Document of The WorldBank FOR OFFICIALUSEONLY ReportNo: 29129 PROJECTAPPRAISAL DOCUMENT ONA PROPOSEDLOANINTHE AMOUNT OFUS$3.2 MILLION AND PROPOSEDCREDIT INTHE AMOUNT OFSDR1.15 MILLION(US$1.60 MILLION EQUIVALENT) AND PROPOSEDGRANT INTHE AMOUNT OF SDR1.15 MILLION(US$1.60 MILLION EQUIVALENT) TO SAINT LUCIA FORTHE HIV/AIDS PREVENTIONAND CONTROLPROJECT INSUPPORTOFTHETHIRDPHASEOFTHE CARIBBEANMULTI-COUNTRY HIV/AIDS PREVENTIONAND CONTROLPROGRAM June 1,2004 CaribbeanCountry ManagementUnit HumanDevelopmentSector ManagementUnit Latin Americaandthe CaribbeanRegionalOffice This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective: April 30,2004) Currency Unit = Eastern Caribbean Dollars Eastern Caribbean Dollars 2.68 = US$1 SDRl = US$0.689 FISCAL YEAR April 1 - March31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care APL II1Adaptable ProgramLending ART I ARV II Antiretroviral Antiretroviral Treatment I EE Eligible Entity ELISA Enzyme Linked Immune Sorbent Assay EMR Electronic Medical Records ERP Emergency Recovery Project EU European Union FBO Faith BasedOrganization FINMAN Financial Management FMR Financial Monitoring Report I GDP Gross Domestic Product GOSL 1 Government of Saint Lucia FOR O F F I W USEONLY MSM Men having sex with men MTP Medium Term Plan NACCHA NationalCoordinatingCommittee on HIV/ALDS NACC National HIV/AIDSCoordinatingCouncil PLWHA P e o m i n F W i t h HIV/AIDS PMTCT Preventionof Mother-to-Child Transmission 1 PPS PP 1ProcurementPlan PharmaceuticalsProcurementService lThisdocument hasa restricteddistributionandmay be used by recipients only in the performanceof their official duties. I t s contents may not be otherwise disclosed without World Bank authorization. 1 " , STD Sexually TransmittedDisease STI Sexually TransmittedInfection TB Tuberculosis TOR Terms of Reference TRIPS Trade-RelatedIntellectualProperty Rights UNAIDS UnitedNation's Programon HIV/AIDS UNICEF UnitedNationsChildren's Fund UPS UninterruptedPower Supply USAID UnitedStates Agency for IntemationalDevelopment USD US Dollars UWI Universityof West Indies VCT Voluntary CounselingandTesting VOIP Voice over InternetProtocol VPN Virtual PrivateNetwork WAN Wide Area Network WB World Bank WHO World HealthOrganization WTO WorldTrade Organization Vice President: Davidde Ferranti Country Managermirector: Caroline D. Anstey Sector Director: Ana-Maria Arriagada Sector Manager: EvangelineJavier Sector Leader: William Experton Task Team Leader: Marv T. Mulusa SAINTLUCIA HIV/AIDS PREVENTIONAND CONTROLPROJECT CONTENTS Page A. 1 1 2. RATIONALE 1.STRATEGICAND SECTORISSUES .............................................................................................. CONTEXTAND RATIONALE ...................................................................... COUNTRY FOR BANKINVOLVEMENT .................................................................................. 2 B.3. HIGHERLEVEL OBJECTIVESTO WHICH THEPROJECT CONTRIBUTES ...................................... 3 1.PROJECT INSTRUMENT.......................................................................................................... 3 DESCRIPTION.................................................................................................... -3 LENDING 2 .. PROGRAM OBJECTIVE AND PHASES ....................................................................................... ................................................... 53 4. PROJECT COMPONENTS ......................................................................................................... 3 PROJECTDEVELOPMENT OBJECTIVEAND KEY INDICATORS 5 5. LESSONS LEARNED AND REFLECTEDINTHE PROJECTDESIGN ............................................... 9 ............................................... 10 C. IMPLEMENTATION 6. ALTERNATIVES CONSIDEREDAND REASONS FOR REJECTION 11 1. ............................................................................................................ 11 2. INSTITUTIONAL PARTNERSHIPARRANGEMENTS (IF APPLICABLE) ................................................................ AND IMPLEMENTATION ARRANGEMENTS ................................................... 11 3 . AND 12 4. SUSTAINAB~~~Y MONITORING EVALUATIONOFOUTCOMES/RESULTS................................................... ................................................................................................................. 12 5 . CRITICAL RISKSAND POSSIBLECONTROVERSIAL ASPECTS .................................................. 13 ...................................................................... D. APPRAISALSUMMARY.................................................................................................... 6. LOAN~REDIT CONDITIONS AND COVENANTS 13 14 2. TECHNICAL......................................................................................................................... 1. ECONOMIC FINANCIAL ANALYSES ............................................................................... AND 14 15 .......................................................................................................................... 15 4. 3. FIDUCIARY SOCIAL ............................................................................................................................... 16 5. ENV~ONMENT .................................................................................................................... 17 ......................................................................................................... 18 7. POLICYEXCEPTIONS READINESS 6. SAFEGUARD POLICIES AND ................................................................................ 18 ANNEX1: COUNTRY AND SECTORORPROGRAMBACKGROUND .................................................... 19 ANNEX2: MAJOR RELATEDPROJECTSFINANCED BYTHEBANKAND/OR OTHER AGENCIES ..........23 ANNEX3: EVALUATION MONITORING AND FRAMEWORK .............................................................. 24 ANNEX4: DETAILED PROJECT DESCRIPTION .................................................................................. 43 ANNEX5: PROJECT COSTS.............................................................................................................. 49 ANNEX6: LNSTITUTIONALANDIMPLEMENTATIONARRANGEMENTS .............................................. 50 ANNEX7: FINANCIAL MANAGEMENTANDDISBURSEMENTARRANGEMENTS................................. 58 ANNEX9: ECONOMIC FINANCIALANALYSIS .......................................................................... ANNEX8: PROCUREMENT............................................................................................................... 64 AND 74 ANNEX10:SAFEGUARD POLICY ISSUES ......................................................................................... 80 ANNEX11: PROJECTPREPARATIONAND SUPERVISION.................................................................. 89 ANNEX13: STATEMENTOFLOANS CREDnrS........................................................................... ANNEX12: DOCUMENTSTHEPROJECT ............................................................................... IN FILE 90 AND 91 ANNEX14: COUNTRY AT A GLANCE ............................................................................................... 92 MAPNo.IBRD26634 ST. LUCIA ST. LUCIA HIV/AIDS PREVENTION& CONTROL PROJECTAPPRAISAL DOCUMENT LATIN AMERICA AND CARIBBEAN LCSHH Date: June 1,2004 Team Leader: Mary T. Mulusa Country Director: Caroline D.Anstey Sectors HIVIAIDSIHT -Targeted Health Sector MangerDirector: Ana MariaArriagada Themes: FightingCommunicable Diseases/HIV/AIDS (P) Project ID: PO76795 Environmental screening category: Partial Assessment LendingInstrument: Adaptable Program Loan Safeguard screening category: B Project FinancingData [XILoan [XICredit [XIGrant [ ] Guarantee [ ] Other: For Loans/Credits/Others: Total Bank financing (US$m.): 6.40 Proposed terms: IBRDLoan(US$3.2 million): 5 years graceperiod: 15years repayment 0.85% per annum commitment charge for 4 years and0.75% thereafter. IDACredit (SDR 1.15 million): maturity 35 years; 0.75% per annumcommitment charge. IDA Grant (SDR 1.15 million): Terms waived for 2004 per IDA Grants FY04 Implementation Guidelines. DEVELOPMENT INTERNATIONAL DEVELOPMENT 1.oo 0.60 1.60 ASSOCIATION IDAGRANTFORHIV/AIDS 1.oo 0.60 1.60 FinancingGap 0.00 0.00 0.00 Total: 4.99 3.01 8.00 Borrower: Government of St. Lucia Ministry of Finance Financial Center, Bridge Street Castries St. Lucia Tel: 758-468-5502 Fax: 758-452-6700 Responsible Agency: Ministry of Health StanislausJames Building, Waterfront Castries St. Lucia Tel: 758-453-6966 Fax: 758-452-5655 Expected effectiveness date: October 30, 2004 Expected closing date: June 30,2009 Does the project depart from the CAS incontent or other significant respects? o No Ref. PAD A.3 Does the project require any exceptions from Bank policies? Ref. PAD 0.7 Have these beenapproved by Bank management? No I s approval for any policy exception sought from the Board? N/A N/A Does the project include any critical risks rated "substantial" or "high"? o Yes Ref. PAD C.5 Does the project meet the Regionalcriteria for readinessfor implementation? o Yes Ref. PAD 0.7 Project description Ref. PAD B.3.a, Technical Annex 4 The Project will finance four Components as follows: Component 1. Community and CivilSociety Initiatives(US$0.75 Million). Theproject will empower civil society groups to respondeffectively to the HIV/AIDS epidemic by providing support to communities andto groups that are normally difficult to reach through regular public services particularly highrisk commercial sex workers (CSW), men having sex with men (MSM), prisoners and vulnerable groups (orphans and youth). Component 2: Line Ministry Response (US$0.97 Million). The project will support line ministries to expand the following HIV/AIDS initiatives for their staff and the population groups they serve through their official mandates: information, education, communication/ behavior change communication; condom distribution; care for the infected and affected families; and work place policy formulation including reductionof stigma and discrimination. Component 3: Strengthening the Health Sector Responseto HIV/AIDS (US$3.59 million). This component will support strengthening, upgradingand expansion of HIV/AIDS prevention, treatment (including anti-retroviral therapy) and care services deliveredthrough the healthcare system. Component 4: Strengthening Institutional Capacity For ProgramManagement, Monitoringand Evaluation, and Legal Technical Assistance(US$2.66 Million). The project will support institutionalcapacity buildingfor coordinating and managing the Government's National HIV/AIDS Program; strengthening programmonitoring andevaluation (M&E); andLegal Technical Assistance. Which safeguardpolicies are triggered, if any? Ref. PAD 0.6, TechnicalAnnex 10 EnvironmentalAssessment (OP/BP/GP 4.01) Significant, non-standard conditions, if any, for: Ref. PAD C.7 Boardpresentation: June 29,2004 under streamlined procedures. Loadcredit and Grant effectiveness are scheduledfor October 30,2004. Covenantsapplicable to project implementation: As referredin Section 5.01. of the Loan AgreementDevelopment Credit Agreement andDevelopment Grant Agreement, the following events are specified as conditions of effectiveness: (a) the Project Account has been opened and an initial amount in EC Dollars of at least one hundredand fifty thousand Dollars equivalent ($150,OOO) has been deposited therein; (b) the Operational Manual has been approved by the Bank and adopted by the Borrower; (c) the Annual Work Plan for the first year of the Project has been approved by the Bank; and (d) the auditors referred to in Section 4.01 (b) (i) of this Agreement have been appointed. A. STRATEGIC CONTEXT AND RATIONALE 1. Countryandsector issues Country andsector background. Saint Lucia, like other countries of the EasternCaribbean, faces special development challengesdue to its small size and vulnerability to natural disasters and other external shocks. It has witnessed several fluctuations ineconomic growth since its independence in 1979. Initialnegative growthinthe early 1980swas followedby annual growthrates averaging 3 percent inthe 1990s. The economy experiencedmajor structural transformation between 1993 and 2001 with the growingimportance of services, especially intourism. andthe reduction of the contribution of agriculture and manufacturing to GDP. Annual average economic growth was 1.3 percent between 1993 and 1997,3.0 percentbetween 1998and 1999, and0.2 percentbetween 2000 and2001. The country faces institutionalcapacity weakness ina number of areas and per capita costs of basic social and infrastructure services are highdue to the size of the population (157,775)'. Government efforts to create a competitive environment inorder to enable private sector growth and diversification are complemented by strategies with a more immediate assault on maskedpockets of poverty, particularly inthe rural areas. The World Bank supported Poverty Reduction FundProject, currently under implementation by the Government of Saint Lucia, is one of the operations that is targeting the poor andvulnerable. The Caribbeanregion, to which Saint Luciabelongs, i s secondonly to the Africa region inadult prevalencerates of the HumanImmune-Deficiency Virus (HIV)andthe Acquired Immune Deficiency Syndrome (AIDS). Surveillance data from Ministry of Health, HumanServices & Family Affairs, andGenderRelations (MOH) of Saint Lucia, while having some limitations interms of reliability of data collection, indicate that from 1990to 2001, HIV prevalence among women attending antenatalclinics has rangedfrom 0.6 percent to 4.0 percent, suggestingthat the epidemic inSaint Lucia is still at a low level. Saint Lucia, therefore, has an opportunity to prevent the epidemic from escalating and posing a significant problemto its socio-economic development as it has inother Caribbean countries. The Government of Saint Lucia's responseto HIV/AIDS has includedprevention measures and very limited treatment or mitigation, due to, among others, limited resources available to respond to the pandemic in a comprehensive manner. Inorder to intensify its responseto the pandemic, the Government has adopted the National HIV/AIDS Strategic Plan2003-2008. The planis basedon a situation analysis of HIV/AIDS inSaint Lucia andbroadconsultation with all major stakeholders. The Plan proposes four main strategies: (1) advocacy and policy development; (2) comprehensive HIV/AIDS care for all people living with HIVIAIDS(PLWHA); (3) preventionof further transmission of HIV; and (4) strengtheningnational capacity to deliver an effective coordinated multisectoral response. The Saint Lucia HIV/AIDS Prevention and Control INational Census 2001. 1 Project will support the implementation of this national HIV/AIDS strategic plan, which has the support of the political leadershipat the highest level and all stakeholdersinthe country. 2. Rationale'forBank involvement The HIV/AIDSpandemic is a global threat to development and the World Bank, together with other international partners, are committed to intensified action to prevent and control the pandemic and mitigate its social and economic impact. Saint Lucia's responseto the pandemic has beenlimiteddue to, among other reasons, resource constraints anda weak institutionalbase. The following reasonsunderpin the rationale for Bank involvement inSaint Lucia. First, the World Bankwill provide additional resourcesto supplementthe national budget to finance highpriority cost-effective interventions for HIV/AIDS that would otherwise not be funded. The funding also targets civil society stakeholders who will ordinarily finditdifficult to obtain fundingfor their initiatives. The Bank support will therefore, contribute directly to scaling up ongoing initiatives. Second, the Bank will share lessonsfrom its involvement inongoing HIV/AIDSprojects includingthose under the current multi-country and multi-sectoral programs inAfrica, the Caribbean, andBrazil. It will also provide technical guidance and share best practices (interventions, technology, coordination and implementation modalities) obtained through Bank coordination with other UNagencies under the auspices of UNAIDS as well as with other multi-lateral and bilateral donodfunding. The Bank also helps governments and key partners focus on HIV/AIDS policy issues at national, regional and global levels. Third, Bank support through the project will generatelargeexternalities by strengthening the coordination and implementation capacity of public and private institutions inorder to builda sustainablebasefor the national response. Project activities are HIV/AIDS specific but the current health systemi s too weak to ensure their successful implementation. Successfulprevention and control of the HIV/AIDSpandemic mustbe anchoredin an effective and efficient national health system. Therefore the project will also support strengtheningthe national health care delivery systemby upgrading clinical laboratory services, disposing safely of biomedical waste, buildinga disease surveillance capacity supportedby an up-to-date informationtechnology platform, modernizing the procurement, storage and distributionof pharmaceuticals and medical supplies, ensuring effective collection of bloodand the safe storage, transportation and application of blood units, andupgradingthe technical and interpersonal communications skills of various categories of healthworkers. Fourth, the public health responseto HIV/AIDS must be grounded in a supportive legal framework to ensure long-term effectiveness. Key parts of the country's legal framework that needupdating are: (i) ensuring all citizens the full benefits of the civil, economic and social rights universally recognized as being of important to people living with 2 HIV/AIDS andto other vulnerable groups; and (ii) the provision of servicesto ensuring all who need them. The project respondsto the Government's request for assistancein strengtheningthe relevant legal andregulatory frameworks inthe two areas. 3. Higher levelobjectives to which the project contributes The proposedproject i s consistent with the Country Assistance Strategy (CAS) for the ,EasternCaribbean Sub-Region of June 4,2001, which identifies HIV/AIDS as an emerging threat to socio-economic development. It highlightsthe needto support HIV/AIDSwithin the context of buildinghuman andinstitutionalcapacity. Itis also consistent with the Caribbean Regional Strategic Plan for HIV/AIDS which seeks to tackle the epidemic on a region-wide basis. The Strategic Plan is supportedby the World BankCaribbean Region Multi-CountryHIV/AIDSPrevention andControl (MAP) Adaptable Program Lending(APL) approved by the World Bank inJune 2001. The Saint Lucia HIVIAIDS Prevention andControl Project will be funded as partof the third phaseof the APL. B. PROJECTDESCRIPTION 1. Lendinginstrument The project i s fundedthrough a Specific Loan/Credit/Grant under the thirdphase of the Bank's Caribbean Multi-CountryHIV/AIDS Prevention andControl Adaptable Program Lending (APL) approved inJune, 2001. The Saint Lucia HIV/AIDSPrevention and Control Project will receive ablendof IDA grant (25 percent), IDA credit (25 percent) and IBRDloan (50 percent). 2. Programobjective and phases The Bank's Caribbean Multi-Country HIV/AIDSPrevention and Control Adaptable Program Lending(APL) of US$ 155.0 million was approved inJune, 2001. It is based on the Caribbean Regional Strategic Planof Action for HIV/AIDS agreed among all stakeholders, includingdonors. The overall development objective of the APL is to assist the Caribbean countries in: (i) preventing the spread of HIV/AIDS inthe general population and reducing transmission among the high-risk groups; (ii) improvingthe access of people living with HIV/AIDS (PLWHA) to care that i s effective, affordable and equitable within the context of the government health policy; and ( iii)strengthening their institutional capacity to respond to HIV/AIDS ina sustainable way. Eachcountry's project under the APL will dependon the stage of the epidemic, income levels, andthe socioeconomic status of the affected. The APL i s implemented inthree phaseswith countries qualifying for support after they have demonstrated adequate preparednessto implement an expandedHIV/AIDSprevention and control programandmeet the following eligibility criteria: (i) have a satisfactory national strategic planbasedon the Regional Strategic Action Plan; (ii) commitment and leadership, (iii) national an implementation strategy that is multi-sectoral and involves multiplestakeholdersinthe public, private, NGO andcommunity areas, (iv) sustainable fiduciary implementation 3 arrangements (financial, legal, procurement and regulatory), and (v) clearly defined institutional arrangements for monitoring and evaluation (M&E) of the epidemic. 4 3. Project development objectiveand key indicators The development objective of the project i s to support the national program that aims to prevent and to control the spread of HIV/AIDS and to mitigate the socio-economic impact of the diseaseon the population. The project will use a two pronged strategy: targeting interventions at highrisk groups and implementing non-targeted activities for the general population. Successfulachievementof the development objective will be evident when: (a) national commitment to the HIV/AIDS responseis sustained; (b) HIV incidence inhighrisk groups i s reduceddue to safer sexual practices ;(c) the quality of life of PLWHA i s prolonged and improved; (d) care and support are providedto families of PLWHA; and (e) the degree of stigma and discrimination associatedwith the disease i s reduced. Annex 3 presents a list of indicators to measurethe success of the national program in general and of the project inparticular. Key indicators will track progressinachieving the desired program andproject impact andoutcomes by measuring: (i) inthechanges prevalence and incidence rates of HIV/AIDS inthe general population and inhighrisk groups; (ii) to antiretroviral therapy andto treatment for opportunistic infections access by infected persons; (iii)support for affected householdsandorphans; (iv) accepting and non-discriminatory attitudes by the population towards victims of the disease inthe workplace andinthe community. More specific indicators will monitor the outputs from usingcorrect processes and the timely inputsthat are causally related to project impact andoutcomes. The following outputs will be monitored frequently: (i) positive HIV cases identified, counseled and treated; (ii)STIcases traced and treated; (iii) of condoms distributed; (iv) number pregnantwomen testing positive andreceiving antiretroviral therapy; (v) bloodunits screenedbefore transfusion; (vi) physicians and nurses trained in managing HIV/AIDS patients; (vii) orphans identified and cared for; (viii) HIV/AIDS IEC messages aired in the mass media; and (ix) Civil Society Organizations (CSOs) actively engaged inthe national HIV/AIDS response. Giventhe important role played by gender relations in HIV transmission, efforts will be made to disaggregatedata by gender and age so as to provide information for developing the most appropriate interventions for the different groups. 4. Project components The project will cost US$ 8.0 millionequivalent andwill be implementedover aperiod of five years. The project will have four components: (i) Community and civil society initiatives; (ii) Line ministry response; (iii)Strengthening the health sector responseto HIV/AIDS; and (iv) Strengtheninginstitutionalcapacity for program management, monitoringand evaluation, and legal technical assistance. 5 Component 1:Community and Civil Society Initiatives (US$0.75 Million) This component will finance HIV/AIDS prevention, care and support activities of Civil Society Organizations (CSOs) including: Non-Governmental organizations (NGOs), faith-based organizations (FBOs), community-based organizations (CBOs), women's organizations, professional organizations, trade unions and private sector organizations. CSOs are effective inreaching HIV/AIDS vulnerable groups inthe community that are normally difficult to reach. They also operate mostly at community level with more opportunities to interact directly with individuals and communities. The types of HIV/AIDS activities to be supportedby this component will bedemanddrivenandwill depend on the proposalspresentedby the respective CSOs. Activities eligible for project support include, but are not limited to: delivery of community basedHIV/AIDS information, education and communicatiorhehaviorchange communication (IECBCC); condom distributionand/or social marketing; home basedcare of PLWHA; community advocacy to reduce HIVIAIDS stigma and discrimination; support activities for orphans and widows/widowers of HIV/AIDS; support activities for people infected and affected by HIV/AIDS, especially those targeted at PLWHA, including income-generating activities; targeted activities for HIV/AIDS vulnerable groups includingcommercial sex workers, out of school youths and single women. While some CSOs may be well developed andready to implement their respective HIV/AIDS program activities, others may needcapacity building to strengthentheir effectiveness. Capacity building activities to be supportedinclude training of CSOs on HIV/AIDS knowledge andcommunication; training of leaders of CSOs on financial managementpractices relevant to the implementation of the project; andprovisionof essential equipment and suppliesfor NGOs. Criteriafor eligibility and procedures for the CSOs to access project fundingwill be specified inthe Operational Manual of the project. Component 2: Line Ministry Response (US$0.97 Million) This component will support the responseto HIV/AIDSby non-health sector line ministries. There are basic cross-cutting HIV/AIDS activities which all ministries are expectedto implement under their respective sectoral HIV/AIDS programs. These include: development and implementation of workplace HIV/AIDSpolicies; IECBCC for HIV/AIDS and STDs; condom distributionandpromotion; advocacy to reduce HIV/AIDSstigmatization anddiscrimination, particularly inthe work place; and establishment of a support group for HIV/AIDSpatients and their families (either as a single ministry or incollaboration with other ministries). There are also HIV/AIDS related interventions that are specific to a particular ministry andeachministry will identifyits specific HIV/AIDS program needs to be supportedby this component. For example, populations potentially at riskwithin the sphere of influence of the Ministry for Home Affairs are prisoners, fire fighters, delinquent youth, juvenile delinquents and police officers. For the Ministry of Education, Human ResourcesDevelopment, Youth and Sports it will be school age children and out of school youth. The Ministry of Tourism's highrisk population groups are commercial sex 6 workers, water sports and tour operators, taxi drivers and street vendors. All ministries are expected to be implementing their respective HIV/AIDS programs by the end of the third year of project implementation. However, anumberof ministries are expectedto participate as of the first year of project implementation: (a) Education, Human ResourcesDevelopment, Youth and Sports; (b) Public Service and Labor Relations; (c) Tourism; (d) Social Transformation; and (e) Home Affairs andIntemalSecurity. Ministries will appoint their respective HIV/AIDS focal points (person or unit) to coordinate the ministry's HIV/AIDS planning, implementation, monitoring and evaluation. Component3: Strengtheningthe HealthSectorResponseto HIV/AIDS (US$3.59 million). This component will strengthenMOHcapacity to provide technical guidance for the national responseto HIVIAIDS and more specifically it will strengthenHIV/AIDS related services for prevention, treatment, care delivered through the healthcare system. The mainservices to be supportedinclude: a) IECBCC. Support will be provided to strengthenIECBCC for HIV/AIDS including support for the bureau of healtheducation to strengthenits capacity to provide technical support for IECBCC anddevelopment of IECBCC interventions usingdifferent media (radio, television, leaflets) for delivery by the MOH, line ministries andCSOs. b) Voluntary CounselingandTesting(VCT). The project will support the provisionof VCT services inall eight health regions of the country. This will include remodeling of rooms inselected facilities to ensure confidentialityto clients for VCT, equipment (including CD4count machines), testing kits, reagents and training inVCT for health care workers. c) BloodSafety. The project will support the ministry to ensure safety of blood from HIV and other bloodborne diseases. d) TreatmentofSexually TransmittedDiseases(STDs). The project will support the strengthening of the STD services includingintroduction of the syndromic managementof STDs. Drugs and training of health care workers will also be funded. e) PromotionandDistributionof Condoms. The project will support promotion, provisionand distribution of condoms through the ministry's health care network, social marketing, other sectoral ministries andCSOs. f) Treatment, CareandSupportofPLWHA. Theproject will support the MOH inscaling upits services for the treatment (opportunistic infections, STDs, anti- retroviraltherapy) and care includinghome-basedcare and nutritional support for PLWHA. It will also support the prevention of mother to childtransmission (PMTCT) includingthe treatment of mothers with anti-retroviral drugs (PMTCT- PLUS). The project will support the strengthening of the laboratory capacity to assist inthe diagnosis, treatment and care of PLWHA, trainingof staff, drugs including anti-retroviral drugs, equipment and supplies requiredfor the managementof PLWHA. 7 Guidelinesand Treatment Protocols. The project will support the development, updating and use of different guidelines and treatment protocols including: IECBCC, VCT, STDmanagement, treatment and care of PLWHA (treatment of opportunistic infections, anti-retroviral care, home-basedcare, interalia). HIV/AIDS Policy and Legislation. The project will support the MOHin developing health sector policies that enhance the delivery of HIV/AIDS services within the health sector. The project will also provide technical support to legislators on issues relatedto HIV/AIDS. Promotion of Safe Workplace Procedures. The project will support strengthening implementation of safe workplace procedures to minimize occupational HIV infectionamonghealth care workers. Medical Waste Management. The project will support training of healthcare staff as part of the implementation of the Government's biomedical waste managementplan, as it relates to the disposal of medical waste createdinthe course of delivery of services to PLWHA. HIV/AIDS Surveillance and Operational Research. The project will support the strengthening of the HIV/AIDS surveillance systemand related operational research(See Annex 3). Technical Support to Line Ministries and CSOs. The project will support the ministry inits efforts to extend its technical HIV/AIDS skills to the non-health ministries and the civil society organizations. Component 4: StrengtheningInstitutional Capacity For Program Management, Monitoring and Evaluation, and LegalTechnical Assistance (US$2.66 Million) This component will helpbuildthe institutional capacity for scaling upthe response through financing of technical advisory services, training, staffing, equipment, goods and generaloperating costs of the following activities: a) Strengthening institutional capacityfor coordinating and managing the GovemmentIs National HZV/AZDSProgram. The project will fund the policy makingand oversight functions of the NationalAIDS Multisectoral Coordinating Council (NACC) ,the technical functions of the NationalAIDS Program Secretariat(NAPS), andthe financial management and procurement functions of the Project Coordination Unit (PCU). Functions of NAPS that will be supportedinclude: (i) reviewingproposals from line ministriesandcivil society implementing agencies; (ii) monitoring and evaluating program progress; (iii) ensuring transparent fiduciary management; (iv) coordinating information technology applications; (v) providing materials andequipment for the operation of the Secretariat andtraining its staff; and (vi) supporting the functions of technical advisory committees that may be formed, as necessary, to advise the Secretariat. Functions of the Secretariat that cannot be provided in-house will be out- sourced. Functions of the PCUthat will be supportedinclude: (i) maintenance of accounting records, (ii) processing disbursements, (iii) preparation of project financial statementsin accordancewith Bank guidelines, (iv) managementof bank accounts, (v) managementof financial information systems, (vi) preparation and submission of quarterly financial managementreports, (vii) preparation and submission of withdrawal 8 applications, (viii) coordination with auditors duringthe annualfinancial audit exercise, (ix) adoption of remedial financial managementactions, as necessary, during project implementation, and (x) all procurement functions. b) Strengthening the Surveillance, Monitoring and Evaluation Systems. The project will assist the M O H indeveloping and strengthening the Surveillance, Monitoring and Evaluation Systems, including the implementation of an HIV/AIDS/STD case managementinformation System(CMIS) andthe required InformationTechnology (IT) platform. Complementing the technical assistanceof the University of West Indies (UWI), the Caribbean Epidemiology Center (CAREC), HealthCanadaandother donor organizations, the project will strengthenthe MOWEpidemiology Unitcapacity with the implementation of standardizedprotocols for behavioral andbiological surveillance and respective programmingandexecution of surveys inthe generalpopulation and populations at risk for HIV/AIDS. The project will finance hardware, software, technical assistanceand trainingto develop and strengthena monitoring and evaluation systemto measureperformance of the activities detailed inthe other project components as well as the output, outcome and impact measuresdirectly related to the overarching goals of the National Strategic Plan. c) Establishing a Legal Framework. The project will assess the country's civil, economic, and social rightslegislation andprovide assistanceindrafting a comprehensive new act that will ensure to PLWHA and other vulnerable populations, includingchildren affected by HIV/AIDS, full equality anddignity under the law, without stigma or discrimination. Itwill also provide technical assistanceto updatethe necessary legal andregulatory provisions to make the country's legal framework compliant with the WTO's Agreement on Trade-Related Intellectual Property Rights (TRIPS) ina mannerthat fully protects the public health andthat promotes access to HIV/AIDS drugs andrelated medicines and supplies to all who needthem. 5. Lessonslearned and reflected inthe project design This project will incorporate the lessonslearnedinthe design andimplementationof the CaribbeanAPL and the Africa Region HIV/AIDS APL. They include: a) The need for high levelpolitical commitment and leadership. This kindof leadership is necessaryto confront the pandemic and deal with stigma anddiscrimination at all levels of society. The decision to establish the NACC to be chaired by the Prime Minister, as Saint Lucia has done, accords the necessary visibility and stature to the HIV/AIDS effort. b) A comprehensiveapproach of prevention, treatment, care and support. While emphasis must still be placedon prevention as the most cost-effective means of managing the epidemic, programs should seek to address the whole spectrum of prevention, treatment, care andsupport services. The current project for Saint Luciahas included HIV/AIDS support ina comprehensive manner. 9 c) Rapidly changing prices and technology. The introduction of antiretroviral treatment for HIV/AIDShas been acceleratedby the declining prices of antiretroviral drugs. The project will support the introduction of antiretroviral treatment inSaint Lucia with the necessarycapacity buildingincluding training of health care workers; strengthening the diagnostic and laboratory monitoringcapacity andprovision of drugs and test kits. d) Monitoringand evaluation is critical inthe scaling up of the national response. Strengtheningof bothsurveillance to provide timely informationfor policymakers on the trends of the epidemic andmanagementinformation for better program management of the responseis an important feature of this project. e) Recognitionof all stakeholders. All key stakeholders are recognized as important inthe fight against HIV/AIDSand it i s important to ensurethat mechanisms are put inplace for the participation of line ministries, NGOs andother key civil society groups inthe design and implementation of the project. This project recognizesthe role of the above mentionedstakeholders. f) Building a strongfiduciary architecture. Priority i s accorded to fiduciary mechanisms(financial management, accounting, procurement, review and approval procedures). Contracting out of services i s important where in-house capacity is inadequate. g) Slow start up. Firstyear of project implementation often shows a slow start for Line Ministries and CSOs. Learning from this lesson, the project developed a detailed Operations Manual, preparedwork plans for Line Ministries andidentifiedNGOs that are had activities that were ready for immediate scaling up. 6. Alternatives considered and reasons for rejection The following alternative approacheswere considered andrejected: A health sector investment loan. This alternative was rejected on the groundsthat, while the health sector accounts for a significant proportionof a country's responseto the HIV/AIDSpandemic, it is not sufficient for achieving a significant impact inslowingit down due to the wide rangeof socio-economic factors (social, cultural, economic, legal, gender etc.) that condition people'sbehavior andfuel the epidemic. There i s a needfor a multi-sectoral approachthat deals with prevention, treatment and mitigation of the impact (a significant proportion of which i s outside the direct influence of the health sector). An operation exclusively targeting highriskand specific vulnerable population groups. This was rejected because it will not adequately cover the requirementsof an integrated and open society of Saint Lucia, which has links with other populations inthe region and beyond. It i s also prudentfor the Government to act swiftly so that the epidemic does not spread rapidly inthe general population. The project will therefore support both targeted interventions as well as interventions for the general population. 10 C. IMPLEMENTATION 1. Partnershiparrangements Not applicable. 2. Institutionaland implementationarrangements InstitutionalArrangements.A Cabinet decision datedMay 3, 2004has createda governance structure for managingthe national HIV/AIDSresponse. (a) Responsibility for program managementhas been assignedto the National HIV/AIDS Coordinating Council(NACC) chairedby the PrimeMinister. The NACC will be accountable to the Cabinet for program results andpresentto the Cabinet policies and strategies that require Cabinet approval. The Council consists of fifteen members, eight of whom represent civil society. The Council will set priorities, approve annual work programs and budgets, prepare an annual report on the nationalresponsefor the Cabinet, mobilize national and international resourcesfor the fight against HIV/AIDS, andensure multi-sector support for the national response. The PermanentSecretaryof the M O His a member of the NACC and the Chief MedicalOfficer (MOH) i s the Secretary to the NACC. (b) A NationalAIDS ProgramSecretariat(NAPS) is the operating armof the NACC and is managedby a Director appointed by and reporting to the NACC via the Permanent Secretary of MOH. NAPS will support, coordinate andoverseeprogramimplementation bythe implementing agencies. Itwill be responsible for coordinating technical and fiduciary aspects of the Project. The NAPS will be located inMOHand will coordinate all HIV/AIDSprevention andcontrol work programs to be executedby the three implementingagencies. Its staffing will include skills instrategic planning,monitoring and evaluation, information technology, communication strategies andepidemiology. An existing PCUwill carry out financial management andprocurement functions of the Project. This unithas experience inmanaging two World Bank projects, i s currently locatedinthe Ministryof PhysicalDevelopment, Environment and Housingand will be transferred to the Ministry of Finance, International Financial Services and Economic Affairs (MOF). Its staffingincludes a financial managementspecialist, aprocurement specialist andadministrative support staff. (c) The National Coordinating Committeeon HIV/AIDS (NACCHA)-an existing multi-sectoral coordinating body - will assist the NAPS inreviewing and evaluating annual work plans of Line Ministries and proposals for subprojects submitted by Civil Society Organizations to be funded under this project. The recommendedproposals will be referredto the NAPS for approval and to the NACC for ratification. The NACCHA consists of representativesof the MOH, Line Ministriesand Civil Society Organizations. Implementationarrangements: A consolidated annual work plan will be preparedby the MOH and included inits annual budget for presentation to the Ministry of Finance 11 and Parliament for approval. The work plan will include the MOH's own work plan, plans of Line Ministries and abudget line for subprojects of civil society groups and the private sector. These groups will access funding through ademand-driven process under which the civil society groups will prepareproposalsfor funding from the project. Annex 6 contains a detailed description of the institutional and implementation arrangements. 3. Monitoringand evaluationof outcomeshesults A full time M&Econsultant within theNAS will beresponsiblefor: (i) developing an overall M&Eplanincludingmanuals, implementation procedures, tools, data flowcharts and a budget; (ii) strengthening the monitoringsystems to ensure sound output and processmonitoring; and (iii) validating databy random sampling recording and aggregating processesandby examining large variations inhistorical trends. Evaluation of the outcome and the impact of project performance on achieving the development objectives will be done through periodic behavioral surveys of high-risk groups, household surveys of the generalpopulation, workplace surveys of arandom sample of companies, and healthfacility surveys. Baseline markers and targets will be establishedfor measuring progress. Outcome/impact indicators are listed inAnnex 3. Monitoringprogram performance 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 progressbeing made and to show variations that occur. Inputand processindicators are listedinAnnex 3. 4. Sustainability The following factors will contribute to program sustainability after project completion: (a) An enabling policy and legal environment with strong political support and leadershipfor dealing with HIV/AIDS; (b) Government's willingness to revise the legal and regulatory framework to address issuesof stigma and discrimination andthe ability to sustainpublic awareness of HIV/AIDS issues ;(c) Implementation sustainability: development of broad ownership and a strong institutionalcoordination mechanismfor the expandedresponseto the pandemic andthe involvement of other key stakeholders (line ministries, NGOs, communities, etc.) inimplementation; and (d) Financial sustainability over the medium term that will include additional Government budget allocations and funding from donors. 12 5. Critical risksand possible controversial aspects Risk RiskRating RiskMitigationMeasure Inadequatecommitment and involvement M A NationalHIV/AIDS Council chaired by the of political and administrativeleadershipin PrimeMinisterand including all stakeholders the responseto the epidemic. has beenestablishedby Cabinet. Project implementing agencies do not have H TheNationalHIV/AIDSCouncil andMOH sufficient authority, leadership,and actively support the National AIDS Program capacity to meetHIV/AIDS prevention and Secretariat and provide additional staffing; control objectives. training and technical assistance . Stigmaand discrimination slow down the S A broadrange of interventions that address expansionand useof services. stigma and discrimination are supported including: IECto different target groups and to the generalpopulation; work placepolicies, training and sensitizationof leaders at national and community level and care givers including healthworkers; and, revision of legislation. M Mitigationof this risk entails encouraging the ~~ Some faith-based organizations oppose ~ xoject activities, e.g. use of condoms. Government to keep these groups involved in the national response. The faith based organizations are currently key participantsin the national responseto HIV/AIDS. Insufficient capacity amongline ministries H Focal points for HIV/AIDS have beenappointed and civil society groups inthose lineministries that will lead inthe first year of the project. Trainingand technical assistance to strengthenimplementation capacity of Line Ministries and CSOs are SUDDOrted. The PCUlocated inthe MOF i s M Reporting relationships, roles and functions of organizationally separatedfrom the the PCUare specified in the OM and the PCU implementing agency (MOH) and the has experience in managing IBRD-financed PCU supports several projects projects. OverallRiskRating S 6. Loadcredit conditions and covenants Effectiveness Conditions. Project Management: The Borrower will have: (i) allocated funds inthe 2004/5 national budget for the project, (ii) an approved work planfor the first year of the project and a procurement planfor the first eighteen months of the project; (iii) adoptedthe operations manual; and (iv) transferred the PCU to the MOF. Fiduciary: The Borrower will have: (i) Appointed external auditors and (ii) openedthe project Special Account andthe Project Account for counterpart funds with an initial amountof US$150,000 depositedtherein to cover at least the first year of implementation. 13 D. APPRAISAL SUMMARY 1. Economicandfinancial analyses Some studies have beencarried out on the economic impact of HN/AIDS in a number of countries in the Caribbean. These studies makea compelling case for the economic benefit from public action to prevent and control HIV/AIDS. A study2conducted by the UWIsuggests that economic lossesdueto HIV/AIDSwill amount to aboutfive percent of GDP inJamaica andTrinidad and Tobago by year 2005. The estimated GDP loss is driven by the numberof HIV/AIDS cases andthe averageloss of income/output associatedwith those cases. The study forecasts the economic impact of HIV/AIDS by modeling the impact on: output, labor supply, employment, savings andinvestment, and spendingon HIV/AIDS treatment. An increase inHIV/AIDS-relateddeaths and morbidity adversely affects labor supply causing wages to increase. Raising wages and decreasing labor supply translateinto lower levels of employment. The increase in expenditure associatedwith increasedHIV/AIDS incidence diverts funds away from productive savings, which inturn affects the levels of investment that canbe achieved. Depressedlevels of labor andcapital affect the levels of output from the various sectors and therefore overall GDP. As shown by a study conductedby the World Bank inSouth Africa (Bell, Devarajan, and Gersbach, 2003), using a "humancapital" model: inthe absence of AIDS, the counterfactual benchmark, there is modest growth, with universal andcomplete education attainedwithin three generations. Ifnothingis done to combat the HIV/AIDS pandemic, however, a complete economic collapse will occur within three generations. This outcome is postulated to be the result o f (a) the erosion of humancapital, especially due to deaths of adults intheir prime; (b) destruction by HIV/AIDS of the mechanismsthat generate humancapital formation (HIV/AIDS decreases quality of child-rearing due to illness; deaths of parentsweakens the transmission of knowledge; children drop out of school due to loss of parents' income); and (c) the inability (or limitation) of children of AIDS victims to raise their own children andto invest intheir education. Furthermore, the economies of the small-island Caribbean states dependon limited sourcesfor foreign exchange- sources that are also the maindrivers of their economies. Inthe absence of bufferingor compensatory sectors, eventhe slightest unfavorable shock has the potential to trigger a downward economic spiral. By simultaneously compromising both the labor productivity and savings pillars of the economic system, HIV/AIDShas all the features of anunfavorable shock. The economiesof the small- island Caribbeanstates are therefore faced with the challenge of not simply the threat of a negative economic experience, but the very capacity of the economic system to hold together. Separate analyses for each of the individualcountries that have so far participatedinthe Multi-Country HIV/AIDS Prevention and ControlAPL showed that * 'HIV/AIDS inthe Caribbean:EconomicIssues-Impactand InvestmentResponse,' WorkingPaper. HealthEconomicsUnit, UniversityofWest Indies, St. Augustine, 2000 and 'Modelingthe MacroeconomicImpactof HIV/AIDS inthe English-SpeakingCaribbean: the CaseofTrinidadand Tobago andJamaica,' WorkingPaper, CAREC/UWI/PAHO/WHO, 2000. 14 for most, the benefits interms of reducedlosseswill far exceedthe costs of their programs, even inthe first year of project implementation. Saint Lucia, like other countries inthe Caribbeansub-region, is confronted by the challenge of ensuring financial sustainability of HIV/AIDSprevention and control efforts. This concern is heightenedby the fact that most countries have adopted a policy of addressingHIV/AIDS as a public healthissue, with no cost recovery. Inall country projects financed inthe sub-region so far, the introductionof the project will require incremental financial commitments of governmentsinthe order of 3-4 percent of present healthsector budgets. However, this figure is likely to belower ifthe costs of treating opportunistic infections are deductedfrom the calculations. 2. Technical The project is consistent with international bestpractices as recommendedbyUNAIDS, WHO and by the Caribbean Task Force on HIV/AIDS. The proposed program is also fully consistent with the World Bank's Strategy inthe HNP Sector as stated inthe Sector Strategy Paper, as it will help achievethree major objectives inthe sector: (i) improve health outcomes among the poor, who are at a higher risk of developing HIV/AIDS, and protect other segments of the population from the impoverishing effects of illness and death associatedwith HIV/AIDS; (ii) enhancethe performance of the health care systems inthe participating countriesbypromotingequitable access to prevention, care and support services for HIV/AIDS;and (iii) sustainablefinancing for HIV/AIDS secure programs. The project design is also consistent with the UNAIDS andWHO (2003) comprehensive approachproposedfor dealing with HIV/AIDSbasedon a balancebetween prevention and treatment, for both to work optimally. By supporting the introductionof antiretroviral treatment in Saint Lucia, the project will contribute to implementing regional efforts for the WHO'Sglobal " 3 ~ 5 "initiative that aims to facilitate HIV/AIDS ~ treatment scale-up at the country level. This inturn i s expectedto actually facilitate and strengthenHIV-prevention inseveral ways: by increasing demandfor voluntary counseling and testing; reducing stigma andpromoting greater opennesson HIV/AIDS; and helping to keep families intact andeconomically stable, thus slowing the growth of at-risk populations such as orphans and sex workers. 3. Fiduciary The PCUcurrently located inthe Ministryof Physical Development, Environment and Housing, which has experience inprovidingprocurement andfinancial management support to World Bank financed projects, will be responsible for fiduciary activities underthe project and will have overall financial and accounting responsibilities for the project. To ensure the same level of commitment to all externally fundedprojects, the PCUwill be transferred to the MOF. Financial management responsibilities will include: (i) maintenance of accounting records, (ii) processing disbursements, (iii) preparation of ~~ The goal of providing antiretroviral treatmentto 3 million people by the year 2005. 15 project financial statementsin accordance with Bank guidelines, (iv) managementof bank accounts, (v) managementof financial informationsystems, (vi) preparationand submission of quarterly financial managementreports, (vii) preparation and submission of withdrawal applications, (viii) coordination with auditors during the annual financial audit exercise, and (ix) adoption of remedial financial managementactions, as necessary, duringproject implementation. The PCU's core staff, which includes the Deputy PCUCoordinator, the Project Assistant- Contracts and the Project Assistant-FM, i s already inplace and will be supplementedby additional staff. Loan/Credit/Grant funds will be disbursedto aunique Special Account (SA)maintained inacommercial bank acceptableto the World Bank. Since accounting will be centralized at the PCU, no additional Special Account for Loadcredit funds will be necessary and all financial transactionswill flow directly from the PCU's Special Account. The PCU will execute all payment orders on behalf of line-Ministries (including MOH) that will receive financial support for approved activities intheir annual work plans. The PCUwill also disburse funds to CBOs, NGOs and CSOs to implement the demand-driven subcomponent of the project. Indoing so, the PCU will utilize the disbursement procedures applicable to community-driven development projects, as explained inFiduciary Managementfor Community-Driven Development Project: A ReferenceGuide (May 2002). The initial disbursementinto the Special Account will be an advance, and, since the PCUhas extensive experience with financial managementof World Bank projects andthe preparation of Financial MonitoringReports (FMRs), subsequent requests for replenishment of the SA will be basedon the quarterly submission of FMRs. All procurement will be conductedby the PCU. The project operational manual under preparation will include details of procurement responsibilities, flow of documentation, funds andprocedures. The PCUhasprepared ageneralprocurement planfor the entire duration of the project and an annualprocurement planbasedon the annual work plan. The procurement planfor each year will be submitted by the PCUto the Bank for approval, not later than the anniversary month of the prior fiscal year, following a standardformat which will list as aminimum(i) goods andservices to be works, procured for the year, (ii)their value; (iii) methods of procurement; and (iv) the the timetable for carrying out the procurement. The methods to be usedfor procurement are outlined inAnnex 8. 4. Social The project is expectedto have positive social benefits for Saint Lucia as it will support the creation of a conducive environment for addressingsensitive social issues concerning HIV/AIDS, especially issues around providing assistanceto certain vulnerable groups such as PLWHA, andsocially marginalized groups such as prisoninmates. Moreover, PLWHA and their families face continued stigmatization anddiscrimination, which this project will work to reduce. The project i s expected to have apositive social impact by assisting and empowering people, communities and institutions to deal more effectively with the pandemic. It will also support information, education and communication/ 16 behavior change communication (IECBCC)that aims at encouraging the development of positive attitudes andbehavior. Genderroles are important inthe responseto HIV/AIDS. Dependence and vulnerability of women and girls expose themto increasedrisks as has beendemonstratedby the increasingfeminization of the epidemic and the relatedrisk of increasedteenagepregnancies. Interventions will try to address ways of bothproviding information and empowering the women and girls as well as improving services for them inbothprevention andtreatment. Similarly, informationand services for menwill be addressed. Interventions for youth inand out of school will also address the different gender roles. 5. Environment Environmental Category: B Most of the project activities underthe project are not expectedto generate adverse environmental effects. Some medical waste i s expectedto be generatedduringthe managementof PLWHA. There will also be small-scalerehabilitation of existing health care facilities to ensure appropriate provisionof HTV/AIDS services. Measuresthat the Government will take to mitigate potential environmental effects are detailed inAnnex 10. Theproject will support the Government to implementthose measures. Of particular importance i s the needto ensure that healthcare staff are adequately trained on medical waste management. The project will provide support for such training, improvement in the legal andregulatory framework, clarificationof management responsibilities and upgrading of facilities and equipment. On the management of environmental risks of small-scale construction works, the project' s coordination unit will incorporate environmental guidelines inthe project's operations manual and standardbidding documents for civil works. 17 6. Safeguard policies Safeguard Policies Triggered by the Project Yes No EnvironmentalAssessment (OP/BP/GP4.01) [XI [I Natural Habitats (OP/BP 4.04) [I [XI Pest Management (OP4.09) [I [XI Cultural Property (OPN 11.03, beingrevisedas OP 4.11) [ ] [XI Involuntary Resettlement (OP/BP 4.12) [I [XI IndigenousPeoples (OD 4.20, beingrevisedas OP 4.10) [I [XI Forests (OPBP 4.36) 11 Ex1 Safety of Dams (op/BP 4.37) [I Ex1 ProjectsinDisputedAreas (OP/BP/GP 7.60)* [I [XI Projectson InternationalWaterways(OP/BP/GP 7.50) [I [XI 7. Policy ExceptionsandReadiness No policy exceptionsare sought. The project has beenpreparedinaccordancewith the provisionsof the Multi-Country HIVIAIDS PreventionandControl Adaptable Program Lending (APL) for the Caribbean. The Bank has assessedthe Government as being ready interms of having a policy inplace for HN/AIDS that is elaboratedinthe National HIV/AIDSStrategicPlan, the commitmentof the leadership,the institutionalframework for managementof the overall National HIV/AIDS Programandthe strengtheningof project managementcapacity. Specifically, the Governmenthas adopted a new institutional framework for coordinatingthe NationalHIVIAIDSprogram. The establishment of the NACC will ensure a multi-sectoralresponse. MOH, key line ministries andcivil society are representedon the NACC. Provisionshavebeen made andbudgetedfor strengtheningthe project's implementationcapacity. * By supportingthe proposedproject, the Bank does not intend to prejudice the final determinationof the parties'claims on the disputedareas 18 Annex 1: Country and Sector or ProgramBackground Saint Lucia HIV/AIDS Prevention And Control Project Strategic context The Country Assistance Strategy (CAS) for the EasternCaribbean Sub-Region of June 2001 (Document No. 22205-LAC, last discussedon June 8,2001), identifies HIV/AIDS among the areas of proposedBank assistanceas part of humanand institutional development. The proposedproject, by assistingthe Government inthe implementation of its National HIV/AIDS Strategic Plani s therefore consistent with the CAS. The Saint Lucia HIV/AIDS Prevention andControl Project will be funded as part of the Caribbean Region Multi-Country HIV/AIDS Prevention and Control APL that was approved by the World BankinJune, 2001. The Caribbean Regional Strategic Plan of Action for HIV/AIDSandthe World Bankreport "HIV/AIDS inthe Caribbean-Issues and Options'' identify the needfor all the countries inthe region to pursue a broad-based responseto the pandemic. This project i s consistent with boththe Caribbean regional and World Bank strategiesfor fightingHIV/AIDS inthe region. Mainsector issuesandGovernment strategy: Country and sector background. Saint Lucia, like other countries of the Eastern Caribbean, faces special development challenges due to its small size and vulnerability to natural disasters and other external shocks. Institutionalcapacity is limited andper capita costs of basic social andinfrastructure services are highdue to a small total population of 157,775 (2001 national Census). Since independencein 1979, Saint Luciahas witnessed severalfluctuations ineconomic growth. Initialnegative growth inthe early 1980s, was followed by annual growth rates averaging 7 percent inthe rest of the decade. Inthe 1990s growth rates averaged 3 percent. The economy experienced major structural transformation between 1993 and 2001 with the growingimportance of services, especially tourism, andthe reduction of the contributionof agriculture and manufacturing. Average growth recorded was 1.3 percent between 1993 and 1997,3.0 percent between 1998 and 1999, and0.2 percent between 2000 and 2001. Government efforts to create an environment of improved competitiveness inorder to permit private sector growth anddiversification are beingcomplemented by strategies with amore immediate assault on maskedpockets of poverty, particularlyinthe rural areas. The World Bank supported Poverty ReductionFundProject, currently under implementationby the Government of Saint Lucia, i s one of the operations that i s targeting the poor and vulnerable. Health status and the health care system of Saint Lucia. Saint Lucia's health profile i s that of a country that has already gone through the epidemiological transition. Diseases of the circulatory system are the major cause of death, accounting for about 31 percent of all deaths. Cancer was the second major cause of death in2002 while communicable diseases andconditions originatingin the perinatal period contributed only 4.1 percent of all the total deaths inthe same year. Life expectancy at birthin2002 in Saint Lucia was 19 77 years among females and73 years amongmales. The annualrate of population growth has rangedbetween 1.3 percent and 1.5 percent between 1960and 1991.Between 2000 and 2002, it was estimatedat 1.8 percent. The percentageof the target population of infantsimmunized underthe expandedprogram of immunization has beenconsistently high each year (between 88 percent and 100percent) for all vaccinations given. The administration anddelivery of healthcare servicesinSaint Luciais dominatedby the public sector, with MOH taking the lead inthe organization of resourcesand services for the health of the country. Private sector health services are relatively small. Most of the private health sector constitutes of medical, dental and pharmacy services. Many doctors anddentists work inboththe private and public sectors. The country is servedby three acute general hospitals (Victoria, St. Jude andTapion), two district hospitals (Soufriere andDennery) andone psychiatric hospital (Golden Hope). There is also adrug and alcohol rehabilitation center. Saint Lucia is inthe process of implementing a healthsector reformprogram which is partof the public sector reform which beganin 1995with the reclassification of the public service. As partof this reform, a minimumpackageof healthservices, which includes services for HIVIAIDS, will be provided to the generalpublic at no cost to the user. The HIV/AIDS epidemicinSaintLucia. The Caribbeanregion, to which Saint Lucia belongs, i s second only to the Africa region inadult prevalencerates of HIV/AIDS infection. Surveillance data from M O Hof Saint Lucia, while having some limitationsin terms of reliability of data collection, indicates that from 1990to 2001, HIVprevalence among women attending antenatalclinics has rangedfrom 0.6 percent to 4.0 percent. The majority of HIV infections in Saint Lucia are through heterosexualrelationships. A small number of infections (estimated at about 6 percent of male cases) are through homosexual transmission. Vertical transmission is estimatedto account for about 3 percent of all reported cases of HIV. Saint Lucia needs to take action quickly to prevent the epidemic from escalating and posing a significant problem to socio-economic development as it has in other countries inthe region. The Government of Saint Lucia's responseto HIV/AIDS has focused on prevention measures. There has beenlimited treatment and other mitigationinterventions, due to, among others, inadequateresources available to respond to the pandemic ina comprehensivemanner. Inorder to intensify its responseto the pandemic, the Government has producedthe NationalHIV/AIDS Strategic Plan 2003-2008. The plan is basedon a situational analysis of HIV/AIDS in Saint Lucia andbroad consultation with all major stakeholders. The Plan proposes four main strategies: (1) advocacy and policy development; (2) comprehensive HIV/AIDScare for all PLWHA; (3) prevention of further transmissionof HIV; and (4) strengthening nationalcapacity to deliver an effective coordinated multisectoral response. The Saint Lucia HIV/AIDS prevention and controlproject will support the implementation of this NationalHIV/AIDS strategic plan, which has the support of all stakeholdersin the country, including the politicalleadership of Saint Lucia, at the highest level. 20 The national responseto HIV/AIDS inthe country is ledby M O H which reachesout to other ministries on HIV/AIDS issues related to the non-health sectors. Other links by M O H are to civil society organizations includingthe faith basedorganizations andthe umbrella NGO organization AAF. A national HIV/AIDS program coordinating committee (NACCHA) has been responsiblefor coordinating HIV/AIDSactivities of various stakeholders. However, the NACCHA did not have the requisite authority to coordinate the response. The Government has recently establisheda highlevel national HIV/AIDSbody, under the office of the PrimeMinisterto address this shortcoming. Surveillance for HIVIAIDS inthe country i s ledby the epidemiology department of MOH. Current information available at the epidemiology department regarding HIV prevalence inthe country i s not sufficiently reliable becauseof the non-systematic way in which the data i s collected. M O Hacknowledgesthe shortcomings inits HIV/AIDS surveillance system and has identifiedthis as an area for strengthening duringthe implementation of this project. The Government strategy The Government has developed the NationalHIVIAIDS Strategic Plan2003-2008 to guide its response. The strategic planwas producedafter in- depthscrutiny of Saint Lucia's HIV/AIDS situation andconsultations with abroad and representative cross section of stakeholders. Those consulted included representativesof bothhealth sector andnon-health sectorministries, NGOs, FBOsrepresentativesof PLWHA, the mass media and young people from different partsof the country. The Plan proposesfour mainstrategies: (1) advocacy and Policy Development; (2) comprehensive HIV/AIDScarefor all PLWHA; (3) preventionof further transmission of HIV;and (4) strengthening national capacity to deliver an effective and coordinated multisectoral response. Advocacy and policy development. Under the advocacy andpolicy development strategy, the country's political leaders will be sensitized to the implications of HIV/AIDSfor the future of the country. This is also linkedto ensuring the allocation of adequatefunds for HIV/AIDSprogramming. Inorder to addressthe underlying determinants of the pandemic, determinants of poverty will also be addressedwithin this strategy. Among other activities, studies will be undertaken to determine and document the interaction between HIVIAIDS andpoverty. Furthermore, this strategy will support the enactment of legislation to protect the human rightsof PLWHA. Comprehensive HIV/AIDS care for all P L W H A . Within the strategy for comprehensiveHIVIAIDS care for all PLWHA, two major priority areas of action are specified. The first area relates to scaling upHIVIAIDS care andtreatment includingthe delivery of antiretroviral therapy. The second arearelates to elimination of stigma and discrimination of PLWHA and their significant others. The workplace, community and healthcareenvironment are areas to be targetedfor reduction of stigma and discrimination of PLWHA. Prevention of further transmission of H I V . The third strategy is the prevention further transmission of HIV. Key elements of this strategy include, the prevention of motherto 21 child transmission of HIV (PMTCT), voluntary counseling and testing (VCT), the treatment of sexually transmitted diseases, the targeting of youth inandout of school and other vulnerable groups. Strengthening national capacity to deliver an effective and coordinated multisectoral response. The fourth strategy of strengtheningnational capacity to deliver an effective coordinated multisectoral responsehas four elements. These are the strengthening of the capacity of the surveillance unit, monitoring the HIV/AIDS situation, empowering NACCHA, andensuringmultisectoral coordination and collaboration to respondto the pandemic. 22 Annex 2: Major RelatedProjectsFinancedby the Bank and/or other Agencies SaintLucia HIV/AIDS PreventionAnd Control Project UNFPA. (US$300,000) A three year project, supportedby UNFPA, targets vulnerable youths in selected areas of the country. The objective of the project i s to increase awareness of HIVIAIDS andmeans of prevention amongthese youths through IECBCC interventions. Caribbean DevelopmentBank. Economic Reconstruction Program - Rehabilitation of PrimarySchools andHealthCenters (AR 03/3 SL). The health relatedpartof this loan will finance renovating fifteen health centers; providingequipment, furniture, fixtures, supplies and vehicles; providingtwelve staff-months of technical assistance to train healthcenter personnel; establishing aNationalHealthManagement Information System; and providingfour staff -months of technical assistancefor the maintenance system of MOH. The total loan amount for education andhealth is US$6.05 million or 86 percent of the total cost of US$7.07. Potential additional projects are: (a) GOSL may obtain funding from the Global Fundsupport to the OECS countries and US$20,000 i s projected for 2004. (b)The UnitedKingdomDepartment of InternationalDevelopment (DFID)may provide support to the regional coordination mechanismfor HIV/AIDS. 23 Annex 3: Evaluation and MonitoringFramework Saint Lucia HIV/AIDS Prevention And Control Project a) Project Evaluation Indicators Some prevalence and incidence baseline data will be available by December 2004 from three ongoing studies: (i) BehavioralRisk Factor Surveillance; (ii) Seroprevalence HIV Survey among Pregnant Women; and (iii) HIVSeroprevalence SurveillanceamongMale PrisonInmates. Additional baseline information will be collected duringthe first year of project implementation through a behavioral. Data will be gender-disaggregated. The Saint LuciaNational HIV/AIDS Strategic Plan2003 -2008 also provides some quantified targets incorporatedin this framework. TBC: To Be Collected Hierarchy of objectives Indicators Baseline and Targets Means of Critical verification assumptions CAS Goal: Sector Indicators: Sector/Count Other macro Reduce risks of growing Secular trends in ry Reports: economic and poverty, especially income growth and Country social variables among vulnerable income distribution Economic within and groups (women, maintained by income Reports and beyond the children, indigenous deciles, age and International control of the people, dependent gender Agencies government are persons) Studies neutral or favorable Economic growth and income protection I Project Development Ot ectives Impact Measures National Strategic Plan Indicatorsand Targets I ~Kev Proiect ImDact 24 Hierarchy of objectives Indicators Baseline and Targets Means of Critical verification assumptions National commitment to an effective HIV/AIDS response By 2008, HIV/AIDSintegrated into national development plan By 2008, government allocation for HIV/AIDS Official increasedto at least 0.75 percent of total Government government budget documents and statistics Integrate HIV/AIDS into poverty reduction strategiesin 2004-2005 budget By 2006, legal and policy measuresto guard the humanrightsof all PLWHAandtheir significant others inplace By 2008,50 percent decrease inreported human rightsabuses towards HIVinfectedand affected persons. Prevent andcontrol transmission of HIV: Initialrise incases due to Reduce incidence of Number of current momentumandbetter NAPS HIV/AIDS in general positive HIV reporting will decline by end of population cases project to achieve an incidence rate that i s half of the 2005 rate. 25 Hierarchy of objectives Indicators Baseline andTargets Means of Critical verification assumptions Public awareness Prevention within By 2008, at least 80 percent of workplaces in Behavioral Workplace public and private sectorswith morethan 25 surveys employees have programs for education among staff Taxi and minibus By 2008, all taxi and minibusdrivers' Surveys by drivers associationsimplement workplace prevention NAPS programs 30 percent of taxi and minibus drivers report Behavioral increaseincondomuse and 30 percent reduce surveys the number of partners measuredbetweenthe 2005 and 2007 surveys and the 2007 and 2009 surveys UniformedServices By 2008, all uniformed services (police, fire, Surveys by prison wardens) associationsimplement NAPS workplace prevention programs 30 percent of uniformed servicesreport increase Behavioral incondom use and30percent reducethe surveys number of partners measuredbetween the 2005 and2007surveysandthe2007and2009 surveys Youth in and out of By September2008,80 percent of all inand out School and school of school youth demonstrate knowledge of HIV community andSTIpreventionmethods surveys Indicators Baseline and Targets Prolong and improve Mean survival time of IIBaseline: 2 years quality of life of people persons with AIDS Target: 5 years living with AIDS from date of AIDS NAPS diagnosis Case fatality rate Baseline: 82 percent (2002) Target: 50 percent 26 Hierarchy of objectives Indicators Baseline and Targets Means of Critical verification assumptions Mitigate the negative Reduction innumber Baseline: TBC Behavioral impact of HIV/AIDS on of children under 15 Target: 50 percent survey & personsinfected and years of age that have reduction NAPS affected lost their mother per Surveillance HIVinfectedfemale Reports Key Project Outcomes (From Median age by which Baseline: TBC objectives and Advance safe sexual 50percent of young Target: Increase by Population outcomes to practices among men and women aged one year based goals) vulnerable/high risk 15-24have had first behavioral populations penetrative sex survey Determinants of percent males and Baseline: TBC Frequency: health outside females 15+ years old Target: Decreaseby beginning, the control of with more than one 30percent midand end the project sex partner last year of 5-year remain neutral percent men and Baseline: TBC plan or favorable women 15+ years that Target: Decreaseby useda condom at last 30percent intercourse percent of infected Baseline: TBC Household Create anenvironment andaffected Target: Reach 80 survey that supports the individuals who percent of target Frequency: infectedand the affected received supportive population beginning, Zounselingover the midand end last six months of project Reduce stigma and percent of workplaces Baseline: TBC Workplace discrimination against with more than 25 Target: 50 percent of survey PLWHA :mployees with non- workplaces Frequency: hcriminatory beginning, ?oliciesand practices midandend nrecruitment, of 5-year idvancements and plan Jenefits for employees nfectedwith HIV 27 Hierarchy of objectives Indicators Baseline and Targets IMeans of Critical verification assumDtions percent of people Baseline: TBC Household expressing an Target: 70 percent survey accepting attitude beginning, towards people with mid and end HIV, of all people of project surveyed aged 15-49 Parentsempowered to Parentsare By 2008,25 percent Population communicate with their comfortable educating more parents based children (both male and their children on expressing comfort behavioral female) on HIV/AIDS/STI with educating their survey HIV/AIDS/STI issues children on HIV/AIDS/STI Youth express By 2008,25 percent satisfaction with increaseinyouth parental expressing satisfaction communication on with parental HIV/AIDS/STI communicationon HIV/AIDS/STI Key Project Outputs Access to VCT Number of public Baseline: 0 Facility (From outputs improved facilities that are Target: 10 survey to outcomes and staffed by trained Frequency: objectives) counselors providing beginning, specialized HIV midand end The national counseling andtesting of 5-year plan receives plan sustained Access to treatment and Number of health care Baseline: 0 Facility support of all care for HIV/AIDS facilities that have the Target: 3 public and 2 survey stakeholders improved capacity to deliver privatefacilities Frequency: palliative care, beginning, Religious treatment andreferral midandend communities for HIV-infected of 5-year will not patients according to plan challenge key national guidelines strategies of the Number of healthcare Baseline: 0 national plan facilities providing Target: 3 public HAARTaccording to facilities Current staff national guidelines shortages will be overcome Number of persons Baseline: 25 NAPS under treatment and Target: 334 Financial care resources earmarked for Number of HIV/AIDS Baseline: 9 NAPS the plan are cases on ARV Target: 178 adequate 28 b) ProjectMonitoringIndicators Monitoring indicatorsfocus on programmatic reporting of input and process measures to be usedby program managers as indicators of project performance. Means o f verification are service statistics and reports aggregated from service delivery sites. Core Indicators are drawn from the UNAIDS Guide to MonitoringandEvaluation (2000), the Caribbean Health Research Council"Caribbean Indicators and Measurement Tools (CIMT) for the Evaluation of National A D S Programmes" (2003),the USAID: Handbook of Indicators for HIV/AIDS/STI Programs (2000), and the Saint Lucia National HIV/AIDS Strategic Plan 2003 - 2008. Ouantified andtime-specific targets in the table below are taken from the Saint Lucia National HIV/AIDS Strategic Plan 2003 - 2008 dated September 2003. ProcessMeasuresfor Prevention ProcessIndicators Activities Voluntary Counseling and Testing FromJune 2005, all VCT services meet the minimum (VCT) : reduce the incidence of HIV nationalandregionalstandardsfor quality infections Number of cases counseled and tested ineach delivery site by age group and gender Sexually Transmitted Infections Increase STI services available in three Primary I control of STIS (STI): Improve the accessibility and Health Care Centers to all 8 regions by the end of 2005 By 2008, all clients with one or more STIs who sought - treatment for STIs are treated Condoms: Distribution of condoms Number of condoms distributed nationwide duringthe improved preceding 12 months divided by population aged 15- 49 PMTCT: FreePMTCT andPMTCT By December 2005, all pregnant women routinely Plus services integrated into all public counseled and screenedfor HIV status without charge and private antenatal services By December 2005, all HIV positive mothers-to-be provided with free and complete treatment and guidance BLOODSAFETY 100percent of blood units transfused are screenedfor HIVaccordingto WHO guidelines 0 percent of HIV/AIDS transmitted by blood PLWHA: Create an environment that By December 2006, all known PLWHA and their 1I transfusions supports the infected and the affected significant others have access to peer support groups PLWHA: Elimination of stigma and By the end of 2008, at least 50 percent of all health discrimination care institutions observing "PLWHA Friendly Health Care Institution" Policv 29 Process Measures for Prevention Process Indicators Activities ORPHANS By December 2006 all HIV/AIDS orphans and vulnerable children receive psychosocial and basic material support SUPPORT GROUPS By 2006, at least one home based care program in operation in each health region ~~ TRAININGANDCAPACITY By January 2006, at least one primary health care BUILDING facility ineach health region staffed with trained VCT counselorsand offering free VCT services Number of doctors trained inHIV/AIDS management INPUT MEASURES National Strategic PlanInput Indicators and Targets IEC programs for general population Average number of television and radio spots with expanded IEC messagesper week Average number of drama activities in the community usingIEC methods Education programs targeting in and From2004, basedon national guidelines, all out of school youth expanded instructionin life skills to include HIV and STI prevention, promote sexual responsibility and address gender issues Beginningin 2004, all teachers receive annual training to increase their capacity to address HIV/AIDS issues Comprehensive care andtreatment By December 2008, comprehensive care and treatment services, including antiretroviral therapy (ART), available to all health regions Capacity of Civil Society to respond By 2007, CSOs double their financial spending on to the needs of PLWHA strengthened HIV/AIDS over 2004 status By 2008,50 percent of private workplaces with more than 25 employees have a program STI and HIV/AIDS surveillance By June 2006, systems and staffing of the surveillance strengthened unitcapable of undertakingcomprehensive HIV/AIDS/STI surveillance By June 2006, all laboratories performingEnzyme LinkedImmune Sorbent Assay (ELISA) HIV tests are linked to National Sureveillance Unit (NSU) through informationtechnology (IT) platform Appropriate institutional and By December 2004, evidence of increasedHIV/AIDS management arrangements for the mainstreaming by key ministries under the umbrella national expanded response of the National Strategic Plan established NAPSestablished and functional bv December 2004 HIV/AIDS Protocols National Guidelines for prevention, treatment and s u ~ ~ odeveloDedand indace bv December 2004 r t 30 DocumentingandReportingOutcomesandImpact The previous Results Framework contains a list of key indicators that will be augmented by indicators included inthe NationalHIV/AIDS Strategic Plan. Tools to document outcomes and impact will include: (i)Behavior Surveillance Surveys (BSS)4 and seroprevalencestudies: youth andhigh-risk groups, STD patients, CSW, MSM,prison inmates; (ii)Knowledge, Attitudes, andPractices( U P ) studies of selectedgroups andthe general population regarding HIV infectionand AIDS; (iii)workplace discrimination surveys; and (iv) key informantinterviews. The HIV/AIDS/STD case management information System (CMIS) and the required InformationTechnology (IT) platformdescribed inthe next section will be the driving force behind the reporting of outcomes andimpact. Researchactivities to be financed would address issuesrelating to the economic and social impact of HIV/AIDS,behavior changes, ART clinical outcomes, andcost-effectiveness of interventions. ProgrammaticReportingof Input,Process, andOutputMeasures Monitoringof ongoing activities andof progressbeingmade is an integral part of managing the process of delivering a planned and supervisedflow of HIV/AIDS/STD preventive, treatment and care services. Programmatic reporting provides an answer- oriented report for managerial purposeson the processesbeingused to achieve the desired outcomes. A number of activities linked to positive project outcomes will be defined for ongoing monitoringby the project. Healthcare delivery personnelwill be trained to ensure the reliability of data recorded for subsequent processing andreporting to management. The MIS will capturethese data at the point of service. Prevention activities: VCT: How many, where and how early are positive HIV cases diagnosed?How many positive cases were counseled?STI:Where and how many STI cases are diagnosed and treated? Condoms:How many, where and to whom are condoms distributed?; PMTCT:new cases, cumulative cases, HIVtreatment given and type of treatment, cost of treatment; BloodSafety:Numberof donors screenedfor HIV/AIDS and number of positive. Treatment and care activities: PLWHA:number of new cases, cumulative cases, AIDS treatment given and type of treatment, number of ART prescriptions, ART expenditures, Opportunistic infections (01s) incidence rate, number of deaths, time elapsedbetween diagnosis and death, number receiving 01prophylaxis, number of hospital patient days; Orphans:number identified, totalnumber identified, numberenrolled, total number The BSS interventions would be programmedtargeting high-riskgroups, including laboratory and seroprevalence surveillanceprotocols for VCT, CSW, MSMwith CAREC support. 31 enrolled, number receiving support; SupportGroups:number of groups, number of groups with trained counselors, average patientdgroup, number of patients enrolled by age and sex. Capacitv buildingactivities: Training: new and cumulative numbers for professional staff, peers, volunteers; number of persoddays of training provided by target group, number of doctors trained in HIV/AIDS, number of patients seen by trained doctors. The CMIS will capture these data at the point o f service. Health care delivery personnel will be trained to ensure the reliability of data recorded for subsequent processing and reporting to management. The project will support strengthening the epidemiological and analytical capacity of MOHto monitor the HIV/AIDS situation and to evaluate the impact of the project, including technical assistance at midterm review and at project completion. BaselineData The anonymous HNseroprevalence survey being carried out with support from CAREC's Special Program on STIs has a sample design of 660 pregnant women. It will provide baseline data: i)to estimate HIV seroprevalence rates among women inthe reproductive age group, ii)to use these rates as a proxy to estimate seroprevalence inthe general population; iii)to obtain information on geographical and age distribution of these infections; andiv) to provide data to encourage use of the VCT programme in antenatal clinics and treatment of infected pregnant women to prevent mother to child transmission of HIV (PMTCT). Results of the seroprevalence survey are expected by December 2004. Another HNseroprevalence surveillance amongprison inmates inSaint Lucia i s being carried out incollaboration with CAREC/SPSTI inthe Bordelais Correctional Facility with 443 inmates. Pointseroprevalence on this population will supplement information about epidemic trends in the general population for estimating general prevalence data andsupport implementation of voluntary counseling andtesting inthe prison setting to care for those who are infected. The survey will supplement limited baseline data on potentially at-risk males in Saint Lucia by age distribution anddistrict of residence. Results are also expected to be available by December 2004. A thirdsource for baseline data is the behavior risk factor surveillance survey to be carried out in2004intwo pilot sites (rural and urban) using the primary health care infrastructure. MOH, Health Canada andCAREC support the survey and data will be available inDecember 2004. The data collection instrument has been designed and includes three questions dealing specifically with HIV/AIDS: Number of "non-regular partners" inthe last 12 months, use of condom with this partner, anduse of condom in general. Other data being captured by this instrument deal with noncommunicable diseases, accidents and injuries, life styles, and substance abuse. 32 Additional behavior-based baselinedatawill be collected duringthe first year of project implementation. HIV/AIDS/STD InformationTechnology Platform and Connectivity Network The project will support the MOWNAPS andthe NACC instrengthening the M&E system. The project will fund the acquisition andimplementation of an ITplatform including an electronic medical records (EMR) application integratedto the HIV/AIDS/STD case management information system (CMIS). The ITplatformwould integrate current surveillance databases operated inthe NSUinthe M O Hand provide HIV/AIDS/STD clinical informationfor decision makingat the point of service. The CMIS will capture demographic andservice provisiondata at the point of service delivery, manageclinical records online (outpatient andinpatient), abstractdata from clinical records for monitoring purposes, andreport results frombehavior and risk factor surveys. The ITplatformwill: i)protecttheconfidentialityofmedicalrecordsthroughencryptedtechnology; ii)improvethequalityofthenotificationandsurveillance informationallowingforcross referenceanalysis from multipledatabases; iii)supportdecisionmakingincasemanagement,byprovidingsecuredonlinerealtime clinical, laboratory and pharmaceutical information at the point of service; and iv) contribute to the National Universal HealthCare Systemby generating a patient and family registry andunique identification (ID)linked to the NationalInsuranceScheme (NIS), providingalso costing and reimbursement mechanismsbasedon discharges and coded procedures [Diagnostic Related Groups (DRGs) andthe ICD9-CM'] . The systemwould provide real time laboratory and clinical information for case management. It would activate notificationand surveillance mechanisms allowing early diagnosis andtreatment inthe areas of antenatalcare, VCT, PMTCT, HIV/AIDS/STD, andtuberculosis )TB. Itwould register patients recording basic demographic information, risk factors andcontact tracing andissue a uniqueID. The IT platform would provide the treating physician with web-based access to online diagnostic and laboratory results on OIs, ART response, CD46and viral load, plan adherence andnon compliance alert, up to date informationon drugprescription, dispensation, online therapeutic protocols, drug adversereaction and resistance, estimated date of HIV transmission, pharmacy7,laboratory, x-ray and other specialty diagnostic interventions,, diagnostic (ICD-lo)* coding and insurance billing processes (ICD9-CM, CPT-49or other codes adoptedby the M O H andthe Universal Health Care/National Insurance Based on the International Classification of Diseases gthrevision 'In white blood cells (lymphocytes). interface with the OECSPharmaceutical Procurement Service system being implemented in the *Victoria Hospital Pharmacy Department. International Classification of Diseaseslothrevision. Common Procedural Classification 4Ihrevision 33 Corporation). The applications would include interfacesfor the electronic transfer of CD4 andViral Loadand other test data andreports generatedby laboratory andblood bank analyzers and for the integration of the HIV/AIDS/STDnotification databases with geo-referencedmapping tools. Featuresto protect patient's Privacy rightsand the integrity and confidentiality of the electronic medical records would include: encrypting technology, double key facilities, and restricted access to medical recordsby authorized personnel. Epidemiological studies and surveillance processes should be basedon codeddata assuringanonymity and confidentiality of epidemiological analysis and research. The system should be able to track quality of care aspects interms of outcomes andcosts, case management- in particular, managementof treatment and adherenceto highly active antiretroviral therapy (HAART). The systemcouldcapture measures of cost effectiveness, efficacy, accessibility, and equity of care to be compared with definedstandards of care treatment and support. The implementation of the HIV/AlDS/STD case managementinformationsystem (CMIS), will include: i)selection,acquisition,andadaptationofapplicationsavailableinthemarketcontaining modules neededto support HIV/AIDS/STD clinical case managementat outpatient and inpatient level through pilot testing inthe Victoria and St. Jude hospitals, the EzraLong NationalLaboratory and BloodBank, and selectedhealth centers; ii)expansioninthesecondphasetoallparticipatinghealthfacilitiesandlineministries; iii)capturedataatthepointofserviceondemographics,clinicalrecordsandbehavior andrisk factor surveys to support real time notification, processing, and reporting ; iv) online, real time access, web-basedinformationfor HIV/AIDS/STI prevention, treatment and second generation surveillance, epidemiologic analysis and research;and v) connectivity with selectedhealth centers, hospitals, laboratories, bloodbanks and central levelMOH. ,line ministries and NGOs. Training will be provided to managers, health professionals andtechnicians, financial and administrative staff of the M O H andrespective health facilities inthe use of information technology andin applications, includingretrieval, geo-referencedstatistical and epidemiological analysis and use of information indecision making. The MIS and the IT will serve as the platformfor the development of MOH's Health InformationSystemcontemplated under the Project inpreparationwith the Caribbean Development Bank (CDB). The implementation in stages will allow pilot testing of the selected applications includingtraining, reengineeringof processes, organization of the ITsupport at the M O H and the selectedhospitals andHealth Centersinthe eight HealthRegions for the first year of the VCT implementation, according to the priorities assignedby the MOH. The first phasewill include the two major hospitals (Victoria and St. Jude, includingpriority wards, VCT/STD clinic, laboratory, bloodbank and pharmacy), Gros-Islet Polyclinic, 34 Vieux Fort HealthCenter andCastries HealthCenter, complemented with the other HealthCentersof the eight regions. The connectivity for the MOH's Wide Area Network (WAN)and the health facilities' LAN(data, VoIP, and video) to be providedby the Project, will benefitfrom the existing wireless backboneoperatedby the Financial Management (FINMAN) ITUnit inthe Ministryof Public Service. A Server room with controlled access and N C , will be required within the offices of the MOH. The secondphaseimplementation will result inthe full scale operation of the HIV/AIDS/STD Clinical MIS and Surveillance andM&Esystems. Itwill include all M O HHealthCenters andDistrict Hospitals andwill be completed by the third year of the project. The proposed implementation should be coordinated with civil works includedinthe Proj.ectfor health facilities selectedfor rehabilitation of VCT rooms, emergency, laboratories and bloodbanks, and should be complemented with connections, the inclusionof embeddedconduits, dedicatedelectrical wiring anduninterruptedpower supply (UPS) for 24 hours power supply. To assure the sustainabilitv of the IT platform, the M O Hwill need an IT Unit at the national level for network and databaseadministration and a help-desk to support networkedfacilities. Specialized ITtechnical assistanceandWAN connectivity support will be obtained from the Government Financial Management (FINMAN)ITUnit. For the implementation of the FirstPhase, the Victoria Hospital will requireestablishing an ITunit.St. Jude Hospitalalready hasthe ITUnit staffed andoperational. The additional human resourcesneededto support the M&Eand surveillance subcomponents include a MonitoringandEvaluationspecialist, an IT specialist for the NAPSMOH andtwo network administrators, one eachfor the MOH's IT Unit and Victoria Hospital ITUnit. Fundingfor the initialoperation of the IT Unitswill be allocated within the Project Management Component. Resourcesfor technical assistance and procurement of the HIV/AIDS/STDCMIS and required ITplatform (hardware and software), clinical and technical staff training and connectivity is estimated inTable 1, and will complement the fundingunder negotiation with CDB. The HIV/AIDS/STD surveillance, M&Eand Clinical Case Management system (CMIS) will be implementedinthe selected HealthFacilities andLine Ministries (See Annex I) providingdecentralized data entry, centralized processing intwo nodes with battery of servers installed at the Victoria and St. Jude Hospitals and access to informationat the point of delivery of care (Hospitals, Laboratories andHealthCenters). Electronic data transfer with MOH's HealthInformationSystem will provideconnectivity, online access to NAPS, the MOH's Surveillance and HIV/STD Units, andfull databaseredundancy andback upprotection. Securedweb-basedbrowsers through IPprotocols (virtual private network (VPN)) and encrypted technology for the protection of patient's confidentiality, should be available to private physicians andlaboratories to access the MOH's health information system. 35 InformationTechnolow Platform. The applications and acquisition of the IT Platform should be modular, scalable and integratedinsteps, according to the following recommendedphases: 1. Preparation of Requestfor Proposals(RFP), short list and selection, andawarding of technical assistancefor the implementation of HIV/AIDS/STDclinical MISfrom applications available inthe market. Inthe preparatory stage, technical specifications for the hardware andsoftware to be acquired and respectivebiddingprocesses will be defined according to the health facilities participating inthe Pilot Phase. 2. Six months parameterization and pilot testinginthe Victoria and St. Jude Hospitals, the national laboratory and the selectedhealthcentersinparallel with the initiation of sensitization and training of the clinical andparamedical staff participatinginthe Second Phasewith the use of case studies with complete medical records of a sample of HIV/AIDSpatients. The pilotwill also includethe implementationof the laboratory and bloodbank test processingmodule (LABIS)" provided by CAREC. Once the modules are operational, connectivity shouldbe established with the M O Hthroughthe FINMAN wireless backbone. 3. Inparallel with the FirstPhase, the project will provide training for the strengthening of the monitoringandevaluation capacity for programdevelopment andmanagement, includingUNAIDS support inthe implementation of data collection and analytical processesinall participating agencies. Lineministries will be providedwith workstations and technical assistancefrom UNAIDS andthe NAPS, to populate and operateUNAIDS/Country Response InformationSystem (CRIS) databases: Indicator database; Projectlresource tracking database; Researchinventory database. 4. Initiationof SecondPhase (second year) implementation inDistrict Hospitals and Health Centers, including the backbone links, testing and implementation of the connectivity and wide area network with FINMANwireless broadband. A tentative budgetis included inTable 1, indicatingthe possible sequence of the procurement processesby year. The proposedtime table is includedinAnnex II. The technical specifications for the ITplatform acceptableto the Bank, should be compatible with the comprehensive national ITstrategy beingimplementedby the GOSL through FINMANITUnit, and will be the basis for the definitionof the final requirementsinHardware and Software to be procured underthe project. Thebidding documents for the purchase and installation of the hardware, should include the responsibility of the provider to install and configure the server's operational software (Microsoft Windows Server 2003 or equivalent with network administrator, servers manager, web page creation), structured query language (SQL) Server with OLAP loCAREC's CariSurv -Lab Information System 2000 "virtual laboratory" application (LABIS) includes specimen and patient registration; test scheduling, barcode label printing and reporting of individual patient results following electronic approval, runningover a LAN with an SQL database. Embeddedis a specimen inventory management system that facilitates tracking o f specimens in short- and long-term storage, and maintains the link between specimen, patient and test data for archived specimens. 36 application or equivalent, with technological upgrade or software assurance for at least two years, network anti-virus and web firewall; multi-licenses for office applications and other geo-referencedmapping software; statistical packages; epidemiological modeling andforecasting applications; uninterruptedpower supply system(UPS) andwiring; switches, panels, structured wiring or wireless as appropriate for voice on IP (VoIP), data andvideo local area networks (LAN). Extendedwarranty for the repair andmaintenance of the equipment for at least three years should be considered. 37 Figure 1: OrganizationalData Flow I Goals I SU$- *44 400 m 0 0 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 I rI 8 8 8 I I 8 I 8 I 8 : I 8 8 8 I 8 I 8 I 8 I 8 I 8 I 8 I 8 I m I 8 ! 8 I 8 I 8 I 8 I 8 I 8 I 8 I 8 b 8 I 8 I I 8 I 8 I 8 I 8 I I 8 I 8 I 8 I 8 8 t 8 8 8 8 8 8 8 8 8 8 8 Develops 8 8 8 8 \ 8 8 8 8 8 Information Products 8 8 Annual Evaluation Reports Disseminatedto CoordinatingCouncil NACC 8 8 8 8 onthly Service Statistics Stakeholdersat national, district m8 8 and local level m 1 0 Mid-term & end of project Private Sector, Public Sector 8 0 0 And Civil Societv 1 44 44 T 0 d I Annex 4: Detailed Project Description Saint Lucia HIV/AIDS PreventionAnd Control Project The project will support the Government of Saint Luciato implement its national responseto the HN/AIDS epidemic inall the key areas of a comprehensive responseincluding prevention, care, treatment and impact mitigation: Prevention includinginformation, education and communication with anemphasis on behavior change communication for specific target groups andthe generalpopulation; condom promotion; and voluntary counseling and testingand ensuring safe blood Care and treatment of STIs and opportunistic infections including tuberculosis antiretroviral treatment; and support to home and community-based care and support services; Capacity buildingfor service provision: training of healthworkers, strengtheningof laboratory services; Strengthening of monitoring andevaluation andresearchincluding: surveillance (sentinel, population-based and behavior) and program managementmonitoringbasedon performance indicators for eachprogram; and, Capacity buildingfor advocacy, policy formulation, program coordination, resource managementand implementation at all levels. The project will be implemented over a periodof 5 years and will be financed through an IDA andIBRDblendof grant, credit andloanwith Government contributionfor counterpart funds. The project will have four componentsas outlinedbelow. Component 1: Community and civil society initiatives (US$0.75 million) Civil society organizations (CSOs) are more effective than public sector agenciesinreaching certain difficult to reach groups vulnerable inthe community, such as commercial sex workers and other hard-to-reach-groups. The civil society organizations also operatemostly at community level where there are opportunities to interact directly with individuals and communities. While some civil society organizations may be well developed andready to implement their respective HN/AIDS program activities, others may need substantial capacity buildinginorder for them to be effective. Thiscomponent will finance HN/AIDS prevention, care andsupport activities ledby communities, NGOs, FBOs, women's organizations, the private sector and other similar organizations. It will also support capacity buildingactivities of civil society organizations to effectively respondto HN/AIDS. The types of HN/AIDS activities to be supportedby this component will be demanddriven and will vary depending on the proposalsthat will be presentedby the respective CSOs. Examples of activities by these organizations that will be eligible for project support include, but are not be limitedto the following: 43 a) Delivery of community basedHIVIAIDS IECBCC; b) Condom distribution andor social marketing; c) Home-basedcare of PLWHA; d) Community advocacyto reduceHIV/AIDS stigma anddiscrimination; e) Support activities for orphans and widows/widowers of HIV/AIDS; f) Support activities for peopleinfectedand affected by HIV/AIDS, especially those targetedat PLWHA, includingincome-generating activities; g) Community targetedactivities for HIVIAIDS vulnerable groups, including commercial sex workers, out of school youths and single women; h) Trainingof civil society organizations onHIV/ATDSknowledge and communication; i)Trainingofleadersofcivilsocietyorganizationsonfinancialmanagementpractices relevant to the implementation of the HIV/AIDS project; and, j) Provisionofessentialgoodsandsuppliesfor NGOstoenablethemtoeffectively function while delivering HIV/AIDSprevention care and support services. Criteria for eligibility and procedures for the civil society organizations to access project fundingwill be specified inthe OperationalManualof the project. Inparticular, the Operational Manual will specify eligibility criteria for funding, the processfor application andapproval of fundingandthe reporting arrangementsbetweenthe civil society organizations and the project coordinating team. Eligibility criteria will be flexible enough to allow greater participation of various categoriesof civil society organization inthe fight against HIV/AIDS inthe country. The reporting arrangementsfor the civil society organizations will be simple enoughto enable accountability without overburdening the limited capacity of particularly smaller organizations. Component2: Lineministryresponse(US$0.97 million) An effective and comprehensiveresponseto HIV/AIDSincludes the responseof all sectors as each sector has aunique role to play inthe fight against HIV/AIDS. This component will support the responseto HIV/AIDS by non-health sector line ministries. There are basic cross-cutting HIV/AIDS activities which all ministries are expectedto implement under their respective sectoral HIV/AIDSprograms andto be supportedunder this component. These include: (a) develop and implement workplace HIV/AIDSpolicies; (b) IECBCC for HIV/AIDSand STDs (c) condom distributionandpromotion; (d) advocacyto reduce HIV/AIDS stigmatization anddiscrimination, particularly inthe work place; and(e) establish support groups for HIV/AIDSpatients and their families (either as a single ministry or in collaboration with other ministries). There are also HIV/AIDS relatedinterventions that are specific to aparticular ministry and each ministry will identifyits specific HIV/AIDSprogram needs to be supportedby this component. For example, populations potentially at risk within the sphere of influence of the Ministry for HomeAffairs are prisoners, fire fighters, delinquent youth, juvenile delinquents and police officers. For the Ministry of Education, HumanResourcesDevelopment, Youth and Sports it will be school age children and out of school youth. The Ministry of Tourism's 44 highriskpopulations groupsarecommercial sex workers, water sports andtour operators, taxi drivers and street vendors. All ministries are expectedto be implementing their respective HIV/AIDS programs by the end of the third year of project implementation. However, a number of ministries are expectedto participate as of the first year of project implementation: (a) Education, HumanResourcesDevelopment, Youth and Sports; (b) Public Service andLabor Relations; (c) Tourism; (d) Social Transformation; and (e) Home Affairs. Ministrieswill appoint their respective HIV/AIDS focal points (person or unit) to lead the HIV/AIDS response. A focal point person is a minimumrequirement but, where feasible, a sectoralHIV/AIDS committee will be set upto support the focal point to help institutionalize the sectoralHIV/AIDSresponse. The focal point will coordinate the ministry's HIV/AIDS planning, implementation, monitoringand evaluation. Focalpoints will receive training to develop the skills required to lead their respective sectoral HIV/AIDS response. Component3: Strengtheningthe healthsector responseto HIV/AIDS (US$3.59 million) This component will strengthenthe health sector responseto HIVIAIDS by supporting health sector HIV/AIDS related services for prevention, treatment, care and support especially in the following areas: a) Information,Educationand CommunicatioflehaviorChangeCommunication (IECBCC). Support will beprovidedto strengthenIECBCC for HIV/AIDS. In particular, support will be providedto the bureau of health education to strengthenits capacity to provide technical leadership for scaling-up of HIV/AIDSIECBCC. The M O Hwill also receive support for development of IECBCC interventions using different media (radio, television, leaflets). This will complement the interventions of line ministries and Civil Society Organizations. b) Voluntary Counselingand Testing(VCT). The project will support the provision of VCT servicesinall eight healthregions of the country. This will include minor civil works in selected facilities to ensure confidentiality to clients duringVoluntary Counseling for HIV/AIDS. Itwill also provide, equipment, testing kits, reagentsand training in VCT for health care workers. c) Ensuringsafetyof bloodsupplies. The project will support the ministryto ensure safety of blood from HIV andother bloodborne diseases. Support will include strengthening the bloodstoragecapacity. d) TreatmentofSexuallyTransmittedDiseases. The project will support the strengthening of the existing STD services providedby the ministry and introduce the syndromic approach to the managementof STDs. Drugs and training of health care workers will be funded. e) Distributionof condomswithin the healthfacilities. At the moment the MOH distributes about 82,000 condoms a year through its health facilities. Condoms are also provided by UNFPA. People also access condoms directly from the open market. The project will support promotion, provision anddistribution of condoms through the ministry's healthcare network, social marketingand by CSOs. 45 Treatment care and support of PLWHA. The project will support the MOHin scaling up its services for the treatment and care includinghome-basedcare for PLWHA. Inparticular, the project will supportthe servicesfor treatment of opportunistic infections, treatment of sexually transmitted diseases, the introduction of the use of anti-retroviral drugs for PLWHAwithin the ministry's services, prevention of mother to childtransmission of HIV/AIDS including the treatment of mothers with anti-retroviral drugs (PMTCT-PLUS), and support of nutritional interventions for PLWHA. Healthcare workers will be trained in managementof HIV/AIDSpatients. The project will supportthe strengthening of the laboratory capacity to assist inthe diagnosis, treatment and care of PLWHA. Inparticular, the project will support the training of staff, acquisition of materials and equipment required for the use of antiretroviral drugs for the managementof PLWHA. Guidelinesand Treatment Protocols. The project will support the development, updating anduse of different guidelines and treatment protocols including: IECBCC, VCT, STD management, treatment andcare of PLWHA includingtreatment of opportunistic infections, anti-retroviral care, home-basedcare, interalia. Health policies formulation and technical support to legislators on issues relating to HIV/AIDS. The project will support the ministryindeveloping health sector policies that enhance the delivery of HIV/AIDS services within the health sector. The project will also provide technical support to legislators on issues related to HIV/AIDS. Promotion of safe workplace procedures inthe health sector. The project will support the ministry instrengtheningthe implementation of its safe workplace proceduresto minimize occupational HIV infection amonghealth care workers. Medical waste management. The project will support the ministry inimplementing its medical waste managementplan, as it relates to the disposal of medical waste createdinthe course of delivery of services to PLWHA. Inparticular, the project will support training of health care staff to keep upto date with the requirements for safe disposal of biomedical waste. HIV/AIDS surveillance and operational research. The project will support the strengthening of the HIV/AIDS surveillance system andrelated operational research (See Annex 3). Technical HIV/AIDS support to non-health ministries and civil society organizations. The ministry has technical HIV/AIDS capacity that can be usedby the non-healthministries andcivil society organizations to implement their respective HIV/AIDS programs. The project will support the ministry inits efforts to extend its technical HIV/AIDS skills to the non-health ministries and the civil society organizations. Component 4: Strengthening institutional capacity for program management, Monitoring and Evaluation, and Legal Technical Assistance (US$2.66 million) This component will help buildthe institutional capacity for scaling upthe responsethrough financing of technical advisory services, training, staffing, equipment, goods and general operating costs of the following activities: 46 Strengthening institutional capacityfor coordinating and managing the Government's National HZV/AZDS Program. The project will fund the policy makingand oversight functions of the National HIV/AIDS Coordination Council (NACC ) inthe Office of the Prime Minister to coordinate the national responseandensure an appropriate policy and legal environment. The Council i s chaired by the Presidentandincludes key stakeholdersfrom the public sector, and civil society. The NationalHIV/ADS Secretariatwill provide operational support to the NACC. Functions of the Secretariatto be supportedinclude: (a) overall coordination of project implementation; (b) monitoringandevaluation; (c) financial management and procurement through the PCU; (d) HIV/AIDSrelated training of staff of the Secretariat; (e) support of the functions of the NACC to advise the Secretariat. Financing will include consultant services, staff with specialized skills inspecific areas, technical assistance, materials, furniture, and equipment for the operation of the Secretariat. Functions of the Secretariat that cannot be provided in-house will be out-sourced. Strengthening monitoring and evaluation including the information technology plagorm. The NationalHIV/AIDS Secretariatwill monitor the progressof project implementation in: (i)strengthening program monitoringcapacity; (ii) developing and strengthening the HIV/AIDS/STI case management; and(iii) measuring the trend of the epidemic. The project will train managers; healthprofessionals andtechnicians; financial and administrative staff of the M O Hand respective health facilities inthe use of informationtechnology. It will also support connectivity andwide area network services andinternet service provider and technical assistancefor developing a national plan and activities on surveillance, research, and evaluation. The HIV/AIDS/STIsurveillance, monitoring and clinical case managementinformation system (MIS)will be developed modularly to support project components. It will capture demographic and service provisiondata at the point of service delivery, manageclinical records online (outpatient and inpatient), abstractdata from clinical records for monitoring purposes, and report results from behavioral surveys. Information will be providedfor real time decision making, and for processing, and reporting VCT, STI, PMTCT and ARV interventions. Resourcesfor hardware, software, staff, training and technical assistancehave beenestimated. (Annex 3) Legal Framework. Under this subcomponent the project will: (i) the country's civil, assess economic, and social rights legislation and provide assistanceindraftinga comprehensive new act that will ensure to people living with HIV/AIDS and other vulnerable populations, including children affected by HIV/ADS, full equality and dignity under the law, without stigma or discrimination. UNADShas extensive knowledge and experience inthe promotionof human rightslegislation, has a well-developed methodology for drafting this kindof legislation and will be apartnerinthe execution of this subcomponent; and (ii) provide technical assistanceto help the Registrar of Industries and Intellectual Property RightsandMOH's Pharmaceutical Office update the necessarylegal andregulatory provisions to make the country's legal framework compliant with the WTO's Agreement on Trade-Related Intellectual Property Rights(TRIPS)ina manner that fully protects the public health and that promotes access to HIV/AIDSdrugs and related medicines and supplies to all who needthem. Saint Lucia will participate in the Caribbean Community (CARICOM) wide 47 assessment of patent and drug regulatory systems to be carried out under the The PAN Caribbean Partnership against HIV/AIDS Project. Technical assistance to be providedunder this subcomponent will be dovetailed with the CARICOM assessment. 48 Annex 5: Project Costs Saint Lucia HIV/AIDS PreventionAnd Control Project Local Foreign Total Project Cost By Component and/or Activity us us us $million $million $million Community and civil society initiatives 0.75 0.0 0.75 Line Ministry response 0.87 0.10 0.97 Strengthening the health sector response to 1.54 2.05 3.59 HIVIAIDS Strengthening institutional capacity for program 1.76 0.90 2.66 management LoanFee 0.00 0.03 0.03 T O ~ IProject Costs' 4.92 3.08 8.00 'Identifiable taxes and duties are US$700,000 and the total project cost, net of taxes, i s US$7,300,000. Therefore, the share of project cost net of taxes is 91percent. 49 Annex 6: InstitutionalandImplementationArrangements SaintLuciaHIV/AIDSPreventionAnd ControlProject InstitutionalArrangements The project will be implementedthrough an institutional andmanagementstructure that will permitthe widest participation of public sector andprivate sector stakeholders andallow incorporation of current and future donors of the international community. A Cabinet Decisiondated May 3,2004: (i) createdthe NationalHIV/AIDS Coordinating Council (NACC) to be chaired by the Prime Minister andconsisting of fifteen members of which eight membersrepresent civil society; (ii) createdthe NationalAIDS Program Secretariat (NAPS); and (iii) authorized the appointment of a Director for NAPS and appropriate staff. The NACC will guide program execution and advise the GOSL on HIV/AIDSpolicy, set project priorities, advise on budgetparameters, and ensureexecution of the National Strategic HIV/AIDSPlan 2003-2008. The NACC will be accountable to Cabinet for project results. NAPS will be the operating armof the NACC and will implement its decisions. It will coordinate implementation of the project. The responsibilities of the NAPS will be twofold: (i) providingtechnical support to the implementing agencies inplanning and preparing the project's work plans and monitor and evaluate results; and (ii)supporting the implementing agencies with efficient and transparent financial andprocurement management services. The governancestructure proposedby GOSL for the national HIV/AIDS response i s depicted in Figure 2. The NationalHIV/AIDS Coordinating Council (NACC): The GOSL will assignthe responsibility for supporting, overseeingand coordinating the national responseto the NACC. This will provide strong visibility and accountability of the national response and the project to the Cabinet and to the broader public interest. The NACC will: 9 include public andprivate sector stakeholder groups: representatives of line ministriesandrepresentativesof relevant private institutions suchas NGOs, FBOs, CBOs, Chamber of Commerce, manufacturing associations, Hotel and Tourism Association, andhealthcare providers; ii) befullyaccountabletoCabinetviathePrimeMinisterforprogramresults; iii) advisetheCabinetonpoliciesandstrategiesthatrequireCabinetapproval; iv) set the priorities for the program; v) advise on program and budget parameters; vi) prepare an annualreport on the national response; vii) mobilize national and international resourcesfor the fight against HIV/AIDS, and viii) mobilize multi-sector support for the national response. The Prime Minister will chair the NACC and will appoint an alternatechair. The Chief MedicalOfficer of M O Hwill act as Secretary to the NACC and will: i) bea national spokespersonfor the NationalHIV/AIDSResponse, ii) interface between the public and the Government on mattersof HIV/AIDS advocacy, 50 iii) serveasamajorpointofcontactbetweentheGovernmentandtheinternational HIVIAIDS community. The NationalAIDS Program Secretariat (NAPS) will support, coordinate and oversee program implementation by the implementing agencies. It will not itself be engagedin implementingthe nationalresponse. Itwill carry out its supportive and coordinating roles through two units: (i) a Technical UnitlocatedinMOH; and (ii)PCUresponsible for a handling all financial management andprocurement activities. The Director of NAPS reports to the NACC via the PermanentSecretary of the M O H will be directly responsible for managing the technical aspects of the NationalAIDS Program Secretariat. The Directorwill liaise with the MOF via the PermanentSecretary of the MOF for providinginstructions and guidance to the PCUon financial management andprocurement activities. The NAPSwill facilitate, coordinate andprovidetechnical oversight for allHIV/AIDS prevention andcontrol work programs and plans to be executedby the three types of implementing agencies (described below). It will ensure that all proposed activities are in line with the National Strategic Plan. The NAPS will be staffed by programofficers with skills and experience in strategic planning, monitoringand evaluation, information technology, and communication strategies. It will also have a coordinator for the Line Ministries and the CSOs and an internal auditor to verify compliance with financial and technical guidelines, and supportive administrative personnel. Such staff may be recruited through personal services contracts or secondedfrom other branches of government service inorder to promote sustainability of the Unit. The NAPSwill receive support from technical departmentsinMOHinspecific substantive areas. Itwill aggregatethe results from the monitoringand evaluation processes of the national responsefor consideration and eventual decisions on changes inpolicies andoperating procedures by the NACC. The Proiect Coordination Unit(PCU) is currently locatedinthe Ministry of Physical Development, Environment and Housingandhas experience inmanaging two World Bank projects. The unit will be transferred to the Ministry of Finance by Cabinet Decision. It i s an ad hoc unit staffed by expert consultants infinancial management and procurement to provide services to externally financed projects including this HIV/AIDS Prevention and Control project. The PCU Coordinator reports to the PermanentSecretary of MOF. The Permanent Secretary of M O Hand the Director of NAPS will evaluate PCU's performance annually and transmit the evaluation report to the PermanentSecretary of MOF. The PCU will handlefinancial managementtasks (keeping books of accounts for all project resources inaccordancewith GOSL andWB regulations, disbursingfunds to implementers, requesting payments or reimbursements from the World Bank, preparing consolidated financial reports) and procurement activities (procuring goods and services, biddingand contracting tasks) and will be staffed by a financial management specialist, a procurement specialist and appropriate administrative support personnel. The National CoordinatingCommitteeon HIV/AIDS (NACCHA) consists of representativesof the MOH, Line Ministries and Civil Society Organizations and will assist NAPSinreviewing andevaluating annual work plansof LineMinistries andproposals for 51 subprojects submittedby Civil Society Organizations. RecommendedCSO proposalswill be referred to NAPS for approval and to NACC for ratification. IMPLEMENTING AGENCIES Since the first case of AIDS was reportedin Saint Lucia in 1985, M O H has provided strong clinical andtechnical leadershipinthe fight against the spreadof HIV/AIDS and will continue to do so. It has done this usingits technical departments andservice providing institutions. Responsibility for project implementation will fall on the function-specific central level departments and units (MCH, Health Education, Nutrition, etc.), on the national and district hospitals, on the health centers, on the clinical laboratories, and on the blood bank. Assigningimplementation responsibility to MOHline unitswill increasethe capacity of M O Hline departments to executehealth programs. M O Hwill appoint aperson responsible for implementing all aspects of the HIV/AIDS program within the Ministry who will work with all central level line units, with hospitals, health centers, diagnostic services, bloodbank and any other M O Hservicethat will support project implementation. MOHwill also beresponsible for implementing an improvedbiomedical waste managementprogram. HIV/AIDS Focal Points inLineMinistries: A number of national ministries andagenciesin the public sector will assume responsibility for HIV/AIDS prevention and control. Populations potentially at risk within the sphere of influence of the Ministry for Home Affairs are prisoners, fire fighters, delinquentyouth, juvenile delinquentsandpolice officers. The Ministry for Labor Relations, Public Service and Co-operatives will promote the application by private industry of ILO guidelines on workplace policies dealing with discrimination and humanrights. Populations potentially at risk for the Ministry of Education, HumanResourcesDevelopment, Youth and Sports are school age children and out of school youth. The Ministry of Tourism's highriskpopulations groups are commercial sex workers, water sports and tour operators, taxi drivers and street vendors. A focal point - an individualidentifiedineachparticipating Ministry - will be responsible for coordinating andmanagingHN/AIDS relatedactivities intheir respective institutions adaptingthe components of the national responseto the specific needs and characteristics of their constituencies and target populations. A sectoral HIV/AIDS Committee will support and provide guidance to the focal point person. Line Ministries will receive technical and financial support for developing andimplementing work programs from the Technical Unit of the National AIDS Program Secretariat. A staff member inNAPS will work with line ministries. Details of these arrangementsare contained in the Project Operations Manual. Civil Society Organizations: NGOs, FBOs and CBOs, PLWHA groups, and other private sector entities will be invitedto initiatenew HIV/AIDSprevention andcontrol activities or to extend and/or continue those that they are currently managing. The NGO Act providing a legal framework for NGOs is under preparationfor approval by Parliament and will regulate eligibility criteria, registration and licensing of NGOs. SelectedNGOs may also be invitedto performspecific functions such as lEC/BCC activities or support formulatingand/or implementing work programs of line ministries. Depending on their comparative advantage, they will serve the needs of specific target groups at risk or inneedof care. As inthe case for the line ministries, technical and financial support for program development and for program implementation will be provided by and through the NationalAIDS Program 52 Secretariat. Many civil society organizations are relatively small, of recent origin anddo not have the necessary fiduciary andmanagerial structure to enter into performance-based contracts with the NAPS. Recognizing that these grassrootsorganizations however could play an important role intheir respective communities, sustainedefforts will be made to mentor, coach and support them. Largerwell-established NGOs could serve as mentors to smallemergingNGOs. A staff member of NAPS will work directly with civil society organizations. Details of the relationships between the NAPS andthe civil society community are contained inthe Operations Manual. Figure 2: InstitutionalArrangements Office of the PrimeMinister Cabinet NationalHIV/AIDS CoordinatingCouncil(NACC) Chair: PrimeMinister National AIDS ProgramSecretariat NationalCoordinating Financialand Committee on HIV/AIDS (NACCHA) IPrnriirementMot I I I I ImplementingAgencies 1 1 1 MINISTRY HEALTH OF NON-HEALTH CIVIL SOCIETY MINISTRIES NGOs Central Level Units Education, Youth & Sports FBOs Hospitals& HealthCenters Public Service CBOs Laboratories Tourism PrivateSector BloodBank SocialTransformation Trade Unions Home Affairs 53 Implementation Arrangements for Line Ministries Component 2 will support the responseof the non-health sector ministries to HIV/AIDS. There are basic cross-cutting HIV/AIDS activities that all ministries will be able to implement. Theseinclude: (a) development andimplementation of workplace HIV/AIDS policies; (b) IECA3CC for HIV/AIDSand STDs; (c) condom promotionand distribution; (d) advocacy to reduce stigmatization and discrimination; and (e) establish support groups for personsinfected with HIV/AIDS. Some HIV/AIDS related interventions are specific to a particular ministry's external clients, for example, pupils, students andteachers for the Ministry of Education; the hotel industry for the Ministry of Tourism; and the uniformed forces and the prison population for the Ministry of Home Affairs. All ministries will beeligible to obtain fundingfor their HIV/AIDS activities under the project. To access funding, a Ministry should have: Identifieda person (focal point) responsiblefor managingthe HIV/AIDSactivities within the Ministry. Ministries will designateHIVIAIDSfocal points (person or unit) who will lead the HIV/AIDSresponse. The focal point will coordinate the ministry's HIV/AIDSplanning, implementation, monitoringandevaluation functions. Focal points will be supportedby the project to receive training to develop the skills to lead their respectivesectoral HIV/AIDSresponseeffectively. Established an HIV/AIDS team to provide guidanceto the HIV/AIDS focal point. A focal point personi s a minimumrequirement but, where feasible, a sectoral HIV/AIDScommittee should be set upto support andprovide guidance to the focal point for the purposeof institutionalizing the sectoral HIVIAIDS response. Developedan annualwork planfor its proposed activities. The'annualwork plan should be inline with the priorities of the NationalHIV/AIDS Strategic Plan. It should indicate the funding sources for proposed activities including: Ministry's own contribution through its budget; requestedfunding from this project, funding from any other donors andexternal agencies, and funding from the private sector. While all relevant ministries are expectedto be funded under the project, the following ministries andany other ministry that has met the above readinesscriteria will preparework plansfor the first year of project implementation: (a) Education, HumanResource Development, Youth and Sports; (b) Public Service and Labor Relations; (c) Tourism; (d) Social Transformation; (e) Home Affairs and Internal Security. Annual work plans will be reviewed by the NationalCoordinating Committee on HIV/AIDS (NACCHA), referred to the National HN/AIDS Program Secretariatand to the NationalHIV/AIDS Coordinating Council for ratification. 54 SUBPROJECT CYCLEFORLINEMINISTRIES Stage Activity 1 Timing Responsible Party Planning Issue Guidelines to line ministries Annually National HIV/AIDS on work plan preparation and assist Secretariat (NAPS) indesigningandbudgeting project mid-term evaluation Project Completion Report Mid2009 NAPS Implementation Arrangements for Civil Society Initiatives. Civil society organizations (CSOs) will implement component 1through sub-projects to be fundedby grants. CSOs include: Associations of PLWHA, NGOs(local andinternational), community groups, professional associations, trade unions and private sector organizations. They will all be eligible for funding and will apply for grants through subprojects. The NAPS may also solicit particular CSOsto prepareproposals for undertaking specific activities. Private sector organizations may be requestedto provide co-financing and will follow procedures specified inthe operations manual including: Principles of operation: The Secretariat will coordinate the activities of the CSOs to ensurethat they are fully integratedinto the national HIV/AIDS program; The project review, monitoringand accounting process will be open andtransparent; and Systems will facilitate interaction betweendifferent CSO's working together e.g. NGOs and CBOs. 55 Eligibleapplicants: 0 Establishedgroup recognizedby the NAPS, registered through a relevant Government agency, or have international recognition; 0 Have demonstrableexperience incommunity work or be endorsedby community leaders; and Have a management andaccounting structure. IfthesecriteriacannotbemetthentheNAPSinsome cases mayhelp attaineligibility or suggest twinning arrangementswith an eligible group. Proceduralarrangements:CSOs will prepareand submitproposalsfor subprojectsto the NAPS. Followingapproval of the subproject, they will implement the subproject andsubmit quarterly progressreports and a completion report at the endof the project. The NAPS will disseminateinformationand guidelines on proposal preparation. NAPS will review the eligibility of CSOs. The National Coordinating Committee on HIV/AIDS (NACCHA) will evaluate the technical soundness of the proposal and refer themto NAPS for approval andto the NACC for ratification. NAPS will provide technical assistanceto CSOs and monitor implementation of sub-projectsprovidingregular progress reports to the NACC. Eligibleactivitiesinclude: IEChehaviorchangeactivities (drama, seminars and talks), guidance to care-givers, provision of care and support to PLWHA, support to orphans, schemes for income generation to replace income, guidance on treatment for STD, opportunistic infections and ARV, voluntary testing and counseling. 56 SUBPROJECTCYCLEFOR CSOS Activit Timing ResponsibleParty Annually National HIV/AIDS Secretariat(NAPS) Annually NationalHIV/AIDS Secretariat I Preparesub-projects DreDaration andsend Annually or bi- cso proposalsto NAPS annually Appraisal Review eligibility of applicants and Annually or bi- National HIV/AIDS annually Secretariat NACCHA to evaluateproposals Annually or bi- National Coordinating andrecommendapproval in annually Committee on accordancewith guidelinesand HIV/AIDS budget Transmit list of recommendedsub- Annually or bi- National HIV/AIDS projectsto NACC for approvaland annually Secretariat financing. Approval Approve eligible subprojectsand Annually or bi- National HIV/AIDS authorizeNAPS to sign contracts annually CoordinatingCouncil with CSOs Contracting Sign contract with CSO specifying Annually or bi- National HIV/AIDS rights andobligations andincluding annually Secretariat a financiaVprocurement plan Disbursefunds accordingto signed As needed National HIV/AIDS contract Secretariat Implementation Report project progress Quarterly cso _ _ - Supervision Review progressof implementation Quarterly National HIV/AIDS Coordinating Council Mid-termevaluation of CSO Mid2007 National HIV/AIDS initiatives as part of project mid- Secretariat Mid2009 National HIV/AIDS Secretariat 57 Annex 7: Financialmanagementanddisbursementarrangements SaintLuciaHIV/AIDSPreventionAnd ControlProject Summary Conclusionof FinancialManagementAssessment. On the basis of the assessments performed, the financial managementteam recommendedthe following: (i) The Project Implementation Unit(PCU), currently locatedinthe Ministryof Physical Development, Environment and Housing and responsible for managing the fiduciary aspects of two World Bank projects (ERP and ERDMP),will managethe fiduciary aspects of the project. (ii) The PCU will be transferredto the Ministry of Finance, after Cabinet approval, to provide fiduciary services to externally financed projects, including ERP, ERDMP and the proposedHIV/AIDSproject. This transfer is neededto ensure the same level of commitment to all externally financed projects. (iii) The PCU already has inplace an adequatefinancial managementsystemto manage the fiduciary aspects of World Bank projects. (iv) After the PCUcarriesout the proposedaction plans presentedinthis assessment, especially the hiring of a Project Accountant, it will have inplace adequate financial management arrangementsthat meet the Bank minimumfiduciary requirements to managethe financial activities of the project. The following actions will becarried out: (1)the PCUwill opena Special Account denominatedinUSDin a commercial bank acceptableto the World Bank; (2) since the PCU has extensive experience with report baseddisbursementprocedures, loan funds will be disbursedto the Special Account on the basis of FMRs; (3) each quarter, the PCUwill preparethe Financial MonitoringReports (FMRs) to be submitted to the Bank (the FMRs will include a narrative outliningthe major project achievementsfor the quarter, the project's sources and uses of funds, a detailed analysis of expenditures by sub-component, a physical progressreport, a procurement report, a procurement table and any additional schedules requiredfor disbursementpurposes); and (4) annual project financial statementswill be audited inaccordancewith InternationalStandardsonAuditing issuedby the International Organizationof SupremeAudit Institutions (INTOSAT), by the Office of the Auditor General of Saint Lucia, in accordance with terms of reference (TORS)acceptableto the Bank. Annex 6 details the implementing agencies includingthe National HIV/ADS Coordinating Council (NACC) and the NationalA D S Program Secretariat (NAPS). The responsibilities of the NAPS would be twofold: (i) providingtechnical support to the implementing agencies inplanningandpreparing the project's work plansandmonitor andevaluate results; and (ii) supporting the implementing agencies with efficient andtransparent financial and procurement management services through the PCU. The PCUhasexperience inproviding procurement and financial managementsupport to World Bank financed projects and wili be responsiblefor fiduciary aspects of the project, such as maintenance of accounting records, processingdisbursements, maintaining administrative records, reviewing contracts and makingpayments for activities relatedto the project. 58 The useof the PCUto managethe fiduciary aspectof the project (both financial management and procurement activities) was recommendedfor two reasons: (i) the MOHhas little experience with managing fiduciary aspects of donor-funded projects, hence considerable work would be neededto meet the minimumBank requirements for the financial management of the proposed project, and (ii) the PCUhas experience inmanagingthe fiduciary aspects of Bank projects through its involvement with the Emergency Recovery and Disaster Management projects. This arrangement utilizes the existing resources and expertise inBankfinanced projects in Saint Lucia. The PCU will be transferred to the MOF by Cabinet decision andwould provide financial management and procurement services to all externally financed projects, includingthe proposed project. The financial management aspectsof the proposedproject will be managedcentrally by the PCU, as detailed inthe flow of funds sectionbelow. FIow ofFunds. Project funds will be channeledto the project through a SpecialAccount denominated inUS Dollars to be openedby the PCUina commercial bank. The PCUwill operate a local currency SpecialAccount, to finance project expenditures inlocalcurrency, where funds from the maindollar Special Account will be periodicallytransferred (funds sufficient to cover no more than 30 days worth of expenditures) and will be operatedin accordance with the proceduresandguidelines set forth inthe Bank's Disbursement Handbook. The PCU will also operate a Project Account for the purpose of receiving counterpart funds from Saint Lucia. This account will be maintained ina commercial bank. As depicted inthe graph below, as eligible expenditures are incurred, the PCUwill withdraw the amount to be financed by IBRDfrom the Special Account (US$ or EC$) inaccordance with the financing percentage agreed. It will also withdraw the counterpart portion of the payment from the Project Account. Therefore, in most cases, payment to vendors will need to be done usingtwo checks or transfers. This will ensure that government andIBRDfunds are not comingled. 59 Figure3: Flow of Funds I I FMR AIlocation Applications Request I I Portion IBRO I Financing \ Counterpart funding will be provided by Saint Lucia under the umbrellaof M O Hoverall budget. Each year, the PCUwill coordinate with the Financial Analyst at MOHto ensure the inclusion of project counterpart fundingneeds inthe overall MOHbudget, basedon approved annual work plans submitted by eachof the implementing Ministries. Budget allocation will be made to the Project Account, via M O Huponreceipt of a requestby the PCU. The proposedproject funding will be included inthe annualbudget startingwith the 2004/2005 fiscal year budget where a total of EC$2,782,353 was includedfor boththe World Bank andcounterpart contributions estimates underthe new initiatives category inthe M O Hbudget. The PCU will execute all payment orders on behalf of the line ministries (including MOH) that will receive financial support for specifically approved activities in their annual work plans. The PCUwill carry out the procurement for services andlor goods inaccordance with Bank procurementguidelines, and make payments to vendors for specific eligible expendituresincurredby line ministries, uponreceipt of requests. This arrangement will not require additional accounts for Bank funds, as all financial transactionswill flow directly from the PCU's Special Account. Furthermore, this will allow all expenditures under the project to appear as expenditures for the M O H andinaddition will appear inthe MOHs financial statements. This arrangement will also fall under the normalscope of work for the annual external audit. The PCUwill also disbursefunds to CBOs, NGOs andFBOs to implement the demand- driven subcomponent of the project. Indoing so, the PCUwill utilize the disbursement procedures applicable to community-driven development project, as explained inFiduciary Managementfor Community-Driven Development Project: A Reference Guide (May 2002), as it also applies to HIV/AIDS projects. Disbursements to Civil Society Organizations will 60 bebasedon signed sub-project agreements. Sub-project agreementswill require (a) a minimumstandardfor financial reporting andaccountability and (b) the Bank's prior review and clearance of the template used. Tranche paymentsto community groups will be treated as eligible expenditures for replenishment, as longas they are madeinline with the provisions of the financinghbproject agreement. Reporting and accounting for the tranche paymentswill be submitted by each subproject to the PCU, ina form and content appropriate for the project (the report will include at least progress and completion reports, minuteof community meetings, and a statementof expenditures). Second andthirdtranche payments will only be made upon submission of satisfactory financial reports or appropriate supporting documents for expenditures by the subproject to the PCU. Accountingand Reporting. The PCUwill be responsible for producing the Financial Monitoring Reports (FMRs) on a quarterly basisto be submitted to the Bank. The FMRs will provide useful monitoring informationand will be usedfor disbursement purposes. The FMRswill include anarrative outliningthe major project achievementsfor the quarter, the project's sources anduses of funds, a detailed analysis of expenditures by sub-component, a physical progressreport, a procurement report, a procurement table and any additional schedules requiredfor disbursementpurposes. FMRsshould be submitted to the Bankno later than45 days after the end of eachreporting period. The annualfinancial statementswill include the project's sources anduses of funds, a detailed analysis of expenditures by sub-component, a schedule of withdrawal applications presentedduringthe year and areconciliation of the Special Account. These reports will be preparedby the PCU and made available to the auditors after the endof each fiscal year. Audit Arrangements. Project financial statementswill be auditedannually. As inmost OECS countries, the Director of Audit i s responsible for auditing and reporting on the public accounts of the country, includingprojects funded by international organizations. The Auditor General's Office has performed adequatelyinthe past interms of the quality of the audit reports provided andthe timely delivery of annual audited financial statements for World Bankprojects. Therefore, annualproject financial statementswill be audited in accordancewith International StandardsonAuditingissuedby the InternationalOrganization of SupremeAudit Insitutions (INTOSAI), by the Office of the Auditor General, inaccordance with TORs acceptableto the Bank. Auditors should provide an audit opinion on project financial statements, and a report on internal controls. The TORs should include the financial activities undertaken by implementing Ministries and civil society (NGOs, CBOs, FBOs, etc.). The project's annual audit report will be requiredto be submittedto the Bank no later than 4 months following the end of the fiscal year (April-March). DisbursementArrangements. Proceedsof the loan/credit/grant would be disbursedto the US Dollar denominated special account managedby the PCUfollowing effectiveness. Disbursementswill be made basedon report baseddisbursement procedures (FMR applications) submittedto the Bankon a quarterly basis (no later than 45 days after the end of eachquarter) since the PCUhas extensive experience with financial managementof Bank projects andthe preparation of FinancialMonitoringReports (FMRs). The FMR will include a narrative outlining the major project achievementsfor the quarter, the project's sources and 61 uses of funds, a detailed analysis of expenditures by sub-components, a physical progress report, a procurement report and a procurement table. BudgetingProcess. A consolidated annual budget would be prepared by the NAPS in coordination with the PCUfor all participatingimplementing agencies. Below i s a summary of actions requiredto be completed for project effectiveness : Financial Management Action Plan ~ _ _ _ _ Area I Action 1. Flow offunds 1.1 PCU to open the project bank accounts: the Special Account in US Dollars in the bank selected, and the Project Account in local currency inthe bank selected. 2. Staffing 2.1 Submit new TORs for financial management staff, taking into account the addition of the Project Accountant. 2.2 Submit for review and clearance CV of selected person for the Proiect Accountant and internal auditor to the Bank. 3. Accountingand internalcontrol 3.1 Create the Chart of Account inthe accounting system to reflect the disbursement categories for the project andproject activities. 3.2 Create the Draft FinancialManagement Procedures including sections describing payment procedures, flow-of-funds, format of FMRs, disbursement procedures(based on FMRs), coordination with implementing ministries, procurement section and chart of accounts. 3.3 FinalFinancialManagement Procedures. 4. Externalaudit 4.1 Submit final audit TORs to the Bankfor review and clearance. 4.2 Once the Bank clears the TOR, proceed with the appointment of the auditors.. 5. Reporting 5.1 Submit draft FMR Format. 5.2 Submit first FMR. SupervisionPlan. Given the complex nature of the project, an FMSpecialist fromthe World Bank will need at least two staff weeks for FMsupervisionfor three separate missions andreview of periodic financial reports duringthe first year of implementation. In subsequent years, the number of missions could be reduced to two per year. 62 Allocation of Loan/Credit/Grant Proceeds 63 Annex 8: Procurement Saint LuciaHIV/AIDSPreventionAnd ControlProject A. ProcurementArrangements Procurement for the proposedproject will be carried out inaccordancewith World Bank "Guidelines: Procurement Under IBRD Loans and IDA Credits", publishedinJanuary 1995 (revised JanuaryIAugust 1996, September 1997, January 1999, November 2003, andMay 2004); and "Guidelines: Selectionand Employment of Consultants by WorldBank Borrowers" published inJanuary 1997 (revised in September 1999, January 1999, May 2002, November 2003, andMay 2004), and the provisions stipulated inthe Loan Agreement. B. ProcurementResponsibility:The Project Coordination Unit(PCU) inthe MOFwill be responsible for the procurement activities under the Project. The PCU will be strengthenedby adding a procurement specialist, a project accountant, and a senior assistant clerk. An operations manualpreparedby the MOWPCUincludes the details of the procurement responsibilities, flow of documentation, funds andprocedures. The MOWPCUhas prepareda generalprocurement planfor the entire duration of the project and a detailed procurement plan for the first 18 months along with the annual work plan. The FinalPP will be annexedto the OM. The procurement planfor each year would be submittedby the PCU throughthe M O H to the WB for approval, no later than the anniversary monthof the prior fiscal year, following a standardformat which would list as a minimum(i) works, goods and services to be procured for the year; (ii)their value; (iii) methodsof procurement; and(iv) the timetable for the carrying out the procurement. The procurement planmay be updated at any time, if required, underparagraph1of Appendix 1to the Bank's Guidelines. C. ProcurementMethods: The methodsto beusedfor the procurementdescribedbelow and the estimatedamounts for eachmethod are summarized inTable A. The threshold contract values for the use of each methodare fixed inTable B. Goods and works for this project are estimatedto cost US$ 3 millionequivalent. a. Procurementof Works: Works under this Project will include refurbishment of STI clinics and other smallrehabilitation works. Contracts above US$l,OOO,OOO will be procured following International Competitive Bidding(ICB). Contracts above US$150,000 but below US$l,000,000 will be procured following NationalCompetitive Bidding(NCB) procedures, usingstandardbiddingdocuments agreedinadvancewith the World Bank. Small works, estimatedto cost less than US$150,000 equivalent per contract, may be procured on the basis of comparing at least three quotations, received from qualified contractors inresponseto a written invitation, which will include a detailed description of the works, includingbasic specifications, the requiredcompletion date, abasic form of agreement acceptableto the Bank and relevant drawings, where applicable. b. Procurementof Goods:Goods under this project will include ARVs and other pharmaceuticals, laboratory reagents, test kits, condoms, laboratory equipment, office supplies,IT supplies andIEC/BCC dissemination campaign equipment. 64 To the extent possible, contracts for goods [other than "Specialized Medical Supplies and Laboratory Equipment"] will be grouped into biddingpackages of more than US$150,000 equivalent andprocured following ICB procedures usingBank-issuedStandardBidding Documents (SBD). Contracts below US$150,000 but above US$25,000 may be procured under NCB, usingbiddingdocuments acceptableto the Bank. Contracts for goods [other than "Specialized Medical Supplies and Laboratory Equipment"] which are estimated to cost below US$25,000 per contract may beprocuredusingNational Shopping (NS) or International Shopping (IS) procedures. Procurement of specialized medical suppliesandlaboratory equipment (e.g., test kits, reagents, viral load and CD4 count machines)will be determined by the market situation of eachproduct (Le., the number of available qualified suppliers) andthe nature of the medical supplies. Regardlessof the contract value, they may be procured usinglimitedinternational bidding,shopping or single sourceproceduresinaccordancewith the provisions of paragraphs3.2, 3.5 and 3.7 of the Guidelines. For procurement of condoms, the following proceduresshould be followed: through SS with PharmaceuticalsProcurement Services (PPS) usingcompetitive proceduresacceptableto the Bank (see below) or incase the condoms are procureddirectly by MOWPCU: -IS for contracts amounts below US$150,0OO and Limited International Bidding(LIB)for contract amounts above US$150,000. PPS services and Procurementprocedures. Saint Lucia participates inthe central OECS drug procurement organization to procure drugs for the public sector health services. Drugs are procured inaccordance with "National Formularies"(1ists of types andquantities of various name brand and/or generic drugs). Drugsneededare pooled across the OECS countries and prices are obtained through offers from regional wholesale suppliers that represent manufacturers. Contracts are awarded on the basis of the lowest price for a specified quantity to be delivered to each country throughout the year. A preliminary assessment of this systemwas conductedin2003 to verify its conformity with World Bankguidelines for procuring drugs . Drugs would be includedinits NationalFormulary and procured through the OECS system. Drugs would be procured from suppliers according to registeredbrand names, at prices that are negotiated with manufacturers (Saint Lucia i s currently participating inthe Caribbeaninitiative to negotiateprices of ARV drugs on aregionalbasis with manufacturers)and the procurement would be proposedto the World Bank (when loan proceeds are to be usedto finance the purchase) as "direct contracting". The PPS may act as a procurement agent for the Borrower, who will be responsible for paying PPS's fees. The Bank would assess prior to any approval of a PP that PPS would follow procedures and use biddingdocuments acceptableto the Bank. A 2003 preliminary capacity assessment of PPS has been attachedto the PCA of the Borrower and the proposed PCU. For procurement of Specialized Medical Supplies and Laboratory Equipment [including condoms] PPS will be required to follow the principles described above, that will 65 be also respectedby the Borrower, should they decide to purchasedirectly any specialized medical Supplies and laboratory equipment. c. Selectionof Consultants: Consulting services will be required for technical assistance for prevention, care, support of HIV/AIDS/STIpatients, for management information systems, and for monitoringand evaluation. These services are estimated to cost US$3.2 millionequivalent. d. Firms. Contracts with firms estimatedto cost over US$lOO,OOO wouldbeprocuredusing Quality and Cost-BasedSelection (QCBS). The short-list of consultants for these services, estimated to cost less than $50,000 equivalent per contract, may be comprised entirely of national consultants. Small and simple contractsestimated to cost US$lOO,OOO equivalent or less would be procured following other procurement methods such as Consultant Qualifications (CQ). ITtraining and connectivity services, radio spots and any other services for dissemination campaigns will be procured on a SS basis. Contracts with NGOs, FBOs, CBOs [Eligible Entities @E)] will be awardedon a single source basis, irrespective of their amount, if the proposedproject is acceptedinaccordance with proceduresto be establishedinthe Operations Manual. For services procured by NGOs, FBOs, CBOs [EE,i.e. Eligible Entities] under subprojects, inthe case of contracts above US$lO,OOO, the EEwill be required to procure such services under CQ or (individual consultant) IC as appropriate. e. IndividualConsultants[IC]. Other assignments where neither teams of personnel nor additional outside professional support are required would be performed by individual consultants selectedby comparison of qualifications of three candidates andhiredin accordancewith the provisions of paragraphs5.1 through 5.4 of the Consultant Guidelines. Prior review will be applicable for assignmentsabove US$50,000. Below such threshold, the prior review will only cover the TOR for the assignment. f. Training. The Project will finance trainingfor the provisionof servicesfor ARVs, OIs, STI, PMTCT ,training for IT, capacity building, strengthening the Line Ministries andCivil Society Groups response to HIV/AIDS, biomedical waste management, training for laboratory workers, trainingfor voluntary counseling and testing centers personnel, workshops and materials. g. Operatingcosts. Sundry items, office rental, utilities and other operational costs would befinanced on a declining basis and would beprocuredusingadministrative procedures acceptableto the Bank. The Bank will finance about US$264,400, declining annually in accordancewith an agreedplan. D. PriorReview: The proposedthresholdsfor prior review are basedonthe procurement capacity assessment of the M O Hand the PCU and are summarized inTable B. Arrangements for prior review of the procurement processes are described above under ProcurementMethods. Inaddition to this prior review of individualprocurement actions, the planandbudget for Operating Costs will be reviewedand approved by the Bank annually. 66 E. ProcurementCapacityAssessmentReport: The WorldBankcarried out aPCAin January 2004 andMarch 2004to evaluateM O H and the PCU. The M O Hwill be the responsible agency for implementing the HIV/AIDSPrevention and Control Project. The PCAis inthe Bank's files. M O Hstaff lacks experienceinprocurement but the quality andquantity of the staff inthe existingPCUis satisfactory. The assessment determined that ingeneral, a sufficient number of qualified staff are available to carry out the normalprocurement tasks that would be assignedto them. The existing staff has relevant knowledge of the disciplines andthe capacity required for carrying out the proposedprocurement plan . Additional staff to support the procurement andimplementation are proposed inthe Action Plan as the PCU will be required to managetwo projects at the same time. The conclusions of the assessment show the country's weak procurement environment, lack of proper legislation for procurement, lack of skilled personnel inprocurement within the M O Hat international level, weaknesses inthe national biddingprocessesand award of contracts and in general, lack of internationally recognized standardrules. The risk assessment of procurement implementation for this project is considered HIGH, irrespective of the present good performance of the existing PCU, mainly due to the present weaknesseswithin the MOH. This assessment is strictly tied to implementation by the M O H of the proposedaction planbelow, as well to the fact of their assumingcomplete responsibilities for technical matters [specifications andTOR] and for managing functions of all the contracts. Ifattheendof thefirst 18monthsthe Borrowerdemonstratesgoodperformancein procurement andacceptableplanningand managementcapabilities, the risk assessment will be updated andproposed to be AVERAGE. FPCUStaffing The existing PCU has managedtwo World Bank projects, namely the Emergency Recovery and Disaster Management projects, and will be responsible for the fiduciary activities of the project. Currently, the staff at the PCUincludes a Project Coordinator, a Deputy Coordinator, a Project Assistant for FinancialManagement, an Accounts Clerk, a Senior Accounts Clerk, a Project Assistant for Procurement, a Clerk for Procurement and a SecretaryEypist (as depicted inthe organizational chart below). "The PCUwill be transferred to the Ministry of Finance 67 Figure I:PCU Organizational Chart I I The Deputy Project Coordinator who supervisesthe Financial Management team has a Bachelor's degree inaccounting and more than 10years experience inaccounting with government agencies. The Assistant -Financial Management has a first degree in accounting and 10 years experienceinaccounting (3 years experience with the government). The two Accounts Clerks have minimumqualifications of afirst degree in finance/accounting or a diplomain accounting. Therefore, the PCU already has a core team with adequate skills to fulfill the accounting andreporting needs of the project. To enable the PCUto handle the additional workload andthe added complexity of the proposedproject, staffing at the PCU will be strengthenedwith the addition of (i) a Project Accountant, (ii) a Procurement Officer, and (iii)Senior Assistant Clerk/Typist. a Qualifications for the Project Accountant positionwould include a Bachelor's degree in accounting, finance or equivalent and at least 5 years experience inGovernment accounting and/or internationally funded projects. The Project Accountant would be responsible for providing guidance to the existing financial management staff and would strengthenthe capacity of the unit to handle the additional workload likely to be generatedby the proposed project. G.ActionPlan The following planwas agreedto minimize the highrisk of delays inimplementation : 0 Agreementthat the M O Hwill use the proposed PCUfor all the procurement activities. 0 Designation of a managerwithin M O Hwith authority to take any procurement decision on behalf of the M O Hand represent the MOHinthe contractual relation with all the suppliers /contractors/ consultants. 68 Designation of technical staff inM O Hto assist the PCUindraftingtechnical specifications and TORS. Suchtechnical staff to be integratedinany evaluation committees. Recruitment of a full time procurement expert for the PCU Preparation of a training planfor the PCU staff. Establishment of a procurement filing systemsatisfactory to the Bank by negotiations. Preparationby the MOWPCUof a procurement plan (PP) for the first 18 months of implementation. Finalplanto be agreedupon by negotiations andto be annexedto the Legal Agreement. The final PP should have a detailedbreakdown of all the components and indicationof expectedamount, applicable procurement method, and use of prior or post review. Preparation by the PCU of an operationsmanual (OM) with a specific chapter on procurement detailing all the procedures and channels of responsibilities and flow of documentation . Preparation by the PCU of draft standardbiddingdocuments for all processes, by effectiveness. For purchases [specialized medical supplies and laboratory equipment ] that MOH intends to carry out through PPS, M O H should provide evidence inthe PP of such purchasesandconfirmation by M O Hthat they would pay the administrative fees of PPS out of their own budget; signingof a special M O UbetweenMOHandPPS [if needed, inaddition to the permanent agreement with PPS]; commitment by PPS to follow procedures and use biddingdocuments acceptable to the Bank Eligibility and selection criteria for EE [Eligible Entities=Civil Society Organizations] defined includingproceduresfor assessment of EE's capabilities. A project launch workshop will becarried out after project effectiveness andwill include the participation of staff from the MOH, PCU, NGOs, FBOs, CBOs and Line Ministries. It will be followed during the first year by another intensive workshop of at least two days inBank procurement procedures andrules. H.ProcurementPlan. At thebeginningof eachcalendar year [or earlier, ifrequiredunder paragraph 1of Appendix 1to the Bank's Guidelines] the PCUwill update the Procurement Planwith adetailed procurement schedulefor the coming year. I.FrequencyofProcurementSupervision: Theprojectwouldreceiveaminimumofone full supervision missionto carry out post review of procurement actions, every six months duringthe first year and every 12monthsafterwards. Based on the overall risk assessment (HIGH)the post-review field analysis shouldcover a sample of not less than 1in5 contracts signed. A procurement audit shouldbecarried out every year. 69 Table A: Project Costs by Procurement Arrangements (US$ x lo6) 1. Works 0.00 0.20 0.28.A.i 0.00 0.48 (0.00) (0.10) (0.23) (0.00) (0.33) 2. Goods 0.20 0.20 0.53 B/ 0.00 0.93 (0.15) (0.15) (0.43) (0.00) (0.73) 2.1 SpecialHealthGoods 0.00 0.00 1.50 0.00 1.50 (0.00) (0.00) (1.29) (0.00) (1.29) 3. ConsultantServices 0.00 0.00 3.09 C! 0.00 3.09 (0.00) (0.00) (2.44) (0.00) (2.44) 4. Training 0.00 0.00 0.26 0.00 0.26 (0.00) 5. Civil SocietyFund(Grants) 0.00 (0.00) 6. OperatingCosts 0.00 (0.00) Unallocated (0.18) (0.18) Total 0.20 0.20" (0.15) (0.25) (6.02) (0.00) (6.42) Note: N.B.F.=Not Bank-financed (includes elements procuredunder parallel co-financing procedures, consultancies under trust funds, any reserved procurement, and any other miscellaneous items). Figures inparenthesis are the amounts to be financed by the Bank IoadIDA credit Footnotes: A/ Three quotations (Le.: Small works procuredunder lump-sum, fixed-price contracts awarded on the basis of quotations obtained from three (3) qualified domestic contractors in responseto a written invitation .The award shall be made to the contractor who offers the lowest evaluated price quotation for the required work, and who has the experience and resourcesto complete the contract successfully. B/ Shopping(National and International) and LIB C/ Consultants Services. Details provided inTable A-1 * Estimatedadministrative fee paid by the Government to PPS 70 Table Al: Consultant Selection Arrangements (0.32) (0.00) (0.00) (0.32) (0.08) (0.00) (0.72) B. Individuals 2.38 2.38 I ( 1 I 0 I 0 I 0 I (1.89) I(1.89) (0.32) (0.00) (0.00) (0.00) (0.32) (1.97) (0.00) (2.61) QCBS = Quality- and Cost-Based Selection; LCS = Least-Cost Selection; CQ = Selection Based on Consultants' Qualifications; Other = Selection of individual consultants (per Section V of Consultants Guidelines) Figuresinparenthesisare the amountsto befinancedby the BankLoadCrediUGrant. 71 Table B: Prior Review Thresholds Thresholds for Procurement Methods and Prior Review [inUS$equivalent x OW] Contract Value Procurement Contracts Subject to (Threshold) Method Prior Review 1. Works >1.000 ICB All I I 150-1,000 NCB >500 All I3Quotations 4 0 0 First 4 5 0 None 2. Goods" >150 ICB All 150>x>25 NCB None c25 Shopping None DC/SS with EE, that 2A. Subprojects >25 will be requiredto [NGOs,FBOs,CB procure Firstand Specs or TOR Os= Eligible subcomponents afterwards Entities=EE] ** through NCB or CQ or ** Selection IC [as appropriate] and approval 25>x>10 DC/SS with EE, that proceduresto be should procure First andSpecs or detailed in the subcomponents TOR afterwards Operations Manual through Shoppingor CQ or IC [as appropriate] 150 LIB I est kits, All DC and specs of 72 reagents, viral load Irrespective of the Method determined by other methods ~~ and CD4 count amount market's economy: machines DC/IS/LIB OR SS with PPS, that will All first year and Special goods and Irrespective of the be requiredto follow Specs afterwards suppliesat points amount procedures and use 1/,2I,J3 above**** biddingdocuments acceptable to the Bank ~~ 3. Services 3.A Firms ZA.1 >loo QCBS All 3.A.2 e100 Irrespective TOR only of method 3.A.3 ITtraining andconnectivity, Irrespective of value ss All radio spots and dissemination campaigns 3.B Individuals >50 Comparison All of 3cv <50 [Chapter V of TOR only Guidelines1 *with the exception o f the specialized medical supplies and laboratory equipment ***Procurement of Specialized Medical Supplies and Laboratory Equipment (e.g., test kits, reagents, viral load and CD4 count machines) will be determined by market situation of each product (Le., the number o f available qualified suppliers) and the nature of the medical supplies. Regardless of the contract value, they may be procured using limited international bidding, shopping or single source procedures in accordance with the provisions of paragraphs 3.2,3.5 and 3.7 of the Guidelines." .This principle and procedures will be applicable for any purchases done by the MOH-PCU. andlor any other purchases channelled through PPS . ****All the purchases [Specialized Medical Supplies and Laboratory Equipment ] carried out through PPS under commitment by PPS to follow procedures and use biddingdocuments acceptable to the Bank. OverallProcurementRiskAssessment: Average Low 73 Annex 9: Economic and FinancialAnalysis Saint Lucia HIV/AIDS Prevention And Control Project There are strong reasons for public intervention inHIV/AIDSprevention and control: a) HIVis acommunicable disease which inflictsnegativeexternalities on society; a purelyprivate responseis therefore likely to fall short of the social optimum; b) InformationregardingHIV transmission is imperfect; c) HIVmakespeoplevulnerable to other infectious diseases includingtuberculosis; d) Some individuals (spouses, newborns, victims of rape, accident victims who need bloodtransfusions) cannot control their own risk to HIVinfection; and e) Early intervention is neededto prevent the epidemic from reaching the proportions it has reachedinother parts of the World. While an economic impact analysis of the HIV/AIDS assessment has not beencarried out for Saint. Lucia, the following analysis of the HIV/AIDSpotential impact inthe Caribbean and other parts of the World demonstrate the importance of early intervention to curb the growth of the pandemic in Saint Lucia. Costing an HIV/AIDS prevention and control programfor the Caribbean12 A very rough estimation of the cost of acomprehensive HN/AIDS prevention programwas conducted among a team of epidemiologists and economistsfrom the CaribbeanI3. The purpose of the exercise was to estimate the cost of anHIV/AIDS prevention and treatment package for 23 Caribbean co~ntries'~ under various scenarios. The model structure was loosely basedon a simulation modelbeingdeveloped by the World Bank15and the parametersunderlying the base scenario were obtained from the literature and from the aforementioned panel of experts. Modeland MainAssumptions Interventions The followinganalysis is drawn fromthe World BankProjectAppraisalDocument(Report22184-LAC), for the Multi-CountryHIV/AIDS PreventionandControlProgram(APL), June 6,2001 (Annex 8). l3 The teamof epidemiologists,publichealthspecialistsandeconomistsfrom UNAIDS, PAHO, CAREC, CARICOM, the World Bankandthe HealthEconomicsUnit at the University of West Indiescollegially decideduponepidemiological, cost andcoverageparametersduringa two-day workshopheldinTrinidadand Tobago (August 17- 18,2000). The estimateswill needto be validated inthe country-specificanalyses. l4 The countrieswere loosely groupedaccordingtheir geographic, cultural andeconomicproximity.Group 1: Anguilla, Antigua & Barbuda,BritishVirgin Islands, Dominica, Grenada, Montserrat,St. Kitts, Saint Lucia, St. Vincent. Group 2: Bahamas, Bermuda, Cayman, Turks & Caicos.Group 3: Haiti, DominicanRepublic. Group4: NetherlandsAntilles, Aruba, Guyana, Suriname.Group5: Barbados, Belize, Jamaica, Trinidad & Tobago. Group6: Cuba l5 BonnelR., et al., 'The Cost of Scaling-Up HIV/AIDS Programsto aNationalLevel for Sub-SaharanAfrica,' Working Paper, WorldBank, April 2000. 74 An exhaustive list of the principaltypical interventions supportedby HIV/AIDSprograms around the world to prevent the transmission of the HIV virus and to mitigate the impact of HIV/AIDS onpersons andcommunities was drawn. Indirect interventions include surveillance, research, monitoring and evaluation, advocacy, and enhancing regional and national institutionalcapacity to carry out the programs. Preventive interventions include those activities that have strong spillover benefits to society as a whole inpreventing HIV infections and thus reducing the spreadof the disease: public awarenesscampaigns, programs aimed at preventing the spread from high-risk groups such as prostitutes and intravenous drugusers into the general population, screening, ensuring safe bloodsupply, fostering behavior change, increasing access to condoms andpreventing the transmission from infected mothers to their babies. The third set of interventions includes various aspects of care andfinancial assistancefor persons or relatives of personsliving with HIV/AIDS: palliative (prevention of opportunistic infections, counseling, home-basedcare, anti- retroviral therapy) since there is no cure for AIDS; and support to orphans of AIDS patients. Unit costsassumptions Unitcosts were then estimatedfor eachof theseactivities. Thecosts were for the most part taken from the simulation exercise undertakenin Sub-SaharanAfrica16 and from the consensusview of the panel of experts17. The informationderives from the literature and from the direct experience of the team of experts with HIV/AIDSprograms indeveloping world settings. Populationand epidemiologicalinformation Estimates for the model parameters were collected or extrapolatedfrom the latest published sourcesor generatedby the panel of experts who participated in the simulation exercise. The main variables usedby the model are: population, HIVprevalence, birthrates, access to health services, use of ante-natal care services, ante-natalcare HIV prevalence, percentage of sexually active populationreporting non-regular partnerships, annualincidence of treatable STIs, proportionof STIs that are symptomatic, average annual number of commercial sex actdsex worker, prevalence of syphilis among women, cumulative number of orphans, HIV prevalence rates among high-risk groups (prisoners, MSM, CSW, military), migrantandtourist populations, andpublic spendingper capita inhealth. l6See footnote 3. " Seefootnote 1. 75 Programcoverageassumptions The final set of model inputs was the coverageassumptions. For nearly all the interventions contemplated, it was assumed that 100 percentof the relevant population was targeted(e.g., allCSW, allHIV-infectedmothers, all youngstersinschool, etc). Therewere two main departuresfrom the universalcoverageassumption: it was assumedthat on1 20 percent of AIDS patients will benefit from home-basedcare, and that only 15 percent of HIVpatients Y, will benefit from HAART, the three- and four-drug combinations against HIV. A 100- percent coverage was deemedimprobable for thesetwo interventions if only because the health system cannot reach all patients andbecausethe take up of home-basedcare i s partly predicated on client behavior. The cost estimatesderived from the model are extremely sensitive to the coverage assumptions. Note that the implicit assumption here is that scaling upis achievedimmediately-amore realistic costing scenariowill involvegradual scalingup over aperiodof a few years. MainResults Usingthe assumptionsdiscussedintheprevious sections, the following results were derived: Table 1. Low Cost Package Program Total Cost with Percent Total Cost with Percent TotalCost Percent of HAARTat $7,000 of Total HAARTat $1,000 of Total without Total for 15 percent of for 15 percent of HAART HIV-infected HIV-infected (US$ population population million) (US$ million) (US$million) "Indirect 5 1.1 4 51.1 7 percent 5 1.1 9 percent activities" percent Public 162.1 12 162.1 23 162.1 28 percent Awareness percent percent and Prevention Basic Care 362.2 26 362.2 52 362.2 63 percent percent percent HAART 828.1 59 118.3 17 0.0 0 percent percent percent Total 1,403.5 100 693.7 100 575.419 100percent percent percent The cost of providinga comprehensive package of prevention and care activities for the relevant populations the Caribbean will therefore be prohibitively expensive at about US$1.4 billion. Table 2 below shows how these costs will translate into per capita terms for a few countries and compares the estimatedHIV/AIDSprogramcosts with current overall per capita spending on health. l8 Inthe successful Brazil program, only 15 percent of the infected population are on anti-retroviral access despite 100%access. l9 Of which $358 millionfor Haiti and the Dominican Republic, $67 million for Cubaand $150 million for the rest of the Caribbean. 76 Table 2: Per CapitaCosts (US$) Implementingacomprehensivepackageof interventions (prevention, basic care, and HAARTfor 15percent of the HIV-infected population at current prices) will increasecurrent overall spending inhealthfrom by 180percent inGuyana. Ifthe cost of providingHAART falls to $1,000 per patient per year, then a comprehensive packageof interventions (prevention andcare includingHAART) will imply a 10percent increase inhealth spending inthe Bahamasanda 183percentincreaseinHaiti. The HAARTcosts are overstated becauseefforts have since beenmade to reduce the cost of anti-retroviral drugs. The costs of drugsfor HAART have been reducedto levels of $350 andcould even go lower with the continuedefforts underway to further lower the costs of drugs. This make it possible for countries that hitherto could not consider providing HAART to all patients who needto include it intheir programs. Potentialbenefits2'fromcheckingthe spreadofHIV/AIDS inthe Caribbean The benefits traditionally associatedwith HIV/AIDS programs are: (i) they contribute to that reducing productivity lossesdue to HIV/AIDS-relateddisability and premature mortality; and (ii) that they contribute to reducing the need for expensive care. These measures ignore the demandfor such programs from the general populationto reduce the risk of getting the infection, creating a safer environment, and so on. The benefits calculated heredo not include these possibly substantial `consumption' benefits. One study21was conducted by the University of West Indies and suggests that economic losses due to HIV/AIDS will amount to about five percent of GDP inJamaicaand Trinidad and Tobago by year 2005. The estimated GDP loss is driven by the number of HIV/AIDS cases and the averageloss of income/output associated with those cases. The study forecasts the economic impact of HIV/AIDSby modeling the impact on five blocks: output, labor supply, employment, savings andinvestment, and spending on HIV/AIDS treatment. An increaseinHIV/AIDS-related deaths and morbidity adversely affects labor supply causing wages to increase. Raisingwages and decreasing labor supply translate into lower levels of 2oThe benefitsconsideredinthis sectionare exclusive of externalities. 21`HIV/AIDS inthe Caribbean:EconomicIssues- Impactand InvestmentResponse,' Working Paper.Health EconomicsUnit, Universityof West Indies, St. Augustine, 2000 and `Modellingthe MacroeconomicImpact of HIV/AIDS in the English-SpeakingCaribbean:the Case of TrinidadandTobago andJamaica,' Working Paper,CAREC/UWI/PAHO/'WHO, 2000. 77 employment. The increaseinexpenditure associatedwith increasedHIV/AIDSincidence diverts funds away from productive savings, which inturn affects the levels of investment that canbe achieved. Depressed levels of labor and capital affect the levels of output from the various sectors and therefore overall GDP. See Table 3 below for impacts on a number of key variables for Trinidad and Tobago andJamaica. Table 3: The macroeconomic impact of the HIV/AIDS epidemic in Jamaica andTrinidad andTobago. 1 Impact Variables Jamaica 1 Gross Domestic Product percent -6.4 percent Savings III -4.2 Trinidad and Tobago -10.3 percent -23.5 percent Investment -15.6 percent -17.4 percent Employment inAgriculture -3.5 percent IIII/-5.2 percent Employment inManufacturing -4.6 percent -4.1 percent Employment inServices -6.7 percent -8.2 percent Labor Supply -5.2 percent -7.3 percent HIV/AIDSExpenditure +25.3 percent +35.4 percent The same study suggests the losses to the economiesof the English-speaking Caribbean could reach a level around $2 billion per year. Inother words, stopping HIV/AIDS transmission for that sub-region yields abenefit of $2 billion per year. The table below, adaptedfrom Jhaet al. (2001)22summarizes rangesof values from the literature relating to the cost-effectiveness of some of the most frequent interventions in HIV/AIDS prevention andtreatment. Table 4: Cost-effectiveness of different types of interventions Sex worker STI Voluntary Anti- IECto Anti- intervention managemen counseling retrovirals change retrovirals S t and testing in risky 24 pregnancy beha~io?~ Cost per HIV $8-12 $218 $249-346 $276 $1,324 -- infection averted Cost per $0.35-0.52 $9.45 $12.77- $10.51 $66.2 $720- DALY saved 17.78 $2,355 Individualcountry programs will maximize the number of infections averted and the number of DALYs savedif they were to ensure that the most cost-effective interventions obtain sufficient attention andfinancing. Countries that proposeto finance HAART should particularly be attentive to makingsure that preventive interventions that are known to be 22 Jha, P., et ai. (2001) `The evidence base for interventions to prevent HIV infection in low and middle-income countries.' Background paper of the Commission on Macroeconomics and Health, the World Health Organization. 23UNAIDS 24UNAIDS:Brazil Program 78 cost-effective are not crowded out inthe process. Saint Lucia has selected a comprehensive approachwhich has fundingfor preventive interventions bothfor targeting high-riskas well as for reaching the generalpopulation inaddition to the proposed scaling up of treatment and care. 79 Annex 10: Safeguard Policy Issues Saint LuciaHIV/AIDS PreventionAnd Control Project 1. The proposed Saint Lucia HIVIAIDSPrevention andControlProject has two areas of activity where environmental impacts must be considered: (i) the generationof bio- medicalhazardous waste; and(ii) small-scalerehabilitation of existing physical structures. The Government is currently implementingabiomedical waste managementplanthat addresses the management of biomedical waste. The biomedical waste management assessment and plan are summarizedbelow. The full report is available inGovernment and World Bank project files. Inaddition, environmental guidelineswill be provided inthe project operational manual for the minor civil works inthe project. Introduction 2. InSeptember 2000, GPEC International Ltd. (GPEC), through discussions with various Saint LucianGovernment officials, includingpersonnel from Saint LuciaSolidWaste Management Authority (SLSWMA), determined the needfor hazardouswaste management strategies to deal with various hazardouswaste streams that were currently threatening human health andthe environment of Saint Lucia. Withjoint fundingfrom GPEC andthe Canadian InternationalDevelopment Agency's IndustrialCooperationProgram (CIDA INC), GPEC developed a planto address the current hazardouswaste managementneeds inSaint Lucia. The full waste managementplancan be found inthe project files anddescribes in detail the minimumrequirements for the safe handling, transportation, treatment, and disposal of bio-hazardous wastes beinggeneratedinSaint Lucia. The bio-hazardous waste management planprovidedinthe report addresses waste generatedinthe healthcareindustry (e.g. hospitals, medical laboratories, healthclinics, doctors and dentist offices, veterinary, and funeral parlors) as well as condemnedmeats and quarantined foodstuff. This summary report i s confined to the assessment and recommendations for handling waste from hospitals, healthclinics, andmedical laboratories. 3. The waste managementplanwas developed basedon the informationprovided to GPEC by SLSWMA, the various hospital andMinistry of Healthpersonnel interviewed during GPEC's site visit in Saint Lucia; observationsmade during GPEC's site visits to hospitals and health clinics; waste managementpractices inSaint Lucia and international best-practice on waste management strategies. The waste managementplan was developed specifically for the handling and disposal of medical waste inSaint Lucia. Study Findings 4. Type of Waste Generated and HandlingPractices. Ingeneral, the types of bio- hazardouswastes being generatedinthe various Saint Lucianhealthcare facilities include sharps, pathological and anatomical wastes, human blood andbodily fluids (including soaked materials such as dressings), microbiologicalwastes, pharmaceutical wastes, general refuse, and liquid wastes (both hazardous and non-hazardous). Based on the findings of a recent waste generationsurvey, the hospitals in Saint Lucia have a medical hazardouswaste generationrate of approximately 1kghedday, and a general refuse waste generation rate of 80 approximately 1.8 kg/bed/day. These rateswere basedon an occupancy rate of 50 percent. Inaddition, the total hazardousmedicalwastebeinggeneratedfor allhealthcarefacilities, including hospitals, health clinics, dental anddoctor facilities, and veterinary facilities, was estimated to be approximately 300kg/day (or 110ton per year).Oof relevant documents and reports, it was revealedthat, ingeneral, the hospitals andhealth clinics have various waste managementstrategiesinplace inorder to limit humanexposure to hazardous medical waste streams. Most hospital facilities have a two bag systeminplace. Black bags are usedfor general refuse and redbags are usedfor hazardous (infectious) medical waste. Inaddition, sharps are collected separately from the rest of the waste streamsin designatedrigid containers, however it is not uncommon for sharps to be disposedwith the other bio- hazardous redbag wastes. Some anatomical wastes such as placenta, are either buriedon- site or disposed via the hospitals septic sewage system, while other pathological wastes are burned. Liquidwastes are disposedinthe hospitals sewage system. Inaddition, some liquid wastes which are suspectedof beinginfectious are disposeddown the drain with a liquid bleach solution. 6. Waste segregationactivities varies between the 34 health clinics in Saint Lucia. Some health clinics segregate hazardous andnon-hazardoussolid waste inred andblack bags respectively, andalso segregatesharps into empty bleachbottles. Other clinics only segregate the sharps while mixing together all other solid waste streams. 7. It is a common practice at hospitals and health clinics for black andredbags to be intermixedsuch that redbags are usedfor non-hazardouswastes, andblackbags are usedfor hazardous wastes. Inaddition, no cold store facilities are available for the long term storage of medical waste at many of the healthcare facilities on the island. Thus, stockpiled medical waste is typically stored at warm ambient temperatures andhighhumidity. 8. Hospital staff responsible for handlingof medical waste are supplied with personal protective equipment includingdisposal gloves, andgowns. However, it i s commonfor staff to handle medical waste without the use of gloves or gowns. This illustrates the lack of appreciation personnelhave for the true health risks associatedwith the handlingand disposal of medical wastes. 9. Training. Currently there are no formal medical waste managementtraining programs available inSaint Lucia, however some limited training i s providedto staff handlingmedical waste. Inaddition, hospitals have appointed Infections Control Officers to inform staff of the dangers associatedwith the handlingof bio-hazardous wastes. M O Hprovides some information sessions to healthclinic staff inorder to informthem of the potential dangers associatedwith the handlingof hazardous medical wastes. 10. While there is somelevelof understanding of the hazards associatedwith bio-hazardous wastes being generatedin Saint Lucia, the lack of appreciation by waste handlers for the risks associatedwith these wastes and the current poor bio-hazardous waste managementpractices are puttingSaint Lucian's at risk of potentially developing a disease or infection, or causing personal injury. 81 11. LegalFramework. InSaint Luciathere are currently no specific regulations or legislation concerning the handling, transportation and disposal of medical wastes. However, existing legislation, which indirectly regulatesthe disposal of medical waste, include: the Public HealthAct; the Litter Act; Employees (Occupational Healthand Safety) Act; Saint Lucia SolidWaste Management Act; and the StandardsAct. Inaddition, since Saint Lucia is a memberof the Base1Convention, the handling, transportation and disposal of medical waste will also needto be consistent with convention guidelines. 12. GPEC has adoptedproven NorthAmerican standardsanddeveloped a customized bio- hazardouswaste management systemthat i s specific to address the current concerns inSaint Luciafor hospitals, healthclinics, doctor and dentist practices, veterinarian facilities and other bio-hazardous waste generatorsinSaint Lucia. Recommendationsfor Bio-Hazardous Waste Management 13. Inorder to implement GPEC's proposedcentralized bio-hazardous waste treatment and disposal facility inSaint Lucia, a proper bio-hazardouswaste managementsystemmustfirst beestablished. GPEC's proposedbio-hazardouswaste management system is similar to NorthAmerican standards and will include following elements: a) Waste designation: The first step in safely managing bio-hazardous waste i s to specify which wastes are to be deemedinfectious andor hazardous,in accordance with the known standards.For the purposes of this bio-hazardouswaste managementplan, the following waste streams are identified: isolation bedwastes (highly infectious waste); pathological/ anatomical wastes; microbiologicaUlaboratorybio-hazardous wastes; humanbloodandbody fluidwastes; contaminated sharps; cytotoxic wastes; and, pharmaceutical wastes. b) Segregation:Bio-hazardous waste shouldbe separatedfrom the general waste stream, at the point of generation, to assure that these wastes will be properly handled anddisposed. Segregation also assistsinreducing overallbio-hazardous waste treatment and disposal costs and permits facilities to effectively divert those materials that are recyclable. Ifbio-hazardous waste is mixedwith general refuse, then the total waste streamwill be considered infectious and require special treatment andhandling. The most efficient means of segregatingbio- hazardouswaste is to provide separate, distinct containers at the points of generation throughout each generator facility (e.g. hospitals, health clinics, doctors offices, dentists etc.). c) Packaginghabelling:Generators should undertakethe necessarysteps to ensure that bio- hazardouswaste i s not placed inwith other general wastes. Bio-hazardous waste should be packagedinsuch a way as to protect personnelhandling the waste, andthe public, from possible injury and exposure to infectious agents within the waste. The integrity of the packaging should be maintainedfrom the point of origin to the point of treatment. In addition, the packaging should deter rodents and vermin which can be vectors indisease transmission. A colour-coded system should be implemented for segregating and packaging bio-hazardouswastes. d) In-house waste movement: Housekeeping staff should collect all other bio-hazardous waste throughout a facility on a daily basis in order to prevent the accumulation of bio- 82 hazardous wastes. The bio-hazardouswaste is to be stored ina designatedstorage area. Handling of bio-hazardous waste should be done ina careful manner andin accordancewith known safety guidelines. Operators should wear protective apparel when handling bio- hazardous waste containers. Housekeepingworkers responsible for collecting and transporting waste should: 0 Collect waste daily; No bags should be removedunless labelled; and, Bags should be immediately replaced with a bag of the same type. Ingeneral, priorto on-site movement of bio-hazardouswaste, the waste shouldbepackaged incontainers which are rigid, leak-resistant,impervious to moisture, andof sufficient strength to avoid tearing or burstingundernormalconditions when beinghandled. Details on in-house movement recommendations are providedinthe fullbio-hazardous waste managementreport. e) Storage:The storagetime of bio-hazardous waste should be minimized. Four factors are to be considered when storing bio-hazardous waste: The integrity of the packaging; 0 Storagetemperature; 0 Duration of storage; and, The characteristics of storage area. f) Contingencyplanningandspillcontroyresponse:A contingency planis included to provide for emergency situations. As previously mentioned, duringthe handling of bio- hazardous waste, staff should wear appropriate personalprotective equipment (PPE). Similarly when cleaning-up an accidental spill, staff should wear appropriate PPEto prevent direct exposure to the potentially infectious agents when cleaning up spills. Details proceduresto follow inthe event of a bio-hazardous waste spill are providedinthe full waste management plan. g) Staff training: Facilities which generatebio-hazardous waste shouldprovide its employees with bio-hazardous waste managementtraining. This training should include an explanation of the bio-hazardous waste managementplan and the assignment of roles and responsibilities for the implementation of the plan. Such training is important for all employeeswho either generateor handle bio-hazardous waste regardlessof their role (i.e. supervisor or supervised) or type of work (i.e. technical, scientific, housekeeping or maintenance). 14. Review ofAvailable Bio-HazardousWaste Treatment Technologies. Different bio- hazardouswaste treatment technologies are currently available andbeing employed inSaint Lucia. However, none of these technologies likely come close to meeting current World Health Organization (WHO) or North American standards of effectiveness inthe destruction of pathogens. To promote the safe destruction of bio-hazardous wastes in Saint Lucia and meet WHO andor North American standards, GPEC has selectedtwo treatment technologies 83 for consideration inSaint Luciabasedon the specific needs and conditions of the island. These two technologies are fixed hearthincineration and steam sterilization (or autoclaving). 15. Operationof a Bio-Hazardous Waste Management Plan. The waste management study recommends the following componentsto ensurethe effective implementation and operation of the bio-hazardouswaste managementplan. These componentsinclude: 0 Selection of a waste managementteam (e.g. Infectious Control Officers, and Inspection Officers); Employee training programs; 0 On-going monitoringand infraction reporting; 0 Accident and incident reporting; 0 Follow-up monitoringactivities; 0 Occupational health and safety guidelines; and 0 Emergency responseprocedures 16. Conceptual Treatment Facility Designand Operation. The following subsections outline the typical requirements of a centralized bio-hazardous treatment facility designedto handle all bio-hazardous wastes being generatedinSaint Lucia. It is important to note that the conceptual treatment facility designprovidedinthis managementplan is for illustrative purposes only. The final design andlayout of the facility may vary significantly for the conceptual design due to various factors including, the cost and availability of labour and construction materials, the treatment technology selected, the costs andavailability of various equipment, vendor specific requirements, andthe availability of utilities. 17. Site Description and Layout. The facility is expectedto be constructed at the Deglos landfill facility. Landhas been reportedly allocated within the recycle areaof the Deglos landfill facility for the bio-hazardous waste treatment facility. Basedon review of existing site plans, the optimum location orthe bio-hazardous treatment facility at the Deglos landfill site will be within the recycle area at the elevation of 12.0 m. The bio-hazardous facility will require a foot print upto approximately 20 mby 20 m (or a total of 400 m2). It i s important to note that additional space may be required, for the reasonsindicated above. Proper landscaping for drainage around the facility buildingwill also be required inorder to prevent flooding of the bio-hazardous treatment facility. The facility will be laidout into zones in order to conduct facility operations ina safe and efficient manner while minimizing exposure to bio-hazardous waste. The different zones (or areas) could include: Bio-hazardous waste drop-off zone and cleddisinfected emptybinloading zone; Bio-hazardous waste weighing zone; Bio-hazardous waste cold storage zone; Waste tippingand treatment zone; Re-usablecarthin cleaning and drying and storage zone; Chemical storage zone; Office/administration zone; Decontamination zone; 84 0 Non-treatable hazardous waste storage zone; and, 0 Treated waste collection zone. 18. The buildingwill be apre-engineeredbuilding, erectedon slab-on-grade foundations complete with required electrical and mechanical systems. The buildingand equipment foundations will needto be designed of sufficient load bearing capacity inorder to support the waste treatment equipment and all associatedfacility equipment. The building should be steel frame with metal roofing. Complete exterior walls around the facility will not be required given the fact that the treatment technologies will generate considerable amount of heat. For this reason, the treatment facility should be fenced. The cold storage facility will be designedto operate outdoors as it will be located adjacent to the facility building. The office space, washrooms, decontamination rooms, and the chemical storage area should be complete with walls and doors (as appropriate). Inaddition, the cart cleaning areawill also be closed-in to contain spray cleaning activities. Proposedactivitiesunder the Saint Lucia HIV/AIDS Preventionand Control Project. 19. Some medical waste managementissues are alreadybeingfunded bythe Government which has, for example, contracted out the removal of medical waste from healthfacilities. However, to improvethe bio-medical waste management structures and processes, and mitigate associatedrisks, the proposed project may support a set of system-wide interventions if establishedas critical: (a) Improvingthe legal and regulatory framework: consultants will review the legal and regulatory framework that exists andpropose improvements indefinitions, management arrangements, scope of coverage of regulation to include the transportation of wastes and residuesand site disposal; (b) Codification of practices: inconsultation with facility managementandwith the support of outside experts, practices and procedureswill be codified, to ensure that all steps inthe systemwere specifically covered, and that "international standards" were applied; (c) Clarification of managementresponsibilities: from practice andregulations, facilities will reinforce and/or establishbiomedicalwaste managementresponsibilities inclear personnel assignments; (d) Staff traininganddevelopment: the MOHshould organize andconduct aprogram to train andfamiliarize employeesinallof the healthcare facilities with the new guidelines and protocols that havebeen developed. It will then continue to monitor the application of these under the authority of the revised regulatory framework; and (e) Upgrading facilities and equipment: the application of new practices will be supported with a complement of small equipment and specific site improvements and/or equipment repairsas necessaryfor their application (protective gear, trolleys, bins and containers, monitoringandrecording equipment, fluid waste containers and piping, etc). Inaddition, consultantswill review the system demands for inter-site transportation of wastes, 85 incineration anddisposal, leading to arecommendationfor investments innew incineration and disposal technology. These investmentswill also be financed. 20. The M O Hwill managethe implementation of the above action planto be supported under the project. 21. Management of Environmental Risksof Small ConstructionWorks. The proposed project envisages small construction, rehabilitating andor conditioning available space of several facilities. Inthe preparation of the request for proposals, the project's Coordination Unit(PCU) ,alongwith the agenciesinvolved, will take into accountthe following guidelines that will be incorporatedinthe project's Operations Manual and StandardBidding Documents for Civil Works: (i) environmental guidelines for the construction of health facilities; (ii) environmental guidelines to be included inbiddingdocuments for civil works; and (iii) guidelines for small construction works. Particularly, appropriate specifications will be described inthe biddingdocumentsfor civil works to mitigate environmental risks that may beidentified. 22. Environmental Screening. The PCUwill assess the potential environmental risks of the project's civil works investments which will dependon the type of construction, area available (congested vs. open area), the location (urbanvs. rural)of the proposed construction and whether it is new work or space conditioning inexisting facilities. a Inaddition, ifrequired, prior to the undertakingof civil works, the identification of the following risks may take place: a Interruption or limitation of accesses to dwellings or businesseseither permanently or temporarily (duringconstruction); a Encroachmentheduction of green areas, parks, and other recreational areas; a Demolition of buildingsof higharchitectural or historicalvalue; a Deterioration of urban quality and property value inthe immediate vicinity of the works or deterioration of uniquearchitectural characteristics inthe neighborhood; a Increasedaccidents inareas with highdensity of schools, hospitals, and commercial use; a Harmingurbaninfrastructure (sidewalks, power andtelephone lines, water and sewerage mains, etc.); a Creating nuisancesduringconstruction (dust, wastes, and heavy construction traffic). a Raisingnatural hazards (floods, soil instability); and a Protectinghistorically and culturally significant sites. 23. Biddingdocuments and contracts will specify terms and conditions governing the works activity to minimize and mitigate these risks as required. 24. Environmental Management Tools. Environmental considerations for the engineering design .Theengineering design of civil works, ifrequired, will take into consideration: (i) connectionsof the buildingsto the potable water system andthe capacity of the existing water distribution network or the needto establish a water supply system for the building (well, storagetank, pumpingstation, etc.); (ii) connection to the sewerage network and the 86 needfor capacity expansion for receiving collectors or the needfor a wastewater treatment systemfor the building (septic tank, infiltrationditch); (iii) the treatment of wastewater before beingdischarged to the sewerage networks or the wastewater treatment system; (iv) the management of runoff and the facilities for its recollection andevacuation, havingin mindthe existingdownstreamsystems; (iv) the systems of recollection, storageand transportation of solid wastes generatedinthe building,incorporating the structures for separation and recycling; (v) appropriateaccess systems for pedestrians, municipal and inter- municipalbuses, bicycles ,children and handicappedpeople; (vii) the need to integrate buildingdesign with architectonic characteristics of the surrounding neighborhood; and (viii) avoiding the use of materials such as wood from tropical forests, lead-basedpaints, asbestos, for example. 25. EnvironmentalEnhancement. The architectural designs could bringopportunities to incorporate andreinforce the criteria of environmentally friendly buildings.The feasibility of incorporating these aspects into the design will be analyzedduringthe conceptualization phase of the architectural designsandduringthe engineering designs. This analysis could include: (i) solar panels to satisfy totally or partially the electricity needs; (ii) water rain storage for the irrigation of gardens and green zones; (iii) maximizingnatural light inorder to minimize artificial light needs; (iv) planting of nativespecies ingardens and green areas; (v) natural ventilation systems, minimizingthe necessitiesof air conditioning; (vi) the stabilization of slopes using vegetative measures; and (vii) access for those with physical disabilities. 26. EnvironmentalManagement of Construction Activities. Biddingdocuments will requestcontractors, as needed, to address the following issueswhen deemed significant by the PCUandparticipating line ministries: (i) pedestrian safety andtraffic congestion during construction due to the increase of heavy traffic (of the construction itself andfrom traffic detours) inhightraffic avenues andexit ramps; (ii) andparticulate materials, causing dust nuisancesto surrounding families andbusinesses, specially to vulnerable people (children, elders); (iii) undesirable noise levels due to the machinery andequipment specially in areas with hospitals, homes for the elderly, schools; (iv) degradation of lateral streets due to heavy equipment machinery and traffic detours; (v) the interruptionof services (water, electricity, telephone, bus routes) during construction; (vi) the adequate disposal of garbage, metals, usedoils, and excess material, generatedduringconstruction; (vii) the need of informing the population about construction and work schedules, interruptionof services, traffic detour routes, provisional bus routes; and (viii) pedestrian security measures, specially for school children, duringconstruction. 27. Biddingdocuments will also ask for the identification of suitable sites for waste disposal, the environmental management necessary (compacting, re-soiling and re-vegetation, drainage control), andthe associatedtransportation costs should be includedinproject design andcost estimates. 28. Environmental Supervision during Construction. Supervision of construction will include the compliance with the environmental specifications of contracts. 87 29. EnvironmentalMeasuresduringthe OperationalPhase. Duringthe operational phaseof the civil works, if required, adequate provisions will guarantee: (i) the maintenance of the systems of collection and treatment of wastewater; (ii)the adequatecollection and disposal of solid waste, incorporating recycling systems and the separationof materials; and (iii) maintenanceofcomplimentarysystems(solarpanels,etc.).Theengineeringdesign the should include the preparationof operational manualsandmaintenanceof all systems. 30. PublicConsultationPriorto the ConstructionPhase. The PCUmay identify the need for community consultation inthe area of influence of the proposedcivil works. To this end, a process will beundertakenwith the assistanceof recognized professionals for disseminating information andgenerating feedback from stakeholders who may be specifically targetedand the public at large. The consultation program may involve both formal and informalpresentationsandmeetings with the target groups, and information dissemination campaigns. 3 1. InstitutionalArrangementsandResponsibilitiesfor Implementationand Supervisionof MitigationActivities. Eachof the participating agencies, with supportfrom the project's PCU,will be incharge of managingthe implementation and supervision of the mitigation activities identifiedin this environmental assessment. 88 Annex 11:Project Preparation and Supervision Saint Lucia HIV/AIDS PreventionAnd Control Project Planned Actual PCNreview 121'1 1/2003 12/11/2003 InitialPID to PIC 12/19/2003 01/08/2004 Initial ISDS to PIC 12/19/2003 01/08/2004 Appraisal 03/16/2004 05/10/2004 Negotiations 04/05/2004 05/26/2004 Board/RVP approval 06/29/2004 Planneddate of effectiveness 08/30/2004 Planneddate of mid-termreview 03/30/2007 Plannedclosingdate 06/30/2009 Bank staff and consultantswho worked on the project included: Name Title Unit Mary Mulusa Task Team Leader LCSHH Mariana M.Montiel Sr. Legal Counsel LEGLA EduardDaoud Sr. Loan Officer LOAG John StephenOsika Sr. HealthSpecialist AFTTR FabienneMroczka Financial Management Specialist LCOAA Guido Paolucci Sr. Procurement Specialist LCOPR Willy De Geyndt InstitutionalManagement Specialist Consultant Patricio Marquez Lead Health Specialist LCSHH Albert0 Gonima InformationTechnology Specialist -- - Consultant Aracelly Woodall Sr. Program Assistant LCSHD Peer reviewers: Jonathan Brown (Operations Adviser, HDNGA) and Helen Saxenian (Lead Health Economist, LCSHH) Bank funds expendedto date on project preparation: Bank resources: US$72,147.75 Trust funds: US$20,485.36 Total: US$92,633.11 EstimatedApproval and Supervision costs: Remaining costs to approval: To be determined Estimated annual supervision cost: US$140,000.00 Supervisionstrategy. The project involves a wide range of im 1 menters in an en rironment with little experience of implementingBank projects and with capacity constraints especially inthe areaof humanresources. The first two years of the project will requirethe rangeof skills used in project design to provide support on each of the key components. Fiduciary aspects inparticular will require regular contact between the Government and the Bank team. To initiate project implementation, a workshop will be held incountry and will require not less than two formal supervision mission visits inthe first year. Given the Bank active involvement inthe region, short visits connectedwith missions to other countries will be usefulinprovidingproactive support to implementation. Regionaltraining sessionsfor project and other implementers will be conducted. 89 Annex 12: Documentsinthe Project File Saint Lucia HIV/AIDS Prevention And Control Project A. Background documents - Saint Lucia National HIVlAIDS Strategic Plan 2003 - 2008 - Cabinet Conclusion No. 337 of 2004 dated M a y 3,2004: "Endorsement of InstitutionalArrangements to Manage and Coordinate Implementation of National HIVIAIDS Strategic Plan2004-2008" - Document on HIV/AIDS Situation in Saint Lucia. Ministry of Health,. Human Services and Family Affairs. - Allocation of Portfolios to Ministers -Government of Saint Lucia - Saint Lucia: Public Expenditure Review - Health; World Bank ,September 2002 - Country Health Profile 2002: Saint Lucia and CountryChapter fromHealth in Americas, 2002Edition; PAHO; Washington DC - HIV&AIDS Surveillance Report -Saint Lucia 1985-2001; MinistryofHealth,. HumanServices andFamily Affairs. - HIV/AIDS inSaint Lucia -A Situation & Response Analysis; Suzanne D.Burke and Ainsley P. Charles; October 2002 - National Coordinating Committee on HIV/AIDS -Terms of Reference-April 2003 - Health Systems and Services Profile - Saint Lucia - September 7,2001; PAHO, Washington DC - AIDS -The Response- Saint Lucia; M a y 22,2002; prepared by Dr.M. Grandison-Didier et al. - Report on Regional WorkshopheldinBelize City, September 17-19,2003 by Cyrus Reynolds, Deputy Permanent Secretary, Ministry of Labor Relations and - Public Service HIV/AIDS inthe Caribbean. Issues and Options. World Bank. 2001. B. ProjectDocuments -- Draft Project Operations manual. Health Care Waste Management Plan. C. BankAssessments - Financial management capacity assessment. - Procurement management capacity assessment. 90 Annex 13: Statement of Loans and Credits Saint Lucia HIV/AIDS Prevention And ControlProject Differencebetween expectedandactual OriginalAmount inUS$Millions disbursements Project ID N Pumose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd PO77687 2002 Saint Lucia Emergency RecoveryProject 1.89 4.41 0.00 0.00 0.00 3.15 -0.04 0.00 PO70244 2002 LC Water Sector ReformTechAssist 1.30 1.30 0.00 0.00 0.00 2.27 0.86 0.00 PO77712 2002 6 0 LC Education (APM1) 6.00 6.00 0.00 0.00 0.00 12.64 3.41 0.00 PO54939 2000 LC-POVERTY REDUCTIONFUND 1.50 1.50 0.00 0.00 0.00 0.44 0.36 0.00 Total: 10.69 13.21 0.00 0.00 0.00 18.50 4.59 0.00 SAINT LUCIA STATEMENT OF IFC's HeldandDisbursedPortfolio InMillions of US Dollars Committed Disbursed IFC IFC NApproval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. Total portfilio: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ApprovalsPendingCommitment NApproval Company Loan Equity Quasi Partic. Total pendingcommittment: 0.00 0.00 0.00 0.00 91 Annex 14: Country at a Glance Saint Lucia HIV/AIDS PreventionAnd Control Project Saint Lucia at a glance 3110104 Latin Upper- POVERTYand SOCIAL Americ middle- a Development diamond' Saint &Carib. income Lucia Lifeexpectancy 2002 Population,mid-yea GNIpercapita (Atla T GNI Per capita Population(percent) 1.4 1.5 1.2 Laborforce (percent) 2.2 1.8 Accessto improvedwater source Poverty (percent ofpopulationbelownationalpoverlyline) Urban population(percent oftotalpopulation) 38 76 75 Lifeexpectancyat birth (years) 71 71 73 Infantmortality(per 1,000 livebirths) 13 27 19 Childmalnutrition(percen n under5) 9 Access to an improvedwa (percent ofpopulation) 98 86 90 Illiteracy (percent ofpopulationage 754 11 7 primaty enrollment (percent of school-age 106 130 105 On) 105 131 106 Female 108 128 105 KEYECONOMICRATIOSand LONG-TERMTRENDS 1992 2001 2002 Economic ratios' GDP (US$ billions) 0.14 0.48 0.65 0.66 Trade Grossdomestici T Domestic Investment Gross nationalsa saving5 Currentaccount Indebtedness Total debt/GDP Total debt servicele Presentvalue of d (averageannualg 92 I STRUCTURE of the ECONOMY Growth of investmentand GDP [%I 1 1982 1992 2001 2002 20 (percent of GDP) b Agriculture 13.9 13.4 6.3 6.7 -20 Industry 20.8 20.0 18.8 18.8 Manufacturing 9.1 7.5 4.9 5.0 -db Services 65.3 66.7 74.8 74.5 -GO1 -GDP Private consumption 68.5 70.2 68.6 70.5 Generalgovernmentconsumption 24.0 14.6 16.9 16.5 Importsof goods and services 83.8 76.5 56.8 58.7 1982- 1992-02 2001 2002 92 Growth of erports and imports [%I (average annualgrowth) 10 T 5 Agriculture 6.4 -6.6 -24.4 7.2 b Industry 10.2 1.5 -3.7 -0.6 -5 Manufacturing 9.6 -0.8 -4.9 1.2 -io -15 Services 7.1 2.3 -3.7 -1.1 -2b -Export$ -Import$ Privateconsumption 9.9 1.5 -6.0 4.6 Generalgovemmentconsumption 4.2 2.4 4.9 0.7 Gross domestic investment 9.9 -1.8 -26.9 7.6 Importsof goods and services 11.1 -1.2 -16.4 5.3 Note: 2002 data are preliminary estimates. * The diamonds show four key indicators in the country (in bold) compared with its incomegroup average. If data are missing,the diamond will be incomplete. Saint Lucia PRICES and GOVERNMENT Inflation [%I FINANCE 2001 2002 Domesticprices (percent change) Consumer prices 2.5 2.5 Implicit GDP deflator 1.3 1.8 - 2 r 97 48 94 bb 01 b2 -d Government finance ( percent of GDP, includes current -GDP deflator -CPI grants) Current revenue 25.3 23.3 Current budget balance 2.6 -0.3 Overall surpluddeficit -4.6 -8.3 TRADE 2001 2002 (US$mi/lions) 93 Total exports (fob) 52 71 Bananas 15 17 II Fruitsand vegetables 1 1 Ezport and import levels[US$ mill.) Manufactures 11 26 I 4 b 0 - r Total imports (cif) 311 333 Food 65 69 300 Fueland energy 15 16 Capital goods 61 65 200 100 Exportprice index (1995=100) 95 94 I Import price index (1995=100) 84 0 Terms of trade (1995=100) 113 $6 97 9f 94 00 01 02 aExports m Import5 BALANCE of PAYMENTS 2001 2002 (US$ millions) Exportsof goods and sewices 357 361 I Current account balance to GDP [ X ) C Importsof goods and sewices 368 387 b Resourcebalance -10 -26 -2 Net income -41 -43 -d Netcurrent transfers 14 13 -I -I -10 -12 Current accountbalance -37 -56 -14 -16 Financingitems (net) 47 48 Changes in net reserves -10 7 Memo: Reservesincludinggold (US$ mi//ions) 87 80 Conversionrate (DEC, /oca//US$) 2.7 2.7 EXTERNAL DEBT and RESOURCE FLOWS 2001 2002 (US$mi//ions) Composition of 2002 debt [US$ mill.) Total debt outstandingand disbursed 236 414 IBRD 5 5 A 5 8:PO IDA 12 20 Total debt service 25 98 IBRD 1 1 IDA 0 0 Composition of net resourceflows Officialgrants 18 0 Officialcreditors -5 10 Privatecreditors 7 30 Foreigndirect investment 51 0 Portfolioequity 0 0 - World Bank program A . IBRD E Bilateral B IDA D Other multilateral - F Private Commitments 0 12 C IMF -- G Short-tcrm .- Disbursements 1 8 Principalrepayments 1 1 Netflows 0 7 Interestpayments 0 0 Nettransfers 0 7 94 95