85. MOHCommunitv LevelPrevention Initiatives: MOH's prevention efforts are guided by the BCC Strategy. Technical guidance for implementation i s providedby outreach/mobile workers, Community Peer Educators and Targeted Intervention Officers. Phlebotomists from within the localcommunities and at-riskhulnerable groups such as PLWHAs and CSWs as well as individuals inthe general population support the effort. They employ a series of innovative methods and educational tools to reach diverse audiences of at risk groups such as CSWs, MSMs,out of school youth and schoolchildren aged 10-14years old. The contribution of the Media Component of the national responsehas also beenimportant in developing appropriate IEC materials and involving local artists, DJs and party providers inefforts to influence norms and move socio-cultural barriers. Future media campaigns will focus on HIV testing, stigma and discrimination and consistent condom use for sexually active adolescents and adults. 86. The main behavior change activities to be supportedby the project will be evidence- basedBCC interventions, guided by surveillance and research. They will be targeted at: raising awarenesson HIV; delaying sexual initiation, abstinencewhen appropriate; promotingcondom use; reducing the number of sexual partners; and promotingHIV T&C. They will include face to face interventions by community peer educators, mass media campaigns, public relations and culturalvehicles to involve opinion leaders such as faith-based organization leaders, targeted community interventions, training of NGO/CBO and government agencies, in school programs, 32 workplace education program, condom provision and social marketing. These activities are complemented by expansion of HIV testing and counseling as well as a comprehensive package of services for prevention of mother to children transmission. Fundingwill be providedfor: development of IEC materials, mass media campaigns, and outreach aimed at most at risk groups (CSW, MSM,inand out of school youth, inmates, and drug users) as well as targetedcommunity interventions. Special studies to aid tailoring of interventions will also be financed. 87. Condom Promotion. Condoms are widely available free of charge throughout the public health services and providedas part of outreach activities and through condom social marketing. However condom usehas leveled off. Thirty percent of men and 40% of women, having sex with anon-regular partner, do not use a condom. Among CSW, condom use i s still low for non- commercial partners (39%). There i s also indicationof poor positive prevention behavior such as low condom use among HIV+ CSW and multiple pregnancies among HIV positive women. The project will support promotion, procurement and distributionof condoms and lubricants. This support will complement condoms from other sources such as the GFATMandUNFPA. 88. Voluntary Counseling and Testing (VCT). Progressinthe area of VCT includes: (i) increasedacceptancefor HIV testing; (ii) expansion of entry points to VCT to point of care (ANC, testing to all persons with STI at health centers; selective family planning clinics, innovative approachesfor VCT such as walk-in clinics, mobiletesting e.g. drive-through, bashy bus); (iii) of more than 2,250 VCT counselors in2004-2006; (iv) introduction of rapid training testing (Determine, Uni-gold); and (v) decentralization of testing to regional laboratories. The program currently tests about 75,000 persons per year inthe public sector (82,000 personsin 2006) and an additional 40,000 inthe private sector. Outreach activities to specific vulnerable population (CSW, inmates, MSM)have improveduptake of VCT inthese groups (41% of CSW reported having a HIV test done inthe past year). A provider initiated strategy with opt-out testing for all public hospital admissions was piloted in 2006. Over 16,600 hospitals admissions were testedfor HIV throughout the island of which 1,186 testedpositive. This strategy i s currently being introduced inall public hospitals. 89. The impact of increasedVCT is still low in spite of increased acceptance towards HIV testing and scale up of services; more than half of the estimated PLWHA inJamaica are unaware of their status. The percentage of persons 15-49 who received an HIV test andknow their results i s 12% for males and 18% for females (MOH, KAPB 2004) and 38% of notifiedHIV cases are first reported as AIDS case. The use of rapidtest hasbeen a great advantageto increasedaccess to testing services. However, testing algorithms are complex and should be reviewed inlight of WHOPAHO recommendations with afocus on reducing the number of tests as well as including proficiency testing among personnel while defining the characteristics for kit selection basedon cost, sensitivity, specificity and predictive values. Insufficient skilled staff (with a high turnover), limited laboratory equipment, stock interruptions and deficient transport systemof blood samples for confirmatory testing all are factors delaying the effective scaling up of VCT. 90. Expansion of VCT for scaling up treatment and care and for preventing HIV transmission. The project will support innovative approachesto further expand VCT to hardto reach and vulnerable populations, (walk-in and mobile VCT services), increasenormalization of 33 VCT and expand provider initiatedVCT) It will support staffing, training, laboratory strengthening, testing kits, reagents and supplies. 91. Prevention of Mother to Child Transmission of HIV. PMTCT i s integrated into a packageof services that includes prevention of HIV and congenital syphilis through rapidtesting and treatment. Public opt-out testing and counseling of pregnant women startedin late 2000 and was scaled up in2002 and 2003, with funds from the Elizabeth Glazer Foundation, and in2004 with funding from the GFATM. More than 90% of women attending ANC in2006 have been tested for HIV through rapidtesting, scaling up from 40% in 2003. Single dose Nevirapine or AZT (inSERHA) hasbeenprovided for PMTCT since 2003. In2006, over 75% of the pregnant women that tested positive for HIV received antiretrovirals. HAART i s now the nationally recommended regimen for PMTCT, a strategy that has been financed through the GFATMand World Bank-financed loan. Ninety percent of infants bornto HIV infected mothers have received ARV for PMTCT. Nutritionalcounseling is providedto the mother regarding nutritional alternatives for the infant. Infantformula, in addition to bromocriptine to inhibit breast milk production, i s also available through the public health system. Early infant diagnosis of HIV infection is carried out using PCR testing at the NationalPublic HealthLaboratory (NPHL). HIVperinatal transmission rate i s estimated to have decreased from 25% (estimate perinatal transmission rate in absence of PMTCT interventions) to an estimated 8-10% in2006. Technical support has beenprovided through UNICEF and PAHO. 92. The project will also support strategies and activities to promote sexualhealth for HIV positive persons such as encouraging a supportive environment for disclosure, promoting peer support groups within the health services, providingreproductive health services, and ensuring social support. 93. Human ResourcesTraining: The project will support training inPMTCT, BCC, M&E, STI/HIV Case Management, and treatment and care. Categoriesof staff to betrained include: public health physicians at regional and parish levels, social workers, nursesto assist with PMTCT, physicians to assist inHIV clinics, BCC coordinators and health educators. 94. The project will also support managementof STIs and blood safety for preventing HIV transmission. The latter will include promotion of voluntary blood donation. 95. Subcomponent 1.(b) Prevention Activities by the Non-Health Line Ministries (US$0.30 million). Four key line ministries have been identifiedfor scaling up the contribution of the non- health line ministries to make the national response atruly multi-sectoral. They will be supported to provide prevention activities that are specific to the population that each Ministry has a mandateto serve and/or encounters inthe course of execution of its official mandate. They will also be supportedto implement cross-cutting HIV/AIDS activities. These include: development and implementation of workplace HIV/AIDS policies; IEC/BCC for HIV/AIDS and STDs; condom distribution and promotion; advocacy to reduceHIV/AIDS stigmatization and discrimination, particularly inthe work place; and establishment of a support group for HIV/AIDS patients and their families (either as a single ministryor incollaboration with other ministries). The project will co-finance staffing costs of focal points for the Non-Health Line Ministries. 34 96. The Ministry of Education (M0E)has the most active HIV/AIDS programfinanced by the GFATM, UNICEF, UNESCO, UNFPA,UNAIDS, JICA and PAHO. The financing supports implementation of its sectoral strategy including teacher training and the health and family life education. The Ministryof Labour and Social Security i s currently supported by the ILO and is inthe processof enlarging the occupational health and safetyregulations to include HIV/AIDS protection using the ILO template and wants to establish a mechanismfor receiving discrimination complaints that will includereferrals to courts. Itwill be supported to scale up work place interventions. The Ministry of Tourismhas a large external clientele with many high riskpopulation groups such as commercial sex workers, water sports andtour operators, taxi drivers, and street vendors. Effectively engaging bars, clubs, and hotels i s one of its major challenges and eachestablishment should have an education programinplace and a method to distribute condoms. The Ministryof National Security has untilnow focused mainly on its internal staff Department of Correctional Services, the Jamaica Defense Force and the Jamaica Constabulary Force through BCC training, sensitization workshops, and training of trainers. It has installed condom dispensing machines in strategically located places. It wants to work more aggressively with its prison population but is challenged by a legally and culturally constrained environment. The HIV/AIDS Unit i s now under the Offender Management Division and i s beingtransferred to the Training Department under the HumanResources. This subcomponent would finance annual work programs of three of the four line ministries that would include implementing workplace HIV/AIDS policies, BCC, condom distribution and promotion, and advocacy to reduce HN/AIDS stigmatization and discrimination. The national program will finance technical and material support for focal points, program officers and their respective ministerialHIV/AIDS Committees. 97. Subcomponent 1(c): Prevention Activities By Civil Society Organizations (US$ 0.05 million). Some of the lessons learned over the past five years of implementing the BCC strategy include acknowledgement of the complexity of sexualbehavior and understanding that targeted interventions have to be evidence-basedand adaptedto fit particular sites, locations and audiences. CSOs can play a significant role inreaching particular vulnerable and highrisk groups. CSOs have beeninvolvedinprograms that target priority at risk groups and hold promise for furthering the response. 98. Under the NHP, CSOs will be supportedto scaleup programs for youth inschool (with special attention to 7* and 9* graders) including the Health and Family Life (HFLE)program and innovative work focusing on inner city schools incollaboration with the MOE, the PTAs and agencies dealing with dispute resolution and drug prevention. They include sexuality education, risk assessment, behavior modeling and leadership training conducted through peer education with students takingleadership. Support will also be providedfor CSOs to scale up interventions for CSWs under the Priorities for LocalAIDS Control Efforts (PLACE) methodology. This includes "empowerment workshops" offering literacy classes and referring individuals to other agencies such as housing, banks and drug addiction/prevention. The project will support involvement of club operators and other stakeholders, includingthose inthe tourism industry, to implement risk reduction interventions including condom policy. The project will enhancesupport for identificationand training of MSMto provide risk reduction skills, referral to STI/HN test and treatment and promote adherence to anti-retroviral treatment and positive 35 prevention. CSO activities will be coordinated closely with Government agencies that provide work skills training so as to help empower this population, reducetheir social vulnerability and assist them inentering thejob market. Researchhas revealed the needto target risk reduction strategies inmale dominated occupations particularly, taxi and bus drivers, the police force and auto-mechanics, who are involvedwith CSWs and transactional sex that lures under age girls into sexual activity. The project will scale up existing experiencesinoutreach involving males inthese occupations. As part of the M&Eactivities, a study will beundertaken on the attitudes and behavioralpatterns related to condom use among CSWs, adult males, and MSMs. CSOs work with orphans will also be supported. 99. The GFATMhas allocated US$5 million to fund CSOs which will allow a dramatic scaling up of the response. Support to CSOs will be providedthrough a demand driven process guided by the NHPto ensurethat CSO proposals complement public efforts and are focusing on program priority areas. Support will include costs for training, BCC interventions (described above), condoms promotion and distribution, scaling up of VCT, and specific eligible material support to orphans and vulnerable groups. As part of lessons learned from past programs, capacity strengthening will be provided to CSOs to enhancetheir performance. This project will finance training and the positionof CSO Coordinator inthe PCU who will provide capacity buildingfor CSOs. Furthermorethis project hasdeveloped an organizational structure with standardoperating proceduresfor engaging CSOs. Selection criteria are detailed inthe Project Operations Manual and include proven human and financial managementsystems, demonstrated consultation and participatory processto mobilize and empower target communities, and experience indevelopment program implementation. 100. Component2: Treatment,Care andSupport (US$ 1.81million). This component will support the strategy outlined inthe NSPto implement an extensive health systemthat includes: enhanced screening and diagnostic services; PMTCT services; antiretroviral treatment with a focus on strengthening adherence to treatment; services for managementof sexually transmitted infections, opportunistic infections (includingtuberculosis); post exposure prophylaxis; psychological and social support; provisionof specialized clinical care; and improved access to antiretroviral therapy (ART). 101. Antiretroviral Therapy was initiatedin2004 with funding from GFATMand hasbeen integrated into the existing health services with 19treatment sites inthe country. Teams composed of doctors, nurses, adherencecounselors, social workers, nutritionists, and contact investigators have been specially trained in comprehensive HIV care and treatment. Treatment coverage was estimated to be around 34% in 2006. Guidelines have been develo ed for first and secondline treatment regimens (it i s estimated that 5% of patients may be on 2" line treatment). B Most of the drugs used are generic and pricereductions have been achieved with support from the Clinton Foundation and international bidding process (Kaletra has been reduced from US$350 per bottle to US$83). ReportedAIDS related deaths have decreasedfrom 665 in 2004 to 432 in2006, attributed to scaling up ARV treatment. Treatment initiation is basedon clinical assessment and CD4 count. CD4 testing is carried out at baseline and then on follow up every 3 to 6 months. Viral load (VL) is available for assessment of drug resistanceat the individuallevel. Toxicity assessment i s providedwith support of testing through the regional laboratories. Prophylaxis for PCP i s included within the standards of care for those that require it. A 36 mentoring systemi s inplace to aid with patient management. Stigma and discrimination i s still present inhealth care facilities. Reports of breaches inconfidentiality appear to be less common butcontinue to occur. 102. Sexually Transmitted Infections STIs are strongly associatedwith HIV infection; 47% of persons with HIV inJamaica have reported a history of previous STI. An integrated approach to STIcontrol is beingusedthrough syndromic management. A decline inreported primary and secondary syphiliscases hasbeen seen inthe last decade. Highrisk groups have a high burden of STI (high STIprevalence was found among CSW and their patrons i.e. over 60% STI prevalence in street CSW and 40% inthose that work inbars). Stigma and discrimination persist as barriers to effective prevention and treatment. 103. Opportunistic Infections. The project will support management of opportunistic infections. Support will include development of algorithms, training of staff, and provision of drugs. 104. Tuberculosis. HIV testing among TB patients i s high, with close to 90% (78) of patients tested for HIV in2005; over 35% (29) of these patients were HIV+. There i s a gap inthe case detection rate of TF3 cases (3 per 100,000 notified incidence rate vs. an estimated rate of 7.4 per 100,000 for 2005). Technical support (up-dated guidelines and training) has beenprovidedfrom PAHONHO and financial support through the World Bank loan. The project will support scaling up diagnosis and treatment of TB patients and the detection of HIV in this group through the provision of laboratory equipment, ensuring the required regulatory safety precautions to conduct AFB cultures and antibiogram inNPHL, and supplies to expand AFB smear inregional laboratories. 105. The project will support drugs (not funded through the GFATMgrant), nutritional supplements, substitution infant feeding formula, and training of health care workers in comprehensive management of HIV/STI/TB and PMTCT; interventions to ensure confidentiality and provide a supporting andnon-judgmental environment among health workers to reduce barriers faced by infected and most at risk populations when accessingtreatment and care, including training of health care workers, BCC campaigns and implementing explicit non- discrimination policies inhealth facilities. 106. Blood Safety. There i s a relatively safe blood supply inJamaica. All collected units are screened for infectious markers including HIV at the NationalBlood Bank in Kingston. Most donations come from replacement donors that carry higher prevalence rates of HIV. The project will support testing kits and reagents, training and efforts for increasing voluntary blood donations e.g., communication and outreach and appropriate customer service. 107. Laboratory Services Strengthening. Laboratory services are providedby the referral NationalPublic HealthLaboratory (NPHL) and RegionalLaboratories (Cornwall Regional Hospital Laboratory, Mandeville HospitalLaboratory, St. Ann's Bay Hospital Laboratory and SpanishTown HospitalLaboratory). HIV diagnostic services (rapid test and ELISA) are providedat all of the regional laboratories with confirmationprovided by the NPHL.Rapid testing is also available at peripheral clinics. Shortcomings occur with the transportation of 37 samples for CD4 and VL from the ARV treatment sites to the NPHL. Lack of staff and shortage of equipment and supplies (stockouts of ELISA reagentsinregional laboratories, no back up or maintenanceplan for basic equipment, just one microbiologistinNPLH) hinder interventions for integral HlV prevention, treatment and care. The project will enhancethe decentralized capacity, efficiency and quality of the laboratory systemby supporting provision of reagents and supplies for HIV testing including confirmatory testing, rapid tests for syphilis and HIV, microbiology, hematology and biochemistry. Ensuring adequate staff and skills, review of HIV testing algorithms, and quality control mechanismswill be part of this support. Puttinginplace a maintenanceplan for equipment (e.g. transportation of samples, laboratory equipment) as part of ensuring the sustainability of health services provision. 108. Component 3: Strengthening Institutional Capacity for Policy Formulation, ProgramManagement, Monitoring and Evaluation (US$4.26 million). Subcomponent 3 (a): Policy Formulation for an Enabling;Environment and Human Rights (US$0.41 million). The NationalHIV/AIDS Policy and the National Strategic Plan 2007-2012put significant emphasis on the provisionof a supportive legal and regulatory environment. Importantprogresstoward the achievement of a supportive enabling environment has been made, e.g., a thorough review of the country's legislative framework as it relates to HIV/AIDS was carried out; a National HIV/AIDSWorkplace Policy was adopted; a Draft NationalOccupational and Safety Act was prepared; aNationalPolicy for HN/AIDS Management in Schools was adopted; and key support systems called for by the Child Care and Protection Act, namely the Children's Register and the office of the Children's Advocate, have been establishedand are operational. 109. The GFATMfinancing includes provisions for improving the policy, legal and regulatory environment (inline with the NSP and the recommendations of the legislative review referred to above), expanding the national systemfor reporting and redress of discrimination against PLWHA; and addressinggender inequities and stereotypes, including homophobia. It will finance the position of a legal adviser to work with the Solicitor General's Law Reform Department inthe Ministryof Justice as endorsedby the Legal and Ethical Subcommittee of the NAC inthe Law ReformDepartment inview of that unit's mission within the Ministry of Justice. World Bank financing will provide technical assistancein support of the changes to the legislative framework that have been recommendedby the legislative review including updating of the Public HealthAct to deal with new health challenges such as HIV/AIDS and advocacy for further legislative and policy reformto address stigma and discrimination. 110. SubcomDonent3 (b) Empowerment and Governance (US$3.30 million). This subcomponentwill support strengthening the institutional capacity for coordinating and managing the Government's NHPby contributing to financing staff to carry out the technical functions and the financial managementand procurement functions of the PCU and the RHAs. Technical functions include coordinating implementation by the MOHincluding the RHAs, other line ministries and CSOs, and M&E. Fiduciary functions include financial management and procurement. Programmanagementpriorities include the absorption of key donor-financed PCUpositions by the Government; inclusion of dedicatedprovisions for HIV/AIDS within the recurrent budget; maintenance of the "Three Ones" principle: one national coordination authority; one national HIV/AIDSplan, and one monitoring and evaluation plan; fostering greater harmonization and collaboration among stakeholders including the Global Fund's CCM 38 and the NAC; strengthening the capacity of the public and private sector and work with religious leaders to promote greater tolerance and acceptanceof HIV infected people. Fundingwill include staff costs, materials and equipment for programmanagement. 111. Subcomponent 3 (c): Monitoring andEvaluation (US$0.54 million). A comprehensive management and monitoring systemhas been developed and implemented by the M&EUnit of the NHPPCU inthe MOH. The objectives of the M&E system are to provide continuous feedback to monitor trends inthe epidemic and to strengthenthe delivery of HIV services. To achieve these objectives, the program will emphasize: (a) evidence-basedprogrammanagement that uses results at the population level and on high-risk groups; (b) an informationtechnology (IT)platformthat will: (i) integrate the multiple sources of information and implementing partners; and (ii)complete the procurement of equipment, maintaining the software, training staff and rolling out the Laboratory Information System to the regions; and (iii) integrate the multiple sources of information and implementing partners; and (c) special studies and researchgearedto identify barriers to adopt HIV/STIprotective behaviors, service delivery, and quality of care. There i s an appropriate number of staff trained inM&E at the M&EUnitand at the MOH central, regional, and parish levels. Job descriptions, roles, and responsibilities are clear. This i s not the case at non-health line ministries and inthe private sector (NGOs, CBOs and FBOs) that needpeople trained inM&E. Iti s recommended that the ITplatform inthe M O Hbe strengthenedwith programmers, most probably on a consultant or subcontract basis. A research officer will strengthenthe team for data analysis and design and implement special studies. A strategy will be neededfor other implementing entities including adding M&E staff, training and developing specific indicators tailored to monitor the results of their interventions. 112. The project will support the development of a M&E Operational Plana costed M&E framework and plan; integration of informationfrom multiple data sources and motivating parish and regional staff by involvingthem indata analysis and decision-making; strengthening surveys and surveillance on the population and on special groups including CSW, MSM, STI clinic attendees and prisoninmates. Support will be providedfor staffing, training, technical assistancefor integrating the databases; upgrading of the information technology (IT) platform; and developing a researchagenda that focuses on determining the reasonswhy the HIV protective behaviors are stagnating. 113. Component 4: Health Sector Development Support US$2.10 million). Subcomponent4 (a): BiomedicalWaste Management (US$ 2.00 million). (A detailed analysis of the biomedical waste management is available inAnnex 10.). The project will support upgrading and improvedmanagementof the biomedical waste managementsystem. This will include: (i)upgrading medical waste treatment facilities; waste disposal supplies and materials in all health regions for enabling proper segregationpractices; (ii) interimstorage facilities to support the regional collection and alternative treatment systems will be financed by the Government through the NationalHealthFund; (iii) capacity buildingactivities: develop and disseminate medical waste managementtraining material; train healthcare workers inmedical waste managementand post exposure prophylaxis, including regional `Training of Trainers' workshops; sharebest practices; and train staff for operation and maintenance of new equipment; and, (iv) preparing facility specific waste managementplans including the creation of a systemto 39 support health care facilities inthe documentation of infectious waste generation on a continuous basis. 114. Subcomponent 4 (b): Diagnostic Capacity Assessment of the Health Sector (US$O.lO million). Critical challenges to the capacity of the health sector to deliver quality health services include inadequate staffing levels in all professional categories, a financial burden on families paying out of pocket for private medical care, old and crowded physical facilities, pockets of violence incertain communities impeding access to health services and constraining the movement of health personnel, and bypassing the primary health care level. The April 2004 national report preparedby the PIOJnotedthat Jamaica i s unlikely to achieve the child mortality reduction, maternal health goals and the target for HIV/AIDS by 2015.18 This component will conduct an assessment of the obstacles that limit the capacity of the health sector to deliver quality health care efficiently. The investment and operational cost of the actions identified in the assessment will be calculated and options proposed for financing the cost from national and external sources. l8PlanningInstituteof Jamaica. MillenniumDevelopmentGoals, Jamaica. April 2004. 40 Annex 5: Project Costs Jamaica Second HIV/AIDS Project Summary of Project Cost Estimates (US$ Million) Foreign Local Total A. 1. PreventionActivities 1.a PreventionActivities by Ministry of Health/a 0.589 2.401 2.990 1.b PreventionActivities by the non-health Line Ministries 0.059 0.241 0.300 1.c PreventionActivities by Civil Society Organizations 0.010 0.040 0.050 Subtotal 1. PreventionActivities 0.658 2.682 3.340 E.2. Treatment, Care and Support 2. Treatment, Care and Support 0.734 1.076 1.810 Subtotal 2. Treatment, Care and Support 0.734 1.076 1.810 C. 3. Strengthening InstitutionalCapacityIb 3. a Policy Formulationand Legislative Reform./c 0.165 0.247 0.412 3. b Empowermentand Governance 1.323 1.985 3.308 3. c Monitoringand Evaluation 0.218 0.327 0.545 Subtotal 3. Strengthening Institutional Capacity 1.706 2.559 4.265 D. 4. Health Sector Strengthening and Development 4. a HealthWaste Management 0.800 1.200 2.000 4. b Health Sector DevelopmentSupport 0.040 0.060 0.100 0.840 1.260 2.100 4.091 7.450 11.541 Total PROJECTCOSTS 4.091 7.450 11.541 \a Preventionactivities by the Ministryof Health and Regional HealthAuthorities \b for Policyformulation, program management,and monitoring and evaluation \c for an Enabling Env. & Human Rights Components by Financiers WorldBank Government Total (US$ Million) (US$ Million) (US$ Million) Prevention 3.248 0.093 3.341 Treatment, Care and Support 1.736 0.074 1.810 StrengtheningInstitutional Capacity, Policy Formulation, Program Management,M&E 3.046 1.219 4.265 Health SectorDevelopment Support 1.945 0.155 2.100 Front-endFee 0.025 0.000 0.025 I Total 10.000 1.541 11.541 41 Annex 6: ImplementationArrangements JamaicaSecondHIV/AIDS Project 115. InstitutionalArrangements. The project will be organized at three levels and include the following institutions: (a) The Council for Health and Social Development (COHSOD) reporting to the Cabinet. will be responsible for setting policy, overall coordination, and monitoring and evaluating the performance of the national HIV/AIDS program; (b) The Project Coordination Unit (PCU) located within the NationalHIVETIProgram (NHP) of the Ministry of Health (MOH), will coordinate the activities of and provide fiduciary support to the implementing agencies; and (c) Implementing agencies will be divisions of the Ministry of Health, the four Regional Health Authorities, four non-health line ministries, civil society entities (including the National AIDS Council, an umbrella NGO, other NGOs, CBOs, churches and other FBOs), and the private sector (including employer associations, trade unions, and media). 116. ImplementationArrangements. The project will be coordinatedbythe PCUwithin the NationalHIV/STIProgram (NHP) of the MOH. The PCU consists of an experienced team of professionals that have coordinated the activities of the first HIV/AIDS project. The staff has beentrained inWorld Bank procedures and has performed satisfactorily under the first project. The Uniti s headedby Senior Medical Officer, a civil service position, who directs a core staff that includes: (a) acoordinator for policy and advocacy (financed by the Global Fund); (b) a director of M&Ewith a staff of biostatistician, databaseofficer, M&E officer and HIV informationofficer; (c) a coordinator of health systems and capacity development; (d) a director of prevention assistedby a youth intervention officer and a BCC officer who i s assistedby two BCC coordinators, one for NGOs and one for vulnerable populations; (e) a line ministry coordinator reporting to the director of prevention; (0a coordinator for treatment and care with technical assistant; (g) a national program administrator to manage the fiduciary functions carried out by: (i)a senior finance and administration officer assistedby a finance officer, two assistantfinance officers (one paidby USAID and one paidby the GFATM), two account assistants; and (ii) a senior procurement officer assistedby two assistant procurement officers. The fiduciary unit also managesthe grant funds from the GFATM. 117. Sustainability.Most PCU staff -as shown inthe table below - havebeenpaid with donor funds including the World Bank loan. The processto convert some of these positions into permanent establishment posts has been initiatedwith the intended outcome of creating an institutionalized and sustainable core group of professionals to coordinate and support the implementation of the national HIV/AIDS Program. Inaddition, the Government i s proposing to create a HIV Division within the MOHreporting to the CMO and staffed by the institutionalized professional staff. 42 NationalHIV/AIDS ProgramStaff - - Position -- - MOH IBRD ;FATk JSAID `OTAI gationalProgramStaff 2 16 12 3 33 ItherNationalLevelStaff 1 7 4 6 17 gationalAIDS Committee 4 2 6 3eldStaff: WRHA 13 9 22 44 SERHA 13 51 15 79 NERHA 7 20 3 30 SRHA 7 7 12 26 rota1FieldStaff NA ---- 40 87 52 179 TOTAL 3 67 105 61 236 118. Three types of implementing entities will implement the project: (i) the Ministryof Health through its centralized functions (National laboratory, blood bank, waste management) and through the four decentralized RHAs;(ii) four key non-health line ministries: Education; Tourism, Entertainment and Culture; Labour and Social Security; and National Security; (iii) CSOs, and (iv) the private sector. 119. The implementation strategy has been agreed on and i s detailed inthe Operations Manual. Implementation of project activities will be precededby the elaboration of annual work plans for the public sector entities and by proposals for the civil society entities. The Government Ministries will prepare annual work planswhich are aligned with the Government annual budgets. CSOs will be funded through a demand-driven processbasedon the systemthat has been put inplace under the ongoing Bank-financed project. A consolidated annual work plan will be preparedby the PCU and reflected inthe MOH annual budget for submission to the MOWS. The work planwill include the MOH's own work plan, plans of other Line Ministries, and abudget line for subprojectsof CSOs. 43 InstitutionalArrangementsfor Implementationof the Project Cabinet MOmationalHIV/STI Program ProjectCoordinationUnit Implement.ngAgencies - MINISTRY OF NON-HEALTH CIVIL SOCIETY PRIVATE SECTOR HEALTH MINISTRIES NGO Sector Central Level Education NAC, PAC and other Epidemiology Labour & Social Security NGOs, Churches, and Laboratories Tourism other FJ3Os and CBOs Blood Bank NationalSecurity RHAs Hospitals & Health Centers 120. Implementation Strategy for Line Ministries and Regional HealthAuthorities. A set of steps comprises the elaboration and implementation of activities at the national levelfor non- health line ministries and at the regional levelfor Regional Health authorities. The following steps summarize the strategy: The Project Operations Manual will present a general Project Implementation Plan. This plan i s indicative and planned activities should be adjusted every year. Between June and July, the PCUwill allocate funds for Line Ministries and RHA according to the NHSP updated policies and project approved cost tables. PCU will prepare guidelines to elaborate work plans. The PCU will organize workshops ineach region for RHAs and at the central levelfor line ministries. Guidelines will be distributed and usedto prepare work plans for each public sector implementing agent. It will have the mandate for approving funding work plans submitted by implementing agents. Focalpersons and working teams of each implementing agent will be responsible for preparing and submittingthe work plans to PCU. Work plans for line ministries need to be signed by the Permanent Secretary of the respective line ministries. Work plans for RHAsneedto be signedby the RegionalDirector. PCU applies criteria to appraise and adjust the work plans. Activities are organized inthe MISandproper financing arrangementsareconsolidatedinannualimplementationand procurement plans. PCU submits consolidated annual work planto financiers for No-Objection. After receiving the No-Objection, implementing agencies receive the first advance of financial resources and start implementing the work-plan. PCU staff and facilitators (contracted by the PCU) performperiodic monitoring visits to evaluate progress and overseethe correct application of finance and procurement policies according to donor rules. PCUreleases subsequentfunding advances according to progressreports and presentation of statement of expenditures (SOEs). Each implementing agent submits an implementation report before the end of the Jamaican fiscal year. This implementation strategy i s repeatedeachyear. 121. FundsPre-Allocation. Inorder to set uptransparentrules andequity amongall stakeholdersit i s suggestedto use a simple model for fund distributions: RHAs will receive funds basedon regional needs andregional implementationcapacity as expressedinthe annual work plans. Non-HealthLine Ministrieswill receive funds according to approved yearly work programs. 45 122. HIV/AIDSDemand-DrivenSubprojects. Small grants will be given to non-public sector implementing agencies on a demand-driven basis. This support will encourage community-based activities, particularly innovativeinitiatives -to be known as demand-driven "subprojects". a) EligibleBeneficiaries NGOs, CBOs, andprivate organizations incharge of carrying out subprojectswill target activities to eligible beneficiaries: Youth groups. 0 Commercial Sex Workers e IntimateEntertainment Workers 0 MSM 0 DrugUsers People living with HIV/AIDS e Prison Inmates Other vulnerable sub-population or groups b) Sub-Projects. A subproject is an organized instrument containing at least: i)Justification for an intervention; ii)Identifiedbeneficiaries; iii)Cost breakdown; iv) Counterpart (local contribution); v) Implementation plan; and vi) results based on performance indicators. Complex subprojects will contain additional requirements. c) ImplementingAgencies. To prepareandto manage a subproject requires certain levelof experience and skills. Inthat sense the demand-driven subprojects' strategy will ask for the support of NGOs, CBOs, and private organizations (Implementing Agencies) to carry out activities related with HIV/AIDs initiatives. d) PrincipalActors. Severalactors will be involvedwithin these operating and funding mechanisms. Involvedbodies or entities and their roles are: CommunityBeneficiaries(CB)- Ruralor urban community residentswho will benefit directly from subproject investments. They should be supported and representedby an Implementing Agency to receive benefits. ImplementingAgency (IA) - Eligible entities selectedaccordingto specific criteria. Information of each Implementing Agency will be part of the subproject proposal. SelectionCommittee(SC)- The Selection Committee for the demand-driven subprojects will consist of the Director of the NationalHIV/STIProgram or his nominee, 1 representative of the NAC, 1-2representativesfrom the PCU and 1-2 members of civil society (1PWLHA, 1PAC, 1NGO etc.). f) EligibleCriteriafor ImplementingAgencies EligibleImplementing Agencies may be classified by groups: 46 Private Sector Enterprises with at least twenty (20) employees and in existence for at least Enterprises 3 years, managing budget with annual turnover of more than US$50,000 with good financial management systems in place. Two or more years of Experience inHIV/AIDS or community development. National Nationalcoverage (more than one region) with experience inHIV/AIDS or NGOs social development program implementation experience (minimum2 years experience) and with annual budgets 2 US$20.000with good financial management systemsinplace. Other civil With a minimumof 1year experienceinHIV/AIDS programor society development implementation and budgets2 US$lO.OOO and basic financial organizations managementsystems inplace. (CBOs, NGOs, FBOs) Inaddition IA should demonstrate: Management Capability: Proven human and financial managementsystems and have manageda 1/3 of the funds requested. Community Participation: demonstratedconsultation and participatory process to mobilize and empower target communities 47 Annex 7: FinancialManagementandDisbursementArrangements Jamaica Second HIV/AIDS Project 123. The Financial Management Assessment of the implementing agencies capacity was conducted during the project preparation mission inJanuary, 2008. The first project was approved on March 29,2002 and it i s expectedto close on May 31,2008. The financial management aspects of the first project were well managed. The complete report of the Financial Management Assessment i s available inthe project files. 124. ImplementationArrangements. The project will be coordinatedby the PCUwithin the NationalHIV/STIProgram (NHP) of the Ministryof Health (MOH). The PCU consists of an experiencedteam of professionals that have coordinated all activities of the first World Bank financed HIV/AIDS project. The staff has been trained inWorld Bank procedures and has performed satisfactory under the first project. The team also has experience with implementing other donor-funded projects including the GFATM. The unit i s headedby Senior Medical Officer, a civil service position, who directs a core staff that includes the coordinators for the project components and subcomponents, an M&Eofficer, a financial manager and a procurement manager and their supporting technical and administrative staff. The fiduciary unit also manages the grant funds from the Global Fund. Project implementing entities include: The M O H through its four decentralized RHAs, supported by the centralized functions relating to the following services - NationalLaboratory, Blood Bank, BiomedicalWaste Management; Four key non- health line ministries: Education, Tourism, Entertainment and Culture, Labor and Social Security, and National Security; Civil Society entities including the NGO sector, CSOs, churches and other Faith BasedOrganization (FBOs); and the private sector including the Jamaica BusinessCouncil, private companies, and the media. 125. RiskAssessment andMitigation. As indicated inthe FinancialManagement Assessment the risk of the project i s rated moderate. This i s due to the fact that (a) Jamaica has strong financial managementand procurement capabilities; (b) the PCU and the MOHhave experience and a good track record inimplementing World Bank-supported projects. 126. Flow of Funds. The flow of funds mechanismunder the proposed Project will be similar to that under the first Project. Under the SecondHIV/AIDS Project, the GOJ will continue the usualpractice of issuingwarrants to cover full budgetary allocation for the project. The warrants will contain two parts: one for the GOJ counterpart funding and the other for the World Bank's portion. The arrangement for fundingthe warrant will be inkeeping with the GOJ procedure adoptedfor the fiscal period 2006/2007. Cashpaid out against the warrant issued will only be for the GOJ counterpart portion approved inthe budget for activities to be implemented by RHAs and CSOs. The eligible Bank loan portion will continue to be funded through the DesignatedAccount to be establishedfor receiving World Bank resources. All project funds will be channeledthrough the PCU. 127. Loan funds will be disbursedto one DesignatedAccount (US dollar account for Bank funds). As i s the current practice inJamaica, the DesignatedAccount will be openedby the MOFPS and maintained inacommercial bank with a fixed ceiling of about 10% of the loan. In accordance with the recommendations made inthe 2001 CFAA, and ineffort to streamline the 48 national account management, the Designated Account, for accounting purposesonly, will appear as a sub-account within the government's Consolidated Fund. A secondbank account (the project account) will be establishedinlocal currency to support the day-to-day operations and payments for expenditures eligible under the loan as was the case under the first loan. Advances covering projected three-month cash flows will be transferred from the USD Designated Account to the localcurrency project account to meet small eligible day-to-day local expenditures. A separateBank account would be maintained to handle government counterpart funds. The PCUwill reconcile (monthly) all the project accounts. The reconciliation for the Designated Account and the project account will be submitted to the Bank with each withdrawal application. 128. Additionally, the RHAsand Line Ministries (LMs) may open project accounts, under the project, for receiving financial support for eligible activities intheir annual work plans. Under the guidance of the PCU, the LMs and RHAs will carry out project activities and process payment orders for eligible expenditures from the project account approved for funding the HIV/STIwork plans. Periodic advances will be madeto RHAsandLMto cover no more than 90 days of expected expenditures. Details of the controls and procedurespertaining to the managementof the project accounts are contained inthe Operations Manual. 129. The PCU will also disburse funds to Community Based Organizations (CBOs) and NGOs to implement the demand-driven subcomponent of the project. They will be assessed and placed into classes a, b, or c basedon administrative capabilities. The administrative arrangementwill be guided by the principles outlined inthe HADDSHandbook. The accounting and reporting for all project funds will be on amonthly basis in accordance with the MOH'sLegalFramework and Policy Framework documents. Where necessary, the PCU will ensurethat monthly account reconciliations and financial reports are received and approved before continuing to disburse to the CBOsLNGOs. 49 Jamaica Second HIWAIDS Preventionand Control Project - Budgeting I Flow of Funds I I I I Budget Project Planning Unit of MOH t Approve M O F Warrants Issued (Cash 8, Non-Cash) 1- Fund Release Procedure A -1 Accountant General I - ConsolidatedFund I I I Bank JA$ GOJ US$ World Accounts Counterpart JA$ Project Designated + Bank #- 1 FiindAccoiint Account Account - Local& Foreign ~ Local Suppliers, Expenditure RHA cso Line Small Foreign Suppliers, Advance to Direct Suppliers JA$ Project N C Payment Documentation Document Eligible Expenditure Reports GOJ Reports IUFR's/FMR ~ 50 130. Accounting Policies and Procedures. Administrative procedures will be inplace to ensurethat financial transactions are madewith consideration to safeguarding project assets and ensuring proper entry inthe accounting/monitoring systems. Before payments for acquisition of goods and services can be processed, a purchase order or contract must exist. The project accounting system will have the capacity to record financial transactions of the project, and produce financial statements useful to project managementand meeting the Banks and GOJ fiduciary requirements. The accounting systemi s designed to be able to capture all financial information and allocate among the project components. Furthermore, the accounting system will support the project managementsystem, which oversees all work flows and procurement processes. Changesinone systemshould be reflected with revisedhpdated monthly/quarterly/annualactual funding needs and future budget estimates. 131. The project will also submit detailed monthly statements of expenditures to the Office of Finance and Accounts and to the MOW'SEconomic Management Division inorder that the project's expenditures are recorded on the Ministry's accounts as well as supervisedby the unit responsible for managementof external financing. 132. Segregation of Duties. The PCU has a clear organizational structure and procedures established according to the norms under the Financial Administration and Audit Act (FAA). Said procedures support an adequate segregationof procurement, budgeting, payment and recording activities. All payment orders/requests at the PCULevel are prepared and signedby component heads then passedto procurement and finance officers for comments and approval. They are then reviewed and signedby the SMO or designate. 133. Budgeting. The loan agreement and project cost tables will be the main inputsfor the project budgets and counterpart (GOJ) funding estimates under the Capital Budget. The M O H will follow prescribed governmental budgetary heads, and in adherenceto the FAA Act, the PCU/MOH will prepare at least: The annualwork plan classified by activities, with goals/objectives, physical and financial programs, and cost; The summarized and detailed budget by major components and specific objects, specifying the source of funds; after approval by Parliament: the budget execution programbroken down monthly, and the quarterly document of budgetary commitment authorizationkash flow; the monthly report on budgetary execution to be issued within 8 working days after the end of each month; and the quarterly report on evaluation of budgetary execution to be issued within 15 working days after the end of the quarter. Bank account reconciliations will be prepared on a monthly basisby the assigned officer and will be available within 8 days after the end of the month. 51 134. Safeguardover Assets. Assets acquired by the project will be inthe custody of the respective institutional departments benefiting from such purchase. The PCUwill keep detailed subsidiary records and an asset register of goods and equipment acquired under the project. The amounts inthe register will be reconciled periodically against the respective accounting balances. At least one annual physical inspection will be undertaken by MOH staff, preferably with the participation of staff from the external auditors and the Auditor General's Department (AGD). 135. Administrative Monitoring of Financial Resources.As a coordinating entity it is mandatory that the PCU conduct regular monitoring exercises for all internal and external implementers. The monitoring should include physical site visits (no less than 3 per entity/annum) to review procurement processes, financial records, assess implementation: budget vs. actual and physical inspectionof assets purchased. Following each monitoring visit a report i s to be written no later than 10days after. 136. InternalAudit. The PCU will be subject to review by the MOH's Internal Audit Department and the country's Auditor General's Department (AGD).Although no internal auditor will be assigned specifically to the project, the external auditors will perform visits on a bi-annual basis (see next section), and the AGD, under its sampling/material criteria, will audit the project at least once before completion as i s required for governmental audits 137. External Audit. Annual project financial statements will be audited in accordance with International Standards on Auditing, by an independent firm and in accordance with terms of reference (TORS)both acceptable to the Bank and the GOJ. Inaddition to the audit opinions on the project financial statements, designated account and interim un-audited financial reports (IUFRs), the audit opinion will be required to deal specifically with: (i) observance of the procurement and consultants services provisions of the Loan Agreement; and (ii) special purpose audit carried out on a half-yearly basis to review the demand-driven subcomponent and activities carried out at the Parishlevel by CBOs and NGOs. The memorandumon internal controls ("Management Letter") will be issued after each semi-annual audit. 138. The PCUi s expected to appoint the auditors (for both the annual and special audits) in time to undertake the audits and prepare the reports in a timely manner, with an annual contract to be renewedduring the first quarter of each subsequent year, subject to satisfactory performance. The cost of the audits will be financed from the project. 139. The PCUwill prepare, if needed, an action plan to address any issues and recommendations contained inthe audit reports. The action plan and follow-up activities will be communicatedto the Bank. 140. The table below summarizes audit requirements: Audit Report IDue Date 1 Projectfinancial statements 4 months after the endof the reporting period (coincides (Coincide with GOJrequirements) IUFRs Same as above 52 DesignatedandProject Accounts Same as above Special purpose Twice a year with the secondletter 4 months within the end of the reportingperiod. Reportingand Monitoring. The Progress Reports to be prepared under the Project will summarize the progress of execution of activities inthe annual work plan by component. It will provide a summary of related program activities financed by other sources of funding including the Government and other principle partners. It will providethe updated activity levelprocess indicators and the latest overall project monitoringindicators. 141. Financial statements and InterimUn-audited Financial Reports (IUFRs) will be prepared quarterly, satisfying the Government and the Bank's monitoring and fiduciary purposes. The content and formats of the IUFRs have been agreed. The progress reports includingthe project financial statements, along with procurement sections, will be submitted no later than forty-five (45) days after the end of each quarter. 142. On at least, a monthlybasis, the PCUwill preparethe project's Sources andUses of FundsStatement, amatrix classifying receipts by financing source and expenditures by financing source and disbursement category. The expenditures will be compared to the projected figures per the quarterly budgets prepared as indicated inthe Budgeting section above. This report is submitted to the MOH's Finance and Accounts Division, and the MOFP's Financial Management Division DisbursementArrangements. The disbursementsunder the SecondHIV/AIDS Prevention and Control Project will migrate from a transactions based-disbursementmechanismto a reports based-disbursement mechanism for disbursementsvia the Designated Account. Inaddition, disbursementswill be made on the basis of project components. When submittingIUFRs as supporting documentation for reporting on the use of advances, the IUFRs must include a "Use of Cash Statement" that will be utilizedto document expenditures that were incurredduring the reporting period and a "Cash Forecast Statement" for the next two reporting periods that will provide the basis for the amount to be advanced. Inaddition the I U F R s will need to be supplementedby bank statements for the DesignatedAccounts, Designated Account Activity Reconciliation Statement, Project Account and RHALMReconciliations. The balances inthe I U F R s pertaining to disbursementcategories will be required to be reconciled with those in Client Connection. The documentation to the Bank of payments made on the basis of retroactive financing would be made on the basis of reports. Supporting documentation for all payments under the loan would be made available for review by visiting Bank supervision missions and to the auditors. Direct payments would be fully documented. 143. FinancialManagementAction Plan. The PCUhas satisfactorily met all the actions that were required to be completed prior to the commencementof project implementation, except 53 for the opening of the designatedaccount. Agreement has been reachedthat the designated account would be opened within 30 days after loan signing.. 144. FinancialCovenants. Bank's standardfinancial covenants apply for this project. They include the requirement to submit annual audit reports of the project's account and financial statements not later than four months after the end of each fiscal year and the requirement to maintain adequate financial managementsystems so that the project is capable of accurately recording project transactions and of preparing reliable financial reports. 145. Supervision Plan. The supervision of the PCU, the RHAs and other implementing agencies will focus on: (ijmix of number and qualifications of the staff working on the project, (iijquality andtimeliness ofreportsproduced, (iiijtheprocessing speedof administrative and financial matters, particularly payments processing. Bank's supervision mission will be every six months and will also include civil society organizations and governmental agencies to evaluatehow these entities manage and account for project resources. 146. The timeliness of the audit also is to be monitored closely. The audits will be reviewed to ensurethat it covers all relevant aspects and provideenough confidence on the appropriate use of funds by recipients. Allocation of the Loan Proceeds Component Amount of the Loan Financing I Allocated inUS Dollars Percent Prevention Activities I 3.248 97% Treatment, Care and Support 1.736 95% InstitutionalStrengthening, Program 3.046 72% Management, and Monitoring andEvaluation Health Sector Development and Support 1.945 93% Front-end Fee 0.025 Total 10.000 54 Annex 8: ProcurementArrangements Jamaica SecondHIV/AIDS Project A. General 147. Procurement for the proposed project will be carried out in accordance with the World Bank's `Guidelines: Procurement Under IBRDLoans and IDA Credits' dated May 2004 revised October 1,2006; and `Guidelines: Selection and Employment of Consultants by World Bank Borrowers' dated May 2004 revised October 1,2006, and the provisions stipulated inthe Legal Agreement. The various items under different expenditure categories are described ingeneral below. For each contract to be financed by the Loan the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and timeframe are agreedbetween the Borrower and the Bank inthe Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements ininstitutionalcapacity. 148. Procurementof Works:Works procured under this project will include: upgrading of incinerator facilities and waste managementand small rehabilitations. The procurement will be done using the Bank's StandardBiddingDocuments (SBD) for all ICB and National SBD agreed with or satisfactory to the Bank. Shopping. 149. Procurementof Goods:Goods procured under this project will include: drugs, condoms, waste management equipment, shredders, autoclaves, waste disposal supplies and materials, requisite equipment to facilitate the national Public health laboratory, testing kits, hardware, communication equipment, office furniture and equipment. The procurement will be done usingthe Bank's SBD for all ICB and National SBD agreedwith or satisfactory to the Bank. 150. Selectionof Consultants: The project will participate infinancing the technical functions and the financial management and procurement functions of the PCU. Technical functions of the PCUthat will be supported include providingtechnical support for the health sector, line ministries and civil society implementing agencies. Consultants will be hiredto provide specific technical services and/or conduct studies and researchunder each of the project components. Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. 151. Training: The Project will support training for institutionalcapacity building for health care workers, CSOs and Government entities as well as for direct project interventions within eachof the project components for target population groups (youth, MSMCSW and PLWHA) and the general population. A variety of methods will be utilizedincluding workshops, training of trainers, peer education, community fairs and expositions, in-school formal and informal education programs, workplace education programs and study (local and international) trips to share best practices. Healthcare workers will be trained inIEC/BCC interventions, the managementof HIV/STI/TBand PMTCT including counseling and testing, post exposure 55 prophylaxis, medical waste management; operation and maintenance of new equipment. CHART, UWIand other technical agencies will be involved incurriculumdevelopment and development of training materials. Project management, monitoring and evaluation and fiduciary skills will be providedfor staff of the MOH, involvednon-health line ministries, and csos. 152. OperatingCosts: will includeproject management and administration costs including office space, utilities, supplies, per diems and transport costs associated with execution of the project. These items will be procured using proceduresdefined inthe operational manual reviewed and found acceptableto the Bank. 153. The procurement procedures and SBDs to be usedfor each procurement method, as well as modelcontracts for works and goods procured, are presentedinthe Project Operations Manual. B. Assessment of the Agency's Capacity to ImplementProcurement 154. The project will be coordinated by the PCUinthe NationalHIV/STIProgram (NHP) of the MOH. The PCUconsistsof an experienced team of professionals that coordinated implementation of the first World Bank financed HIV/AIDS project. The staff has beentrained inWorld Bankproceduresandhasperformed satisfactory under the first project. The team also has experience with implementing other donor-funded projects including the GFATMgrant. The unit is headedby a Senior MedicalOfficer who directs a core staff that includes the coordinators for the project components and subcomponents, an M&Eofficer, a financial manager and a procurement manager and their supporting technical and administrative staff. The fiduciary unit also managesthe grant funds from the GFATM. 155. An assessment of the capacity of the Implementing Agencies to carry out procurement for the project was carried out by the Bank inJanuary, 2008. The assessment reviewed the organizational structure for implementing the project and the interaction between the project's staff responsible for procurement and the national procurement authorities. The mission focused on the capacity of the NHP incontracts managementusing bothWorld Bank and Government procedures within the MOH. The main findings and recommendations of the assessment are summarized inthe following paragraphs. 156. ProcurementResponsibility: The PCU will be responsible for all procurement activities, including procurement planning, procurement processes, contract award and contract information system. The PCU will performprocurement processesfor the four line ministries participating inthe project. The procurement team is comprised of a Procurement Officer with strong qualifications and experience inWorld Bankproceduresand two procurement assistants who have more than three years experience inhandling World Bank and other donor's procurement and an excellent filing system. The procurement team i s familiar with the Bank bidding documents for Works, Goods and Services and has been able to handle a large number of contracts in a manner acceptableto the Bank under the current HIV/ AIDS project. Keeping these skills i s of great benefit to the Ministry of Health. 56 157. The needto strengthenthe procurement capacity was identified duringthe capacity assessment of the regional procurement managementunit of the South East Regional Health Authority. The unit i s composed of a procurement managerwho supervises a procurement officer and a one-year consultant working through a very weak organizational system. The unit does not have an adequateprocurement planning capability. The general experience of staff in thisregional unit is lessthan two years and Nationalprocurementprocedures are utilizedfor all contracts awarded for all donors financed activities. The team does not have the required skills inWorld Bank procurement guidelines andprocedures. Basedon the findingsof the assessment itwas recommendedthat the process aprocurement specialist with the necessaryqualifications and experiencebe recruited as soon as the project becomes effective. Inthe meantime, the PCU will provide support to the region untilthe necessary capacity i s inplace. Other measuresto strengthenthe procurement capacity within the four regions will be taken, including training. 158. ProcurementEnvironment:Thejoint Country FinancialandProcurement Assessment (CFANCPAR) carried out by the World Bank and Inter American Development Bank in 2005 and approved in2006 identified anumber of weaknessesinthe Jamaicanprocurement system. It identifieda significant number of improvements neededto render the systemmore transparent. 159. Issuesidentifiedinthe (CFANCPAR) report pertaining to procurement statistics, supplier's registration, procurement performance and monitoring and capacity are still valid and relevant. The discrepanciesbetween the national procurement system thresholds and the World Bank thresholds for projects inJamaica also negatively impact the procurement processes and schedules. 160. NationalProcurementSystemand Thresholds: The MOFPShas overall responsibility for the public sector procurement systemincluding direct responsibilities for informing sector procurement policy, monitoring the implementation of those policies particularly with regard to public expenditures, and facilitating a proper understanding of the governing documentation service-wide. The Contractor General, inaccordance with the contractor general act, monitors and investigates the award of contracts. a) According to Government of Jamaica (GOJ) procurement guidelines procurement functional responsibilities are sharedby the following entities: b) NationalContractsCommission(NCC):promote efficiencyinthe processof award of government contracts and review procuring entities contract award recommendations for procurement of Goods, Services and Works with estimated values equal or above J$4 million. c) NationalContractsCommissionSector Commission(NCCSC): reviews procuring entities contract's award recommendation. d) ProcurementCommittees:Eachentity is requiredto establish aprocurement committee consisting of not less than four (4) persons appropriate to the needs of the entity. The PC comprises the following: - Chairman, Senior Financial management Personnel, Secretary, and Procurement Officer (non voting member). e) MOFPSi s the focal point for information and clarification of public sector procurement. f) The AccountingOfficerenforcesthe procedures. 57 161. Having various levels of clearancefor procurement i s desirable but it also results in delays during contracts processing and projects implementation. Basedon randomly selected cases, it appearsthat the endorsement of contracts award by the National Contracts Commission (NCC) following bidsevaluation by national entities or agency, takes between two weeks to five months. Delays inclearanceof contract awards negatively impact the project implementation schedule and achievement of its objectives. 162. The expenditures authorizations required before aprocurement entity may enter into a contract are currently as follows: I Threshold Authorities Less than J$4,000,000 Agency or Ministry shall approve subject to procedures included herein. FromJ$4,000,000 but less than Minister shall approve on the 5$15,000,000 recommendation of the NCC. 5$15,000,000 and above Cabinet, on the recommendation of the NCC and minister. 163. Specific thresholds are defined for the useof eachparticular method for procurement of Goods, Services and Works. Most of these thresholds are also bottlenecks to the fluidity of procurement management systemas they sometimesconflict with thresholds set by World Bank for projects that it finances inJamaica. 164. ActionPlan:Basedon the abovereview, the following measureshavebeenagreedto improve procurement processes. e Hiringa Procurement Specialist with acceptablequalifications and experienceto assist the South East Regional Health authority. In the meantime the PCU will provide support to the region. e Training inprocurement provided by the Bank to the PCU includingregional staff following loan approval. Further training to be provided duringthe first year of implementation as a capacity buildingactivity. e Update of the procurement procedures inthe operations manual, detailing roles and responsibilities and flow of documentation. 165. Inaddition to the above action plan, the procurement thresholds and methodshavebeen set to mitigate the procurement risk. The overall project risk for procurement i s moderate. C. ProcurementPlan 166. The Borrower has submitted the procurement plan for the first 18 months of project implementation. Itprovides the basis for the procurement methods. The plan i s acceptable to the Bank. It will be available inthe project's databaseand inthe Bank's external website. The 58 Procurement Plan will be updated in agreement annually or as required to reflect the actual project implementation needs and improvements ininstitutionalcapacity. D. Frequencyof ProcurementSupervision 167. Inaddition to the prior review supervision to becarried out from Bank offices, the capacity assessment of the ImplementingAgency has recommended at least a supervision mission each six months to visit the field. Post review of procurement actions will be carried out once a year. E. Detailsofthe ProcurementArrangements InvolvingInternational Competition 168. The following arethe detailed arrangementsfor international competition. 1. GoodsandNonConsultingServices 1 2 3 4 5 6 7 8 9 Ref. Contract Estimated Procurement P-Q Domestic Review Expected Comments No. (Description) Cost Method Preference by Bank Bid- (US$) (yedno) (Prior / Post) Opening Date G1 Autoclave 1,800,000 ICB NA Prior March 2009 G2 Reagentsfor 60,000 DC NA Prior April 2008 Syphilis G3 Reagentsfor 20,000 DC NA Prior Dec 2008 TB Lab G4 HIVTesting 200,000 DC NA Prior April 2008 K i t s G5 ReprintIEC 60,000 DC NA Prior Jul2008 material G6 Laboratory 132,000 DC NA Prior May 2008 Information System Phase 11 2. ConsultingServices (a) List of consulting assignments with short-list of international firms. Ref. No. Description of Estimated Selection Review Expected Comments Assignment cost Method by Bank Proposals 59 (US$) (Prior I Submission Post) Date (b) Consultancy services estimated to cost aboveUS$lOO,OOO per contract and single source selection of consultants (firms) will be subject to prior review by the Bank. (c) Short lists composed entirely of national consultants: Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. F.Thresholds for Procurement MethodsandPrior Review Recommendedthresholds for use of the procurement methods to be specified inthe legal agreement and for Bank prior review of procurement actions are identifiedin the table below. Specific contracts which are subject to prior review will be detailed inthe Procurement Plan agreed at negotiations. I I I >1.500 ICB All I I 150-1,500 I NCB I None I <150 Shopping None 2. Goods >150 ICB/ LIB All I I 50-150 I NCB I Non I loo QCBS,QBS,FBS,LCS All