Report No. PID10562
Project Name                     Barbados-HIV/AIDS Prevention and Control (@) ...
Project
Region                           Latin America and the Caribbean (LCR)
Sector                           Other Population; Health & Nutrition
Project ID                       BBPE75220
Borrower                         Government of Barbados
Environment Category             B
Date PID prepared                January 3, 2001
Expected Board                   June 28, 2001
1. Country and Sector Background:
In most respects, Barbadians enjoy a good state of health, and are being well
served by the national health delivery system. Life expectancy for males is
about 73 years of age, and females about 77 years. Literacy is among the
highest in the Caribbean (95%), availability of safe piped water is
universally available (94% served at home, and the remainder through public
stand pipes). The five leading causes of death have been cardiovascular
disease (about 19%-), malignant neoplasms (17%-), cerebrovascular disease
(14%-); diabetes (10%-); and other diseases of the circulatory system (4%).
Births to adolescent mothers, and STIs have generally been declining. Health
services have been provided by public facilities, centered at the Queen
Elizabeth Hospital (QEH) (with 547 beds, providing 24 hour acute care
services, and wide range of specialized preventive and curative services),
and eight associated polyclinics. An additional 100 private physicians
practice on the island. Laboratories in two public and four private
facilities provide capacity for conducting about five tests per person per
year, and have been sufficient to date for general health support. The
Barbados blood bank has routinely screened blood supplies for HIV, Hepatitis
B and C, Syphilis and HLTV1. The system is supported by the Barbados Drug
Service (BDS) which has been designated a WHO Collaborating Center, and
controls the importation and distribution of essential drugs.
However, since 1995, the Ministry of Health through the AIDS Management Team
(within the Department of Medicine at the QEH) and committed volunteers, have
attempted to address the needs of HIV/AIDS infected and affected individuals,
working with non-earmarked and inadequate resources. Notwithstanding the
numerous efforts made to combat this disease, its spread has continued. In
2000, there were approximately 70%- more HIV infected persons than predicted
in 1990, and the number of new infections is growing relative to that in the
Organization of Eastern Caribbean States (OECS) countries. To date, the
overall national response has been confined to the health sector with limited
support from international and national resources. The current approach with
a predominant health focus to respond to the epidemic, can no longer serve to
promote a broad based expanded response to the epidemic. A proactive
response with a multisectoral approach, has to be launched if there is to be
a reversal in the current trend of this epidemic.
In response to the above problems, the Government of Barbados has issued a
strategic plan for the restructuring of its national HIV/AIDS program.



Barbados' Cabinet approved a Comprehensive Program for the Management,
Prevention and Control of HIV/AIDS, 2001-2006 (the Program), in November 2000
to be managed under a new National Commission for HIV/AIDS (NACHA), supported
by an executive office with a full-time paid staff. The challenge for the
government is to do the following:
?       become proactive in managing the epidemic rather than being reactive to
it;
broaden the effective scope of the activities undertaken to be truly
multisectoral;
address treatment and care as well as prevention as a continuum;
generate more collaboration and partnership among national institutions;
involve the private sector more fully in the management of the epidemic;
establish accountability for results; and
progressively mainstream and then sustain management efforts both
institutionally and financially.
Barbados' strategic plan for HIV/AIDS draws on elements of the Caribbean Regional
Strategic Plan of Action formulated by the CARICOM-led Regional Task Force on
HIV/AIDS, and approved by CARICOM Heads of Government in July 2000.
2. Project Objectives:
The project will concentrate on the following:
Introducing and scaling up cost-effective preventive programs and
treatment efforts, that have been successful in other countries and in
Barbados--in particular, strengthening and expanding the prevention and
control of STIs;
establishing a staged implementation approach to ensure adequate lessons
from experience leading to better informed public and private
stakeholders and decisions on scaling up prevention and treatment
services;
building sustainable and proactive institutions to implement Government of
Barbados's current and future HIV/AIDS management programs; and
ensuring Government leadership at the highest level and multi-sectoral
participation through various line Ministries.
The project would be open to efforts to scale up or introduce initiatives or
actions that hold promise for managing the epidemic (guided by past
experience in other countries), rather than focusing on a pre-selected narrow
set of options. It would be prepared to evaluate the usefulness of such
activities during implementation and either continue or abandon activities on
this basis. Combined private/public sector implementation would be sought,
since NGOs play a central role in effectively reaching high risk groups.
Given the newness of some preventative programs in Barbados and the
complexity of scaling up ART, a phased approach to project implementation has
been chosen.
3. Project Description:
A. Prevention and control of HIV/AIDS Transmission - US$ 5.7 million
Eight Ministries and the Office of Government Information Services would
establish HIV/AIDS Coordination Units each, responsible for designing and
managing implementation of specific interventions according to target
populations. During the first year of project implementation, each Ministry
would start implementing at least two core national program interventions:
Information, education and communication (IEC), specifically addressed to
behavioral change and condom distribution among different target groups. The
following prevention programs would be developed through the different
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Ministries under the coordination, monitoring and evaluation of the National
Commission on HIV/AIDS (NACHA): a) Information Education and Communication,
b) Condom Distribution, c) Prevention and Control of STIs, d) Prevention of
HIV/AIDS Mother to Child transmission, e) Control of Laboratories and Blood
Supply.
B. Diagnosis, Treatment and Care for HIV/AIDS; US$ 14.3 million
The project would scale up the diagnosis, treatment and care for HIV/AIDS
patients in the island, as part of the government's commitment to meet
patient's clinical and emotional needs, reduce opportunistic infections,
reduce work disability, and improve quality of life. Under this component,
the project would support scaling up the following interventions: a)
Voluntary testing and counseling; b) Laboratory strengthening; c) Pharmacy
strengthening; d) Community and home care; and e) Facilities for treatment of
Opportunistic Infections - OI and HAART therapy for patients with AIDS.
C. Management and Institutional Strengthening US$3.5 million
The third component of the project would support sustainable institutional
structure and management that will allow Barbados to effectively control,
prevent, and care for HIV/AIDS over the long term. This would be
accomplished by providing the necessary leadership, advisory services,
staffing, goods, and general operating costs of the institutions discussed
below.
4. Project Financing: The total cost of the proposed program is estimated at
US$23.65 million.
5. Project Implementation:
The project would be implemented under the authority of the Office of the
Prime Minister (who is also the Finance Minister). At the political level, an
Inter-ministerial Committee would set the political strategy guiding the
implementation of the National Program. The Prime Minister and the Inter-
ministerial Committee are finalizing executive appointments of experienced
staff to assure sound implementation of the program.
The National Commission on HIV/AIDS (NACHA) will be responsible for
determining the strategic content and direction for implementing the project
in Barbados. This body has been created by the Barbados Cabinet as a
"statutory board" to oversee the performance of the project and be
accountable for its success to the public. The NACHA would advise government
on HIV/AIDS policy, advocate and promote the active involvement of all
sectors and organizations in implementing HIV/AIDS management actions, create
partnerships to broaden the national response to HIV/AIDS, mobilize
resources, internationally and locally to support the efforts, and to monitor
and be ultimately accountable to the public for the successful implementation
of the project.
6. Project Sustainability:
The project itself is likely to be sustained throughout its implementation
period owing to the high level of ownership and commitment being shown by the
government. The project would involve a broad number of stakeholders in its
actual implementation, which will also raise the level of general ownership
of the program and its subsequent sustainability.
The project would also satisfy other conditions that will build longer term
loyalty and commitment including:
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Having immediate impacts on PLWHAs quality of life;
strengthen NGO capacity to deliver services;
resolving regulatory and legal issues that have been controversial;
encouraging broad participation, involvement, and therefore ownership; and
addressing prevention as well as treatment.
While less problematic in the short term, achieving financial sustainability
of an ambitious program in the longer term will require further study and
policy decisions. Government expects to arrive at a long term financial
sustainability plan at project mid-term evaluation.
7. Lessons from Past Operations:
The project adapts design features that underpin the Multi-Country HIV/AIDS
Prevention and Control Program, and have been successful in other countries.
These include the following:
Demonstrating a high level of government commitment and providing clear
national leadership for a program;
building collaboration networks with NGOs, community groups and CSOs, as a
complement to public sector agencies;
deconcentrating the initiatives for efforts to address the epidemic;
including the focus on treatment and care as a continuum in the program;
providing focus on behavior change as a key element of prevention and
control; and
adopting implementation measures that provide flexibility and
responsiveness to the epidemic as it evolves.
The proposed project also adapts lessons from the Government experience with
the NACHA in that direct line authority for the project's implementation is
attached to the Prime Minister's Office to give institutional structure to
the effort. Second, the project is being driven by pre-identified
monitorable goals with financial resources allocated through Ministries to
achieve them. Third, management of the HIV/AIDS activities is being assigned
to dedicated persons both within Ministries and within the new Office, which
brings managerial accountability.
Other lessons of previous Barbadian experience are less easily built in to
the project's design; notably the difficulty of motivating behavioral change
in individuals even when they may be well informed about the epidemic. The
proposed project is designed to at least accommodate this risk by allowing
for annual evaluation of results and the presumption that the activities to
be financed (especially in the area of prevention) will change over time as a
result.
This project also includes a major lesson from the other regional APL on
Disaster Management in the Eastern Caribbean. Multi-country projects need a
strong regional component to coordinate strategy and actions.     This project
will include such a regional coordinating mechanism.
8. Government Commitment:
The Government of Barbados organized its first nationwide effort to address
the issues of HIV/AIDS in 1985. It established HIV/AIDS in public thinking
and as a part of public dialogue. Government has now placed the advocacy and
responsibility for achieving an effective response to the epidemic directly
in the Office of the Prime Minister. It adopted a comprehensive program for
the management, prevention and control of HIV/AIDS in September 2000. This
program corresponds to recognized "best practices" as agreed by agencies
such as UNAIDS, PAHO/CAREC, and CARICOM. Implementation of the program will
involve a broad cross-section of Barbadian leadership from the public sector,
NGOs, communities and civil society. For 2001, GOB has, in addition
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allocated new budgetary resources specifically for the program, and has re-
qualified for "borrower status" from the World Bank (having previously been
graduated). These are strong indications of commitment to effectively
reversing the epidemic's trend.
Barbados has also been a key leader in mobilizing efforts to prevent and
control the spread of the epidemic throughout the Caribbean. As Chairman of
CARICOM, the Barbadian Prime Minister gave strong impetus to reaching
agreement on a Caribbean Regional Strategic Plan of Action for HIV/AIDS by
Caribbean Heads of Government during July 2000. Barbados hosted a Caribbean
Conference on HIV/AIDS in September 2000 that further built support for
HIV/AIDS programs by governments as well as multilateral and bilateral
donors. Most recently, (January 2001) Barbados has given additional
encouragement to the OECS countries to invigorate their own national
responses to the HIV/AIDS threat.
Finally, Barbados has agreed to devote additional resources to become one of
the two "flagship" countries to launch the Caribbean Multi-Country HIV/AIDS
Program, and serve as a model for subsequent country projects.
9. Environmental Aspects:
Category B. See Annex on environmental aspects.
10. Program Objective Category: The category for this project is Poverty
Reduction and Human Resource.
11. Contact Point:
Task Manager:
Patricio Marquez
The World Bank
1818 H Street, N.W.
Washington, D.C. 20433
Telephone No.:   (202) 473-0163
For information on other project related documents contact:
The InfoShop
The World Bank
1818 H Street, N.W.
Washington, D.C. 20433
Telephone No.:   (202) 458-5454
Fax No.:   (202) 522-1500
Note: This is information on an evolving project. Certain components may not
necessarily be included in the final project.
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