Document of The World Bank FOR OFFICIAL USE ONLY Report No: 42194-BB PROJECT APPRAISAL DOCUMENT PROPOSED LOAN IN THE AMOUNT OF US$35.0 MILLION EQUIVALENT TO BARBADOS FOR A SECOND HIVIAIDS PROJECT July 10, 2008 Human Development Sector Caribbean Country Management Unit Latin America and the Caribbean Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective December 12,2007) Currency Unit = Barbados Dollars (BBD) BBD2.0 = US$1.0 FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS ART Anti-Retroviral Treatment BCC Behavior Change Communication c s o s Civil Society Organizations DU Drug Use EEP Eligible Expenditure Program FBOs Faith-Based Organizations GFATM Global Fund Against AIDS, TB and Malaria GOB Government of~arbados IDU Injecting Drug Use KAP Knowledge, Attitudes and Practices LRU Laboratory Reference Unit (Ladymeade Reference Unit) M&E Monitoring and Evaluation MFYSE Ministry of Family, Youth Affairs, Sports and Environment MHNI Ministry of Health, National Insurance and Social Security MSM Men Who Have Sex with Men MTCT Mother to Child Transmission NAP National AIDS Program NGO Non Governmental Organization NHAC National HIVIAIDS Commission NSP National Strategic HIVIAIDS Plan 01s Opportunistic Infections PDO Project Development Objective PEPFAR United States President's Emergency Plan for AIDS Relief PLHIV People Living With HIV SIL Sector Investment Loan ST1 Sexually Transmitted Infections SW Male and Female Sex Workers SWAP Sector Wide Approach VCT Voluntary Counseling and Testing FOR OFFICIAL USE ONLY Vice President: Pamela Cox Country Director: Yvonne Tsikata Sector Director: Evangeline Javier Sector Manager: Keith Hansen Task Team Leader: Joana Godinho This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization. BARBADOS SECOND HIVIAIDS PROJECT CONTENTS Page I. STRATEGIC CONTEXT AND RATIONALE ..................................................................1 A. Country and sector issues .................................................................................................... 1 B. Rationale for Bank involvement.......................................................................................... 1 C. Higher level objectives to which the project contributes ..................... 7 ...................... I1. PROJECT DESCRIPTION ..............................................................................................8 A. Lending instrument .............................................................................................................. 8 B. Project development objective and key indicators ................... .. .....................................8 C. Project components .......................................................................................................... 9 D. Lessons learned and reflected in the project design ........................................................ 14 E. Alternatives considered and reasons for rejection ............................................................. 16 I11 . IMPLEMENTATION .....................................................................................................16 A. Partnership arrangements .................................................................................................. 16 B. Institutional and implementation arrangements (Annex 6)............................................ 17 C. Monitoring and evaluation of outcomes/results (Annex 3)...............................................18 D. Sustainability ....................... ...................................................................................... 19 E. Critical risks and possible controversial aspects .................... ... ..................................19 F. Loadcredit conditions and covenants .......................................................................... 21 APPRAISAL SUMMARY ..............................................................................................22 Economic and financial analyses (Annex 9) ........................... ................................22 Technical ........................................................................................................................... 22 Fiduciary ........................................................................................................................... -23 Social ................... .. ...................................................................................................... 23 Environment ......................... ........................................................................................ -24 Safeguard policies............................................................................................................ 24 Policy Exceptions and Readiness ...................... ....................................................... 24 Annex 1: Country and Sector or Program Background ..........................................................26 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies ..................32 Annex 3: Results Framework and Monitoring ...................................................................... 33 Annex 4: Detailed Project Description ......................................................................................46 Annex 5: Project Costs................................................................................................................52 Annex 6: Implementation Arrangements ................................................................................3 6 Annex 7: Financial Management and Disbursement Arrangements .....................................73 Annex 8: Procurement Arrangements .....................................................................................7 9 Annex 9: Project Economic and Financial Analysis ...............................................................A 3 Annex 10: Safeguard Policy Issues .............................................................................................90 Annex 11: Project Preparation and Supervision ......................................................................91 Annex 12: Documents in the Project File .................................................................................. 93 Annex 13: Statement of Loans and Credits ...............................................................................94 Annex 14: Country at a Glance ..................................................................................................95 Annex 15: MAP IBRD 33369 ......................................................................................................97 BARBADOS SECOND HIVIAIDS PROJECT PROJECT APPRAISAL DOCUMENT LATIN AMERICA AND CARIBBEAN LCSHH July 10, 2008 Team Leader: Joana Godinho Country Director: Yvonne M. Tsikata Sectors: Health (100%) Sector ManagerDirector: Keith E. Hansen Themes: HIVIAIDS (P);Population and reproductive health (P);Health system performance (S) Project ID: PI06623 Environmental screening category: Not Required Lending Instrument: Specific Investment Loan Project Financing Data [XI Loan [ ] Credit [ ] Grant [ ] Guarantee [ ] Other: For Loans/Credits/Others: Total Bank financing (US$m.): 35.00 Proposed terms: Flexible loan with a fixed spread denominated in US dollars, with a five year grace period, a 30 years repayment term with level repayments, and payment dates of February 15 and August 15 of each year, with all conversion options. Financing Plan (US$m) Source Local Foreign Total Borrower 59.39 0.00 59.39 International Bank for Reconstruction and Development 35.00 0.00 35.00 Total: 94.39 0.00 94.39 Borrower: Ministry of Finance, Barbados Responsible Agency: Ministry of Health Dr. Carol Jacobs, Chair 4nd Floor East, Warrens Office Complex Warrens, St. Michael, 12001, Barbados Tel: (246) 310-1008 Fax: (246) 421-8499 aiordan@barbados.gov.bb Estimated disbursements (Bank FY/US$m) FY 2008 2009 2010 201 1 2012 Annual 4.60 11.00 18.50 26.10 35.00 Cumulative 4.60 15.60 34.10 60.20 95.20 Project implementation period: Start September 1,2008 End: November 29, 2013 Expected effectiveness date: September 1, 2008 Expected closing date: November 29, 2013 Does the project depart from the CAS in content or other significant respects? [ No Re$ PAD I.C. Does the project require any exceptions from Bank policies? Re$ PAD IKG. [XIYes [ ] No Have these been approved by Bank management? [XIYes [ ] No Is approval for any policy exception sought from the Board? [XIYes [ ] No Your approval is sought for making an exception to the graduation policy, based on the fact that under the prevailing market conditions, Barbados would be unable to obtain a loan for the financing of their HIVIAIDS program under terms which the Bank considers reasonable to the country. Bank management granted a waiver of existing Bank policy which provides for the financing of incremental recurrent costs on a declining basis for countries without approved Country Financing Parameters. Your approval of this waiver is sought concurrently with your approval of the urouosed loan. Does the project include any critical risks rated "substantial" or "high"? I [ ]Yes [XI No Re$ PAD III.E. Does the project meet the Regional criteria for readiness for implementation? [XIYes ( I No Ref:PAD ZK G. Project development objective Re$ PAD ZIaC Technical Annex 3 The project would support the implementation of the 2008-2013 Barbados National HIVIAIDS Strategic Plan, specifically to increase: - Adoption of safe behaviors, in particular amongst the most vulnerable groups. - Access to prevention, treatment and social care, in particular for the most vulnerable groups. - Capacity of organizational and institutional structures that govern the NAP. - Use of quality data for problem identification, strategy definition and measuring results. Project description Re$ PAD ZZ.D., TechnicalAnnex 4 Component 1: Prevention and Care (US$31.5million) would contribute to the implementation of the 2008-2013 Barbados National HIVIAIDS Strategy, specifically of the following three I programs: National Program Coordination and Monitoring. This program aims at strengthening the ability of the public and private sectors and civil society to coordinate monitor and evaluate I their gctivities and use data to continually increase the quality of their programs. - - Scaling up Prevention Efforts. This program aims at increasing access to preventive services, particularly (i) behavior change communication, (ii) HIVIAIDS and ST1prevention and treatment, and (iii) condoms, with a special focus on key populations at higher risk. Diagnosis, Treatment and Care. The goal of this program is to increase the length and quality of life of PLHIV. Component 2: Institutional Strengthening (US$3.5 million) would finance training and technical assistance on M&E, management, surveillance, prevention, diagnosis, treatment and care of HIVIAIDS and other STIs, to support the implementation of the Strategic Plan, by strengthening agencies and civil society organizations through training and technical assistance that cannot be funded under the regular program. Which safeguard policies are triggered, if any? Re$ PAD IKF., TechnicalAnnex 10 I The Environmental Assessment (OP/BP/GP 4.01) safeguard policy would not be triggered. I Given that this is a follow on project, with no new construction envisaged, no new environmental assessment is required. The environmental assessment was updated in relation to ongoing health care waste management activities. Even though project activities would result in increases in health care waste, this added volume would be accommodated by the health care waste management system that was put in place with support from the first project. The second project would monitor the proper disposal of health care waste by health care providers supported by the new project. Significant, non-standard conditions, if any, for: (Re$ PAD ZZ1.F.) Board presentation: None. Loadcredit effectiveness: None. Covenants applicable to project implementation: None. I. STRATEGIC CONTEXT AND RATIONALE A. Country and sector issues 1. Barbados is the easternmost country in the Caribbean and has a population of 277,000. It is the national vision of Barbados to become a "fully developed society that is prosperous, socially just and globally competitive by the end of the first quarter of this century". The attainment of this vision will be realized through the implementation of the National Strategic Plan of Barbados 2005-2025: Global Excellence, Barbadian Traditions (NSP). 2. The Plan identifies HIVIAIDS as one of the major threats to its overall success as it endangers the country's human capital, putting productive capacity and resultant economic growth in peril. Indeed, HIV and AIDS form the greatest burden of infectious diseases in Barbados for the 15-49 years age group. The potential for escalation in the burden on welfare services and increasing treatment costs is significant. Such a negative impact on the productive population combined with increases in the aged population could create a cost to the country that is monetarily and socially unsustainable. In response to this threat, Goal 3 of the NSP speaks to: Continued reduction in the spread of HIVIAIDS and minimization of its negative impact. Improved information systems, research, monitoring and evaluation (M&E) to support decision making with respect to HIVIAIDS. Creation of a national multi-sector HIVIAIDS Program. 3. This approach is in consonance with the Government's commitment to the Millennium Development Goals, particularly Goal 6 - combating major diseases. These efforts will be supported by the Barbados National AIDS Strategic Plan 2008-2013, which forms the framework for creating a national sustained and committed HIVIAIDS mitigation response. The proposed project would support the implementation of the Strategic Plan. 4. To date, with some support from the Bank, the Barbados HIVIAIDS Program has achieved high levels of awareness, treatment and care. However, it has been less successful in inducing the level of sustained behavior change required to impact the epidemic's prevention and control. It is imperative that every effort be made to maintain and expand the accomplishments of the initial project to secure the future of the country. The mid-term review of the first Bank- financed project indicated that Barbados may see the number of people living with HIV (PLHIV) grow to 2,900 in 2010 and 4,000 in 2015. These perspectives will have a significant impact on the costs of the program. With the adoption of generic compounds that are currently available on the market for patients initiating antiretroviral treatment, the annual cost of drugs could increase from US$2 million in 2007 to US$8 million in 2015. B. Rationale for Bank involvement 5. Bank financial and technical assistance has been contributing to the achievement of significant results in preventing and controlling the epidemic in Barbados. In 2001, the Bank prepared a horizontal APL to provide rapid support to Caribbean countries to combat the epidemic. The HIVIAIDS Prevention and Control Project for Barbados was included in the 2001 Eastern Caribbean CAS due to the public goods nature of this program, and the leadership role Barbados has in the highly inter-related economies of this sub-region. Despite having graduated, Barbados was one of the first two countries to receive support under the APL, by virtue of its leadership role on HIV in the sub-region and the fear of a region-wide outbreak. Although several of the Caribbean projects have struggled because of inadequate ownership and weak capacity, Barbados has generally performed well. This was the first Bank project in the world to support antiretroviral treatment. Prevention programs have also grown substantially. The challenge in Barbados today is to continue reducing transmission while sustaining treatment and quality of life for those living with the disease. 6. Given the success of the first project and the remaining unfinished work, the GOB has requested a follow-on project that would contribute to tackling the outstanding challenges posed by the HIV epidemic. The request has come from the highest levels of the GOB. Additional Bank assistance would further'leverage Barbados' position in the Caribbean to continue serving as a role model for other regional countries that have been less aggressive toward HIVIAIDS. Addressing the epidemic in Barbados has other regional benefits, as the country is a regional hub for transit tourists and Caribbean citizens traveling within the region and further. The end result is a series of regional public goods. The Bank is the only source of external funding for HIVIAIDS in Barbados - other sources such as the Global Fund against AIDS, TB and Malaria (GFATM), and private foundations, target lower-income countries. 7. HIVIAIDS continues to be a key global development issue in all regions of the world. The Caribbean Region has the highest HIV prevalence among adults outside Sub-Saharan Africa (Table 1). The estimated prevalence rate increased in Barbados from 1.3% in 2001 to 1.5% in 2005. HIV in the Caribbean 2005 Total Adult Population HIV + Adults HIV + Women HIV+ Adult 15-49 years, 15-49 years 15-49 years 15-49 years Country Thousands** #* #* %* 7 &Abbean 21.969 160,000 1.6 ' ' Bahamas 214 6.500 3.800 3.3 Barbados Cuba Dominican Republic Haiti Jamaica Trinidad and Tobago * UNAIDSIWHO 2006. Report on the Global AIDS Epidemic. UNAIDSIWHO: Geneva. **World Bank HNP Stats 8. Although Barbados has achieved significant results in the prevention and control of the epidemic, and new AIDS cases and AIDS mortality significantly declined (46% and 72%, respectively) since the advent of anti-retroviral treatment (ART) in 2001, estimated HIV prevalence continues to increase, as shown in the graph below. This is due to the lack of adoption of safer sexual practices, and the increasing survival of people under treatment. Cumulative HIV cases, AfDS cases. PLHIV cases and H1V deaths 1984- June 2007 4000 3500 3350 8 0 zsuo U g ,000 ij .600 r DO0 500 - Yeer PLHI'J--Cunlulatlve HIV Cases Ci~rnulatlve.&IDSCases -Cumulative Deaths Source: MHNI 2008. HIV Surveillance Report January-June 2007. MHNI: Bridgetown. 9. The first case of HIVIAIDS was detected in Barbados in 1984, at a time when the epidemic was confined to men who have sex with men (MSM). However, the number of reported HIV cases continued to rise, particularly among self-reported heterosexual men and women of reproductive age. There are about 2,100 known PLHIV in Barbados, but the Ministry of Health, National Insurance and Social Security (MHNI) estimates suggest that the total number of infected adults may be significantly higher. In 2006, over 75% of reported infections occurred in the age group 15-49 years. In addition, there has been a rapidly increasing feminization of the epidemic, with a male to female ratio of 1:1 in 2006. 10. Despite the numerous achievements of the National HIVIAIDS Program (NAP), much remains to be done regarding HIVIAIDS and other sexually-transmitted infections (STIs) in Barbados. The single greatest gap in the Program is the fact that the M&E system is not fully functional. Some data have not been collected, analyzed or shared, and in other cases, data have not been routinely collected. These gaps not only prevent managers from being able to assess program performance, hindering their ability to make corrections, but prevent Barbados from knowing if HIVIAIDS investments have been effective and complicate the task of deciding what interventions to further invest in. The M&E system needs to be further improved, which will be especially important for the new proposed project, which would set results-based disbursements. Data analysis, decision making and triangulating results across sectors needs to be strengthened. 11. Outreach for key populations at higher risk needs to be improved1. As a relatively small country, with close-knit family and social networks, people are often reluctant to identify themselves as being part of a vulnerable group, and may avoid government services and their perceived lack of confidentiality. The conservative nature of Barbadian society has also resulted in the social prohibition of providing condoms to men in prison and an overwhelming public outcry against recommendations to decriminalize anal sex among consenting adults. The regional nature of the sex trade, with workers moving frequently among islands, further complicates attempts to reach them. By working more closely with civil society organizations (CSOs) that have the trust of these vulnerable groups, services can be made more readily available to them. 12. The percentage of youth able to correctly identify ways of preventing the sexual transmission of HIV, and who had no misconceptions about HIV transmission, increased only from 0.1% in 2001 to 1% in 2005. Other evidence from the 2001, 2003 and 2005 youth knowledge, attitudes and practices (KAP) surveys indicate that educational messages have been successful in raising knowledge levels but less so in affecting behavior change. About 27% of young men and 16% of young women report using a condom when having sex with a casual partner in the last year. HIVIAIDS prevention campaigns designed to reach particular target groups have not impacted significantly on sexual practices. Part of the challenge lies with the fact that in previous years there has not been comprehensive training in behavior change communication (BCC) and that key populations at higher risk - sex workers (SW), MSM, prisoners, - have to be better targeted and involved in the prevention and control work. 13. While the NAP has engaged in voluntary counseling and testing (VCT), further collaboration with CSOs will make VCT more available. Building capacity among CSOs that work with key populations at higher risk, such as MSM and SW, to perform VCT will greatly increase access, as well as referral to treatment and care, for these underserved groups. Implementing rapid testing could increase the number of organizations that can offer HIV testing services and further increase the number of people tested who return to get their results. 14. Social care of PLHIV also needs strengthening. PLHIV are currently assigned to a social worker if necessary, but access to psychological support services or home care needs improvement. The MHNI reports a great need among PLHIV and high risk groups for counseling and support on drug use (alcohol, marijuana and cocaine). A study by the National Council on Substance Abuse reported that less than 4% of respondents (10 out of 278) in 2005 engaged in intravenous drug use. However, the lack of judgment brought on by drug use (intravenous or other) is often accompanied by high risk sexual behavior andlor sex being traded for drugs. In addition to improving the quality of life of PLHIV and key populations at higher risk, providing individual and group drug counseling can also contribute to reducing HIV transmission. 15. Finally, multi-sector institutional roles and relations have to be further strengthened, especially between the National HIVIAIDS Commission (NHAC) and key ministries such as the 'In Barbados, key populations at higher risk include male and female sex workers (SW); men who have sex with men (MSM), prisoners; people living with HIVIAIDS (PLHIV) and with disabilities; youth, especially out-of- school; and unemployed women (Annex 6 includes detailed information about these groups). Ministries of Health, National Insurance and Social Security (MHNI), Social Care, Education, Labor and Tourism. Although the framework for the national HIVIAIDS strategy is multi- sectoral, the reality is that on the ground it has proven challenging to coordinate all of the Program's partners. Some institutions lack dedicated HIV coordinators and, in some instances, resources to fully cooperate and share information with the NHAC. The MHNI is responsible for important essential public health functions, some of which- for example, surveillance - also need strengthening. 16. Government Strategy. The Government of Barbados (GOB) is fully committed to containing the epidemic. The government specifically requested Bank assistance in 2001, and again now, to contain the HIV epidemic. Extensive work has been done to put in place the UN "Three Ones" principles: there is (i) one agreed HIVIAIDS Action Framework that provides the basis for coordinating the work of all partners; (ii) one national AIDS coordinating authority (NHAC), with a broad-based multisectoral mandate; and (iii) a M&E system has been designed. However, as mentioned before, the M&E system remains the element of the "Three Ones" that most needs additional work. 17. The National Strategic Plan of Barbados 2005-2025 aims at continued reduction in the spread of HIVIAIDS and minimization of its negative impact, and full engagement of the national multi-sector HIVIAIDS Program by 2008. The Barbados HIVIAIDS Program is aligned with the Pan Caribbean Partnership against HIVIAIDS (PANCAP) and CARICOM's Caribbean Regional Strategic Framework for HIVIAIDS. Barbados just completed its next five-year AIDS strategy, to which the Bank has contributed significant support. It reflects all the lessons of the past decade, including the need for greater programmatic focus and better surveillance, and M&E. The Strategic Plan to prevent and control HIVIAIDS was approved by the Cabinet of Ministers on March 27, 2008. 18. A National AIDS Coordinating Authority, with a broad-based multisectoral mandate, is fully functional. In 1988, the National Advisory Committee on AIDS (NACA) was formed, and in 1995 committed to a program designed to transfer ownership of the challenge of HIVIAIDS from government to the individual citizen. The program included several Ministries, CSOs and PLHIV - in sum, a multisectoral approach. The Prime Minister established the National HIVIAIDS Commission (NHAC) in his Office in 2001, with a mandate to coordinate the national expanded multisectoral response to the epidemic, and a Secretariat was established in 2001. Following the election of a new Government on January 2008, the NHAC was integrated into the Ministry of Family, Youth Affairs, Sports and Environment (MFYSE). Of 18 Ministries, 15 report annually to NHAC on the respective HIV prevention programs. The number of AIDS- related CSOs reporting annually to NHAC increased from 4 in 2002 to 11 by November 2007. According to an ongoing ILO/US Department of Labor workplace education project, the percentage of targeted enterprises which have HIVIAIDS policies and programs increased from 5% in 2003 to 75% in 2007. 19. Recognizing the need for a paradigm shift in HIV, a national Behavior Change Communication (BCC) Strategy for Barbados was developed with Bank assistance, and it was approved in 2007. The process itself helped raising awareness with the result that the BCC strategy recommendations have been integrated into the NSP, and the Government tripled its budget for BCC. Barbados is one of the few countries in the region with an explicit BCC strategy and the first with a BCC strategy that focuses on youth and women. The BCC strategy would be implemented under the new proposed project. 20. The blood supply is reported to be safe due to universal HIV screening of all blood and blood products. Data show that SW use condoms 80% of the time with clients, and condom use among MSM is reported to have increased. Attitudes towards PLHIV changed positively. The number of primary schools providing life skills training increased. The percentage of lab and HIV testing increased by 22% and 17%, respectively, from 2002 to 2006. Laboratory capacity was built up, with the Ladymeade Reference Unit (LRU) lab now able to perform routine CD4 and viral load testing for all PLHIV registered at the clinic. The lab will soon be initiating viral resistance testing. All necessary equipment has been procured and installed and viral resistance testing will begin in 2008. The government is currently seeking to provide laboratory services at a fee to other countries in the Caribbean. 21. The GOB has put in place a free, comprehensive treatment and care program for PLHIV. Of the approximately 2,100 PLHIV who are currently alive and know their status, about 1,102 are registered with the government clinic for treatment, and 615 are receiving anti-retroviral treatment (ART). Following the provision of ART free of cost, AIDS mortality decreased by 72% between 2001 and 2006. Hospital admissions for treatment of opportunistic infections (01s) among PLHIV decreased by 42%, and the total number of hospital days fell by 59% shortly after the implementation of the ART program. Maternal transmitted HIV has been substantially reduced, with only one child born HIV positive in the last two years. Barbados was the first country in the world in which the Bank financed anti-retroviral drugs (ARV), and in hindsight this was a decision that reflected very positively on mortality, hospital length-of-stay, and health system costs. The number of patients requiring ARV will continue to grow, as the incidence of HIV will continue to rise in the short-term, and prevalence will continue to increase due to longer survival of PLHIV under treatment. The second project would continue to support ART and finance ARV, as these represent a relatively small percentage of the HIVIAIDS budget (less than 20%), and have had significant benefits. 22. Bank Assistance. The first Barbados HIVIAIDS Prevention and Control project2 aimed at reducing the rate of new HIV infections; increasing the life expectancy and improving the quality of life of PLHIV; and building sustainable arrangements for managing the epidemic. The project closed on December 31, 2007, after satisfactory implementation and full loan disbursement. Overall, the project had a dramatic impact on ultimate outcomes: as mentioned above, annual deaths from AIDS have declined by more than 70%; and among other results, the share of people reporting positive attitudes toward PLHIV has risen from less than 40% to nearly 80%. 23. Although several of the Caribbean AIDS projects have struggled because of inadequate ownership and weak capacity, Barbados has generally performed well. Its success in treatment, in particular, has served as proof of concept and helped encourage other donors and countries to follow suit. Barbados has not only proven the feasibility of providing sustained HIV care and treatment, but also provided key lessons for its neighbors and other countries. Bank support to * P075220-IBRD70660; $23.65 million total cost, $15.15 million Bank loan. antiretroviral treatment predated the creation of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) or the United States President's Emergency Plan for AIDS Relief (PEPFAR). The Bank initiated its support for HIV treatment in Barbados long before most other donors or developing countries were funding treatment. It was costly and controversial at the time, and the Bank had to adapt many of its policies in order to bring resources to Barbados. The dramatic success of this program has vindicated those decisions and paved the way for treatment programs around the world. Prevention programs have also grown substantially. Although not all intermediate project targets were reached, it is clear from today's greater knowledge of HIVIAIDS that some of these were unimportant to controlling the epidemic. Consequently, the project is regarded as having been quite successful. 24. Barbados just completed its next five-year AIDS strategy, to which the Bank has contributed significant support. It reflects all the lessons of the past decade, including the need for greater programmatic focus and better surveillance and evaluation. The key challenges for the next phase would be to institutionalize better M&E practices, improve outreach to the groups at highest risk, and achieve greater behavior change among young people. The new national strategy focuses on these areas, as would the proposed project. 25. The Bank would respond to the specific request of the GOB with a second project that would follow a results-based financing approach. According to Bank policy, graduation reflects the achievements of a country in reaching a certain level of development, management capacity, and access to capital markets, but it does not prohibit the resumption of lending if necessary. The Bank is committed to continue assisting countries where prevalence is highest, and keeping client countries in the "driver's seat". With Bank involvement, the use of the best available regional and global technical experts would be expected. The Bank would bring its implementation experience and M&E expertise to assist necessary improvements in the Barbados program. In addition, the Bank's involvement and knowledge of international HIVIAIDS efforts would facilitate work with key populations at higher risk. 26. In Barbados, the World Bank has been the single largest external source of funding for HIVIAIDS prevention and control during the past six years. Apart from small grants provided through UN agencies and the support of Government's annual budgetary allocations, there is no other funding available to the Government for the National AIDS Program. The Bank also brings a wealth of experience working in non-health sectors and in mainstreaming and unifying the coordination arrangements of HIVIAIDS programs across the globe. In addition, the Bank has been supporting the development of a unified M&E framework, which needs to be consolidated under the second project. Finally, the Bank's financial support serves as a guarantee for future budgetary allocation to sector HIV programs. C. Higher level objectives to which the project contributes 27. The project would contribute to the development of Barbados, and to reducing the burden of disease in the island. If the HIV epidemic were to continue to spread in Barbados, this would create significant image problems for the country and potentially reduce tourism, which is the number one source of income for the country. Due to the significant externalities of HIVIAIDS prevention and control programs, the project would also contribute to contain the epidemic in the Caribbean, and to reduce the risk for tourists and workers originating from other countries. 28. The Project would address main outstanding issues such as acknowledging more openly risk factors, working more aggressively with key populations at higher risk, and making strategic decisions based on results. The project would continue to assist the development of essential public health functions, such as policy development, surveillance, M&E, and prevention, which are relevant for the health system as whole. The improvement in the HIVIAIDS surveillance, M&E and BCC capacity would have significant secondary effects. Due to the small size of the MHNI and other ministries, staff tend to work on a variety of teams and therefore the knowledge would be directly applied to other disease programs. In addition, the success of the project would serve as a model for other teams to try BCC approaches and would lead to a greater appreciation of the value of BCC and of collecting and using high-quality, relevant data. In sum, the project would result in an improvement in the overall health system, which is one of the Bank's strategic goals for the sector. 11. PROJECT DESCRIPTION A. Lending instrument 29. The Barbados HIVIAIDS I1 Project would co-finance the GOB'S National HIVIAIDS Program through a Sector Investment Loan (SIL) of US$35 million to be disbursed in five years (2008-2013). The project would follow a Sector Wide Approach (SWAP). The Bank would co- finance a percentage of eligible expenditures of the government program. For Component 1, on Prevention and Care, loan funding would be pooled with government funding to finance the National AIDS Program. For Component 2, on Institutional Strengthening, loan funding would be disbursed against approved contracts. Bank financing would contribute to the implementation of agreed policies and programs, and to the achievement of specific results, which would trigger disbursements as explained below. The loan would be incremental to government funding. B. Project development objective and key indicators 30. The project would support the implementation of the National Strategic Plan for HIV Prevention and Control 2008-2013, specifically to increase: Adoption of safe behaviors, in particular amongst key populations at higher risk. Access to prevention, treatment and social care, in particular for key populations at higher risk. Capacity of organizational and institutional structures that govern the NAP. Use of quality data for problem identification, strategy definition and measuring results. Project Development Indicators Behavior change Maintain the percentage of young people 15-24 years spontaneously indicating sexual relations as a way of transmitting HIV at least at 90% from 2008 to 2013. Increase the percentage of o sex workers who report the use of a condom with their most recent client from 80% in 2008 to 95% in 2013. o MSM who report the use of a condom the last time they had sex from 64% in 2008 to 75% in 2013. o young people 15-24 years reporting the use of a condom the last time they had sex with a non-marital, non-cohabitating partner from 21% in 2008 to 31% in 2013. Access to prevention, treatment and social care Increase in the number of people from key populations at higher risk accessing preventive services from 250 in 2009 to 500 in 2013. Maintain the percentage of HIV-positive pregnant women receiving a complete course of AV prophylaxis to reduce the risk of mother to child transmission (MTCT) above 95% in the period from 2008 to 2013. Maintain the percentage of PLHIV on ART achieving virologic success in the last 12 months above 70% in the period from 2008 to 2013. NAP Capacity Increase in the funds spent by CSOs under results-based agreements with the NHAC to facilitate the implementation of program interventions for key populations at higher risk in the period from 2008 to 2013. M&E An evidence-based Strategic Plan for the period of 2013-2018 prepared before project closing, taking into account surveillance and M&E data available under the project. C. Project components 31. The proposed Project aims to build on the successful increase in access to HIVIAIDS testing, treatment and care accomplished by the Barbados HIVIAIDS Program with Bank assistance. The new project would further expand this success into increased knowledge and effective, sustainable behavior change. An additional major focus would be to improve M&E of the HIVIAIDS epidemic and program, and its ability to make mid-course corrections. 32. The project would have two components with the same focus, but different implementation and disbursement arrangements. The first component would follow a SWAP approach by financing a percentage of the Barbados HIVIAIDS Program and having funds pooled with those from the GOB. The second component would provide technical assistance and training following Bank procurement guidelines. The GOB and Bank would review annually the budget execution of key programs included in Component 1, aiming at guaranteeing at least 70% execution, and achievement of agreed results. Necessary adjustments would be made by the project Mid-Term Review. Component 1: Prevention and Care (US$89.65 million) 33. This component would contribute to the implementation of the National Strategic Plan for HIV Prevention and Control 2008-2013, specifically of the following three Eligible Expenditure Programs (EEPs): National Program Coordination and Monitoring. This program aims at strengthening the ability of the public and private sectors and civil society to co-ordinate, monitor and evaluate their activities and use data to continually increase the quality of their programs. Specific activities would include (i) building capacity that would help the GOB and civil society increase their ability to formulate a vision, policies, strategies, and plans of action; mobilize financial resources; and conduct operations relevant to HIVIAIDS; (ii) strengthening surveillance; and (iii) addressing the critical issue of M&E within the HIVIAIDS Program. An existing Public Sector-CSO Grant System would be further developed under the project. This is described in Annex 6 and in more detail in the Project Operational Manual. Scaling up Prevention Efforts. This program aims at increasing access to preventive services, particularly BCC, HIVIAIDS and ST1 prevention and treatment, and condoms, with a special focus on key populations at higher risk. These activities are often difficult politically or culturally to start, but once started are relatively easy to maintain. Prevention activities would be implemented in close cooperation between public agencies and CSOs. Improving Diagnosis, Treatment and Care. The goal of this program is to increase the length and quality of life of PLHIV. The program aims at increasing PLHIV access to diagnostic services, treatment services (ART and treatment for 01s) and social care and support (counseling, support groups, drug addiction therapy, and home care), as follows: (i) testing services would be expanded into community organizations, including those working with vulnerable groups; (ii) treatment would be decentralized on a phased basis to the polyclinics that provide free government health services to the entire island; and (iii) referral systems to social care would be strengthened, including assigning each PLHIV to a social worker. Component 2. Institutional Strengthening (USS4.47 million) 34. This component would finance training and technical assistance on M&E, management, surveillance, prevention, diagnosis, treatment and care of HIVIAIDS and other STIs, to support the implementation of the Strategic Plan. The objective of this component is to strengthen agencies and CSOs through training and technical assistance that would not be funded under the regular program. While routine surveillance, seroprevalence and behavioral surveys, and quality audits would be carried out under Component 1, the second component would include non- routine training and technical assistance to review the surveillance system, and put in place sero- and behavior surveillance and quality audits and assist with standardization of data collection methodologies, particularly in the case of behavior surveillance. Component 2 would follow Bank procurement rules, and disburse over the life of the project on the basis of reports. Results-Based Disbursements 35. Bank financing would contribute to the implementation of agreed policies and programs, and to the achievement of specific results, which would trigger disbursements. The Barbados HIVIAIDS Program monitors 43 indicators (Annex 3); of these, the project would monitor 25; of these, 9 would measure achievement of Project Development Objectives (PDO), and those indicated below would be linked to disbursements. The project design aims at (i) having the client and Bank moving from measurement of inputs to measurement of results; and (ii) providing additional incentives for the government to attain agreed results and timely execute the implementation plan. 36. Annual achievement of two Project Implementation Milestones would trigger loan disbursements for Component 1 every year. The selected milestones aim at ensuring government commitment and program execution of agreed financial support: o Increase of the HIVIAIDS Program budget from US$9 million in 2008 to US$11.5 million in 2013 for FY14 (annual targets in Annex 3). o EEPs included in the project disburse at least 70% every year3. 37. Under Component 1, disbursements would be made against EEPs, and triggered by the following results: Maintaining the percentage of people spontaneously indicating sexual relations as a way of transmitting HIV at least at 90% from 2008 to 2013. Increasing the percentage of young men and women aged 15-24 years reporting the use of a condom the last time they had sex with a non-marital, non-cohabitating partner from 21% to 31% from 2008 to 2013. Maintaining the percentage of HIV-positive pregnant women receiving a complete course of AV prophylaxis to reduce the risk of MTCT above 95% from 2008 to 2013. 38. These targets were extensively discussed during project preparation to ensure that indicators linked to disbursements would present a challenge, but not so significant that it would put project implementation, and achievement of PDOs at risk. The baseline for two of the selected disbursement-linked indicators (DLI) is already high (above 90%). However, maintaining these values still presents a challenge, as the program will have to cover new cohorts of young people, and pregnant women during the period. The indicator on increasing condom use by young people is the most challenging, but the target of 10% increase during a 5-year period was considered realistic. Although the second project would focus on prevention of HIVIAIDS among key populations at higher risk of infection, and some project indicators specifically refer to these groups, none is linked to disbursements. It would be too risky to link expected results among highly vulnerable groups to specific disbursements, as the NAP does not have much experience of working with these groups, and sex work, anal sex, and drug use are illegal in the country. The second loan disbursement will follow 70% execution EEPs in the first semester GOB FY09 39. EEPs would have been annually budgeted and formally approved by the GOB, appearing with a budget code (Annex 5). GOB financial systems would track and report EEP budget estimates and actual expenditures, which would enable the use of state systems for purposes of financial management. Loan Disbursement Schedule 2008-2013 # Disbursement Indicators Disbursement Date US % 1 Agreed NAP Budget for GOB FY09 Effectiveness 1,500,000 2 70% execution EEPs in first semester GOB FY09 September 2008 2,220,000 3 Agreed NAP Budget for GOB FY 10 March 2009 2,440,000 >95% HIV positive pregnant women receiving a complete course of ARV to reduce MTCT CY08 4 70% execution EEPs in GOB FY09 September 2009 2,500,000 5 Agreed NAP Budget for GOB FYI I March 2010 3,000,000 >95% HIV positive pregnant women receiving a complete course of ARV to reduce MTCT CY09 6 Mid-Term Review September 20 10 70% execution EEPs in GOB FY 10 90% young women and men aged 15-24 years spontaneously indicating sexual relations as a way of transmitting HIV in survey carried out in 20 10 26% young men and women age 15-24 years reporting the use of a condom the last time they had sex with a non-marital, non- (cohabitating partner in survey carried out in 2010 7 1Agreed NAP Budget for GOB FY 12 - - I March 201 1 >95% HIV positive pregnant women receiving a complete course of ARV to reduce MTCT CY10 8 70% execution EEPs in GOB FY 11 September 20 11 9 Agreed NAP Budget for GOB FY 13 March 20 12 >95% HIV positive pregnant women receiving a complete course of ARV to reduce MTCT in CY 11 10 70% execution EEPs in GOB FY 12 September 20 12 4,300,000 > 90% young women and men aged 15-24 years spontaneously indicating sexual relations as a way of transmitting HIV 31% young men and women age 15-24 years reporting the use of a condom the last time they had sex with a casual partner in Iin survey carried out in 2012- 11 IAgreed NAP Budget for GOB FY14 I March 2013 Undisbursed funds I 1>95% HIV positive pregnant women receiving a complete I course of ARV to reduce MTCT in CY 12 Component 2 3,464,000 Total 34,278,000 Front-end-Fee 87,500 IPrice Contigencies 1 634,500 1TOTAL /35,000,000 40. The Government asked for advances to be made every semester, the first one of each year coinciding with the beginning of the fiscal year on April 1, to cover budgeted expenditures under Component 1 for the subsequent semester. The first project disbursement would take place as soon as the project becomes effective, and reimburse the government for expenditures incurred between April 1, 2008 and effectiveness. The second disbursement would take place in September 2008, and refer to a six month period starting October 1, 2008. Every subsequent year, project disbursements would be triggered by the achievement of project milestones, and achievement of the indicator on vertical transmission of HIV from mother to child, which can be measured annually. Disbursements in March of every year would follow presentation by the GOB of a satisfactory HIVIAIDS Program budget for the financial year; and achievement of the indicator on vertical transmission of HIV from mother to child on the preceding calendar year. Disbursement in September would follow presentation by the GOB of evidence of at least 70% execution of EEPs in the previous financial year. On the second and fourth year, disbursements for the second semester would also be triggered by achievement of the indicators on knowledge about HIV and use of condom by young people, which would be measured twice during the project by a biennial survey. Any undisbursed loan funds would be disbursed before project closing, provided the Bank is satisfied with project implementation and results. Before any advance is made, the GOB would send to the Bank evidence, through the un-audited financial reports (IFR), that the previous loan advance has funded 35% of the EEPs expenditures. Remedies for milestones and indicators not met Milestonelindicator Measurement Remedy Increase of the HIVIAIDS Program Annual If budget is lower than agreed, loan budget from US$9 million in 2008 to disbursement would decrease US$] I million in 2013 (annual targets in correspondingly, as the Bank disburses a Annex 3). fixed percentage against the budget. EEPs included in the project disburse at Annual If expenditures are lower than budgeted, least 70% every year. loan disbursement would decrease correspondingly. Maintaining the percentage of HIV- Annual Disbursement pro-rated according to positive pregnant women receiving a achievement of the indicator (base value complete course of AV prophylaxis to US$l million). reduce the risk of MTCT above 95% Time-bound Action Plan prepared. from 2008 to 2013. Disbursement when target is achieved. Maintaining the percentage of people MTR and end-of- Disbursement pro-rated according to spontaneously indicating sexual relations project achievement of the indicator (base value as a way of transmitting HIV at least at US$] million). 90% from 2008 to 20 13. Time-bound Action Plan prepared. Disbursement when Action Plan is satisfactorily implemented. Increasing the percentage of young men MTR and end-of- Disbursement pro-rated according to and women aged 15-24 years reporting project achievement of the indicator (base value the use of a condom the last time they US$l million). had sex with a non-marital, non- Time-bound Action Plan prepared. cohabitating partner from 21% to 31% Disbursement when Action Plan is from 2008 to 2013. satisfactorily implementated. 41. Milestones (in this case, planned and executed budget) apply to the entire disbursement under Component 1 for a given period. So, if a milestone is not reached, a given disbursement would be pro-rated according to the achievement of the milestone (if the planned budget is 10% lower than agreed, the loan disbursement would be 10% lower than indicated in the table above). If a specific DL1 is not reached, the corresponding disbursement would be pro-rated based on a value of US$1 million per indicator. The GOB and Bank would agree on a time-bound Action Plan which, when considered satisfactorily implemented by the Bank, would trigger the disbursement of the respective retained amount. 42. PDOs, PDIs, DLIs, activities and disbursements would be reviewed, and if necessary revised by mid-term and 6 months before project closing. Each semester, Bank supervision missions would review budget allocation and execution, and project results prior to disbursements. In addition to NHAC reporting, annual financial audits and procurement post reviews, and Bank supervision every semester, two independent technical and financial reviews would be carried out, respectively before mid-term review and before project closing, to certify achievement of agreed technical results. The project would contract a regional or international organization (university, private sector, andlor UN agency) to undertake these technical reviews of agreed results prior to the Mid-Term Review and project closing. D. Lessons learned and reflected in the project design 43. Lessons learned from the implementation of the first project, including the results of a review by the Bank's Quality Assurance Group (QAG) carried out in November 2006, and from other HIV and AIDS projects in the Caribbean and elsewhere were considered in the design of this project. The QAG recommended that the NHAC puts more emphasis on a strategic approach aiming at targeting the most critical problems rather than at comprehensive problem-solving. This would involve a focus on improving: (i) project monitoring; (ii) prevention efforts, including VCT, BCC, condom distribution and fighting stigma; (iii) financial management; and (iv) capacity in these areas. In addition, the following lessons were taken into account: (i) The countries that have been most successful in dealing with HIVIAIDS - Brazil, Thailand and Uganda in the 1990s - are those that have confronted the issue head-on, advocating for safe sex without embarrassment. Barbados' approach to prevention has resulted in an unfinished agenda in creating dialogue on issues of sexual practice in general, sexual activities among key populations at higher risk and adolescents, and the position of women in society. Lessons learned in other countries indicate that this can be done in a manner that is culturally appropriate and respectful of local traditions. (ii) In Jamaica and elsewhere in the Caribbean, there has been an increasing awareness that enabling environments are critical to the reduction of transmission of HIVIAIDS and increased access to treatment and care. This includes policy and legislative changes and workplace and sector-specific policies and programs, to safeguard privacy, and confidentiality and address stigma and discrimination. Popular figures, particularly those admired by adolescents, should continue to be engaged in speaking openly about the risk of HIVIAIDS, how to protect themselves, and the importance of knowing their status and seeking appropriate care. (iii) With the improved M&E from the first project, there will be better epidemiological data to assist in determining and targeting key populations at higher risk. This will include a greater emphasis on the drivers of the epidemic, including unsafe sex with multiple partners, adolescents' lack of access to correct information on sexuality and STIs, the abuse of alcohol and marijuana, and the role of women in society. Recent evidence, including the Disease Control Priority 2 (DCP2) Best Practices Guide to Adolescent Programming, has revealed the most promising programs and channels through which to reduce the risk of HIVIAIDS for adolescents. These best practices would be integrated into the design of the activities. HIVIAIDS prevention campaigns designed to reach particular target groups have not impacted significantly on sexual practices. Part of the challenge lies with the fact that key populations at higher risk have to be better targeted and involved in the prevention and control work; and there has not been comprehensive training in BCC. A study on HIVIAIDS in the caribbean4indicated that for PLHIV, especially women, there were considerable barriers and delays (averaging 16 months) between time of diagnosis and treatment. Half of the women surveyed who were on ART, in the period between 1996 and 2004, were placed on treatment immediately following their first visit, further confirming the late presentation to care. However, since then several actions were taken that should have reduced the average time from diagnosis to accessing services at the LRU, including: introduction of the VCT program with VCT counselors at each polyclinic (2003), preparation of PMTCT guidelines (2006), approval of PMTCT Policy (2008), and greater uptake of HIV care services. This issue would be further investigated during the project. (vii) In an effort to guarantee the highest quality of care for PLHIV in Barbados, these services were centralized in the LRU. Although this centralized strategy resulted in high quality care, it also stigmatized the clinic to the extent that PLHIV are reported to avoid going there. The second project would decentralize HIVIAIDS care and build a quality assurance system to maintain high levels of quality of care. (viii) Barbados was the first country in the world in which the Bank financed ARV, and in hindsight this was a very positive decision. The number of patients requiring ARV will continue to grow, as incidence of HIV in the short-term and survival will continue to increase. The second project would also finance ARV, as ARV represents a relatively small percentage of the NHAC budget (less than 20%). In Barbados, it often can take a year or more for a new public position to be created and filled and the GOB often relies on consultants in the meantime. Measures have to be taken to ensure that the work of consultants is properly documented for future reference and that their knowledge is institutionalized. Separation of biomedical waste is an important public health issue and should be continuously supported. Capacity building on hospital waste management should be continuous due to attrition and the difficulty of maintaining staff up to speed on the latest developments. The design of the results-based disbursement mechanism took into account lessons learned from similarly designed SWAP projects in Brazil. The disbursement mechanism has been satisfactorily tested in Ceara, and is being further developed in operations in Minas Gerais, Ceara, Pernambuco and Federal District. The mechanism Kumar A, Kilaru KR, Forde S, Waterman 12007. Uptake of health care services and health status of HIV infected women diagnosed through antenatal HIV screening in Barbados, 1996-2004. Rev Panam Salud Publica 22 (6): 376- 82. was applied to this project in a relatively modest way as compared with the Brazilian projects (for example, the number of DLIs is 5 as compared to 15-25 in other operations). E. Alternatives considered and reasons for rejection 44. Two alternatives were considered and discarded. The first option was to provide additional financing for the closing project. However, this funding would have to be confined to three years without possibility of extension and would have to be under the original PDOs. The emphasis on surveillance, M&E and BCC required different, more specific PDOs. Also, given the challenges that Barbados faces in hiring new staff and making much needed institutional changes, three years would not be sufficient. The second possibility that was considered was that of a separate, new Sector Investment Loan (SIL) with traditional expense-related disbursement. However, given the sophistication of the GOB and the flexibility that a SWAp- style SIL would bring, as well as the accountability of results-based financing, it was considered that the latter was the best approach. Three options were considered in case agreed disbursement- linked results would not be achieved: (i) delaying disbursement; (ii) delaying disbursement and agreeing on an time-bound Action Plan to correct the causes for DLIs not being met; or (iii) full disbursement accompanied by agreement on, and implementation of an Action Plan. It was decided that the second option was the one most in tune with the rationale of the project's results-based financing mechanism. 111. IMPLEMENTATION A. Partnership arrangements 45. The lead institution for HIVIAIDS in Barbados is the NHAC, which is part of the MFYSE. Several ministries including Health, Education, Labor, Tourism, Home Affairs, Community Development and Culture, and Social Care, Constituency Empowerment and Urban Development, as well as the Office of the Attorney General, and CSOs such as CARE Barbados, the United Gays and Lesbians against AIDS Barbados (UGLAAB), and various community and religious groups, work in partnership with the NHAC. The CSO community in Barbados is nascent and can benefit greatly from institutional capacity building including volunteer recruitment and training, strategic planning, fundraising, and general management. 46. The Barbados and Eastern Caribbean representative for UNAIDS is based in Barbados since April 2007 and provides technical assistance to the national program. Barbados is a regional leader on confronting the HIVIAIDS epidemic and is active in the Pan-Caribbean Partnership against HIVIAIDS (PANCAP). Barbados participates in the World Health Organization's HIVIAIDS drug facility and receives occasional small grants from DFID, PSI and the US Ambassadors' Small Grants Fund, but otherwise has no other source of HIVIAIDS funding. B. Institutional and implementation arrangements (Annex 6) 47. Institutional capacity to implement the national HIVIAIDS Strategic Plan is satisfactory. Institutional and implementation arrangements for the Barbados HIVIAIDS Project I1 would be similar to those for the first project. At the political level, the MFYSE is responsible for HIV matters, and sets the political strategy guiding the implementation of the NAP of which the project is a sub-set. The NHAC's Secretariat would perform the functions of Project Coordination Unit, and manage the project. The structure of the NHAC is reflected in Annex 6. 48. A multi-sectoral framework is in place and the HIVIAIDS strategy has been mainstreamed within key ministries. The NHAC is responsible for overall coordination of the response to ensure complete coverage, without gaps and unnecessary duplication in the implementation of the National AIDS Plan. Each ministry is responsible for the design, work plans, budgeting, procurement, implementation, and M&E of its own activities. The NHAC and MHNI provide technical assistance to ministries as needed. The ministries have the technical capacity to implement the National Strategic Plan for HIV Prevention and Control 2008-2013 through the designated HIV Coordinators/Focal Points. The main limitation is that there are few dedicated posts of HIV Coordinators (five have been established and four have been filled) with many government employees being assigned responsibility for HIV program coordination in addition to their regular duties. In addition, it might be beneficial if a more integrated approach could be adopted to target prisoners through inter-sectoral coordination and collaboration in terms of prevention programming among the NHAC, Ministry of Home Affairs, MHNI and the National Council on Substance Abuse. 49. Unlike some other parts of the world, in Barbados the response to the HIV epidemic is mainly led by the Government. However, CSOs and private sector groups would participate in the project in two ways. When preparing their annual plans, the sector ministries involve the related civil society groupslprivate sector agencies in developing proposals, which once approved are implemented together. CSOs also submit proposals directly to the NHAC, which reviews and endorses some of these proposals for funding based on pre-determined criteria. There are approximately 11 CSOs working on AIDS-related issues in the country. An important advance in recent years has been that the NHAC has managed to get FBOs from different religions, considered critical allies in the Barbadian context, engaged in prevention efforts. Some of these groups no longer publicly oppose condom use as was the case in the past, and religious organizations seem to increasingly organize prevention efforts with and for their members. 50. The majority of the Barbadian CSOs working in the area of HIV prevention are relatively young and face challenges in terms of their organizational and institutional capacities, staffing and resources. They lack a solid strategic planning framework, and have limited skills on proposal writing, fundraising, reporting and administration. The project would further develop a Public-CSO Grant System, and explore the possibility of expanding self-help and support groups by and for vulnerable groups. The added value of the involvement of CSOs is that in most cases they have direct access to vulnerable, hard-to-reach groups and the potential to expand their outreach. The NHAC would develop, as part of the grant model, an institutional strengthening program for CSOs that work, and are interested in working, with hard-to-reach populations. Organizations would be identified and selected according to previously established quality criteria. 51. An important move forward has been the engagement of the private sector. Led by the trade union movement and the International Labor Organization and supported by the Barbados Employers' Confederation, approximately 11 private businesses now have workplace programs in place, and other finance and volunteer staff or are exploring possibilities for prevention programs through their corporate social responsibility programs. 52. This project would not require the establishment of a Project Implementation Unit. According to the World Bank's project implementation arrangements classification criteria, the proposed project rates as integrated in each of the three key features: staffing composition and salary structure, operational responsibility, and reporting relationship. For staffing composition and salary structure the majority of the activities would be carried out by civil servants. In the area of operational responsibility, most activities would be conducted by pre-existing line departments, and most support functions such as procurement and financial management would be conducted by existing relevant departments and units. For reporting, each of the major ministries and partners would report to NHAC, which in turn would report to the Bank. C. Monitoring and evaluation of outcomes/results (Annex 3) 53. Monitoring and evaluation are viewed as fundamental to the management of the Project. As previously mentioned, the Barbados HIVIAIDS Program keeps track of about 43 indicators (Annex 3). The project would track about 25, including: (i) project development indicators to measure progress towards achievement of the Development Objectives (PDO); (ii) project results indicators that would trigger disbursements; and (iii) other project monitoring indicators to measure progress in project implementation. The project M&E system would be based on first, second and third generation surveillance of HIV, AIDS and STIs, as well as on a logistic management information system, and treatment quality audits. Indicators on the proper functioning of the Biomedical Waste Management system would also be monitored. 54. The NHAC has the main responsibility for program and project M&E, with the assistance of the MHNI and other local implementing partners. The NHAC monitors and ensures the quality of the data collected and entered into the program database; oversees the overall design and sample selection of special surveys; carries out the overall analysis, triangulating information from the different sources; and reports to GOB, UNGASS, Bank, public and other stakeholders. The capacity of the NHAC and implementing partners to use data for decision making would be strengthened. The M&E conceptual framework and operational plan included in the Project Operational Manual describe how M&E would be carried out under the project, including human and financial resources required. The M&E system relies on several systems and sources of information, which would be further developed under the project (Annex 3). D. Sustainability 55. The sustainability of the proposed Barbados HIVIAIDS Project is rated high from political, economic, social, and programmatic perspectives, as follows: (i) There is strong support for a second project in the GOB (despite a change in government during the preparation of this project), NHAC, and across the relevant ministries and civil society. Barbados also enjoys a leadership role in HIVIAIDS in the Caribbean region, which it would not relinquish. (ii) Macroeconomic prospects are generally favorable, with growth of 4.3% in 2007. On the microeconomic side, the more effective preventive activities that would be implemented by the project can be expected to reduce new infections and result in cost savings from averted costly life-long ART treatment. (iii) From a budgetary perspective, the project is also sustainable. For 2007-2008, the MHNI has a budget of US$366.6 million. A US$35 million loan over five years represents less than 2% of the entire annual health budget. From a recurrent cost perspective, the economic analysis determined that the project would not result in recurrent costs over 2% of the health budget. (iv) HIVIAIDS BCC programming needs to be sensitive to the unique Bajan culture. Efforts to ensure cultural appropriateness and sensitivity include the involvement of civil society in the design of the activities. (v) Compared to many countries in the Caribbean, Latin America, Africa, and Asia, Barbados has a very strong implementation capacity. E. Critical risks and possible controversial aspects 56. The overall project risk is low. Barbados is a small island economy with one of the largest per capita incomes in the Caribbean region. The country has an investment grade rating and ranks high in competitiveness indicators. Barbados' economy grew by 3.9% of GDP in 2006 and 4.3% in 2007, compared to an average growth rate of 3.1% over the previous 5 years. The economy is dominated by the services sector, which accounts for three-quarters of GDP and 80% of exports, and is highly dependent on tourism. The current account deficit narrowed to 8.4% of GDP in 2006 compared to 12.5% in both 2004 and 2005, though inflation has surged recently from 1.4% in 2004 to 7.3% in 2006, reflecting the pass-through from higher oil prices. Expansionary fiscal policies enacted following a post-September 11, 2001, economic slowdown helped soften the impact but contributed to rising public sector debt, which currently stands at 90% of GDP. Authorities tightened macroeconomic policies in 2006 and achieved a balanced budget. Although the macroeconomic situation is very favorable, the economy remains vulnerable to external shocks, particularly given high debt levels. In addition, liberalization of the capital account in January 2007, a commitment under the CARICOM Single Market and Economy (CSME), further increased vulnerability, heightening the need for continued fiscal discipline. Project Critical Risks I Risk factors Description of risk Rating Mitigation measures I Rating of risk I of risk Macroeconomic Inflation increased from 1.4% to L Authorities tightened - L framework 7.3% from 2004 to 2006. macroeconomic policies in 2006, and Public sector debt at 90% of achieved a balanced budget. GDP. I Economy vulnerable to external Continued Bank monitoring. shocks given high debt levels. Country Change of policy. All major political parties see L ownership and HIVIAIDS as a priority. governance Government does not disburse funds due to low priority. Continued Bank engagement. I I Technical Persistent, high level adoption of PDO focus on behavior change for I L design safer sexual practices in a safe sexual practices. context of low HIV infections Project would follow best practices rates has been a challenge in all from other countries. settings. Activities were designed and would be implemented in partnership with leading experts in HIVIAIDS. I Conservative nature of Barbados PDIs focus on increasing access to I M society, as exemplified by the prevention and treatment for key continued criminalization of populations at higher risk. homosexuality, sex work and use Project would follow best practices of illegal drugs, would prevent from other countries. focus on key populations at higher risk. Activities were designed and would be implemented in partnership with I leading experts in HIVIAIDS: Implementation I GOB funds for the project do not I L I Budget satisfactory to the Bank L capacity and I materialize. I I required for disbursements every I sustainability GOB does not disburse funds. year. Relatively weak systematic M The project provides funding, TA M planning, information, M&E and training to institutionalize systems through the sectors. planning and M&E. The Bank would continue providing TA in the area of M&E. Financial FM Capacity. L FM Capacity is satisfactory. L management FM Action Plan agreed. Procurement Procurement Capacity. L Procurement Capacity is satisfactory. L I Procurement Plan agreed. Social and I Biomedical waste management I L I Biomedical waste management L environmental system not fully improved Action Plan agreed, and-under safeguards satisfactory implementation. Pro-ject indicator monitors further I implementation of Action Plan. Other I Reprioritization of project I L 1Hurricanes are relatively rare in L 1 funding due to catastrophic event I Barbados - direct hits eLery 27 years Overall Risk L F. Loantcredit conditions and covenants 57. The Cabinet approved the National Strategic Plan for HIV Prevention and Control 2008- 2013 on March 27,2008 and the Barbados National HIV Policy on May 8,2008. The budget for the first year of the project as part of the GOB'S budget was approved on March 31, 2008. The project Designated Account was established in the Consolidated Fund on April 8, 2008. In addition, the GOB fulfilled conditions for Negotiations, as follows: Project Operations Manual. The GOB prepared an acceptable draft Project Operational Manual (POM), which includes, as required: (i) the Project implementation plan; (ii) the detailed description of the Eligible Program Expenditures including the budgets by year, ministry and procurement category; (iii) with respect to the grants for CSO: (a) the criteria for approval and the procedures for the implementation and monitoring of subprojects supported by such grants; and (b) the criteria for eligibility of the beneficiaries of the grants; (iv) the detailed description of the Project disbursement mechanism; and (v) the procedures for monitoring and evaluating the Project. Project Reporting and auditing. Disbursements for both Components would be made to the same designated account at the Government's Consolidated Fund, and the GOB would use the same IFRs to report on both components. IFRs would be submitted within 45 days after the end of each reporting period. Content, format and periodicity for the interim un-audited financial reports, and the terms of reference for the annual independent audits were agreed during Negotiations. Project Coordination Unit Staffing. NHAC would maintain adequate technical and fiduciary staffing to manage the project, including a Project Director, a Monitoring and Evaluation specialist, a Behavior Change Communication (BCC) Specialist and fiduciary staff. A Senior Accountant will be appointed to the MFYSE on August 1, 2008. A financial management specialist with qualifications and experience satisfactory to the Bank would be appointed to the Ministry of Social Care, Constituency Empowerment and Urban Development by October 15,2008. a Establishment of Internal Audit Units within the Project Implementing Entities. The Financial Controller in each Ministry is responsible for Internal Audits. With the appointment of Financial Controllers in the MFYSE and MSCU, all project implementing agencies will have Financial Controllers responsible for internal audits. Connection to the new financial management system. All Ministries are connected to Smart Stream. 58. Bank's standard financial covenants apply to the proposed project. They include the requirements to: (i) maintain financial management systems that enable the NHAC to prepare reliable project financial reports every semester; and (ii) submit annual audit reports of the project's account statements no later than six months after the end of each calendar year. IV. APPRAISAL SUMMARY A. Economic and financial analyses (Annex 9) 59. The net present value of the benefits of the proposed project investment were estimated at US$68 million, with an internal rate of return of over 32% over ten years. These benefits would be due to savings in hospital, outpatient, and general treatment and support costs of prevented cases, as well as to the indirect gains of increased productivity due to improved health and longer lives. The assessment of the long term sustainability of the activities supported by the Bank loan shows that, at the end of the project, the GOB would be assuming total new recurrent costs of less than 2% of the current public national health sector expenditure. Given the stability of the Barbados economy and its projected growth over the next five years, this increase in recurrent costs is sustainable. B. Technical 60. The Barbados HIVIAIDS epidemic has been characterized as mixed, which has raised the issue of which surveillance and prevention approaches would better serve the needs of the country. However, this perception is based on weak surveillance, an issue to be tackled as a matter of priority by the proposed project. Surveillance approaches differ according to epidemic stages (WHO 2007): (i) In a low-level epidemic (where HIV infections are confined to individuals with higher risk behaviors, and HIV prevalence has not consistently exceeded 5% in any defined population group, surveillance systems focus on high risk behaviors, looking for changes in behavior which may lead to the spread of HIV infection. (ii) In a concentrated epidemic (where HIV has spread rapidly in a defined sub-population, but is not well-established in the general population, with HIV prevalence consistently over 5% in at least one defined sub-population), surveillance systems focus on monitoring infection in the sub-populations and concentrate on behavioral links between members of these groups and the general population. Surveillance systems also monitor the general population and high-risk behaviors among its members. (iii) In generalized epidemic states (where HIV is established in the general population, with HIV prevalence consistently over 1% in the general population and pregnant women), surveillance systems concentrate on monitoring HIV infection and risk behavior in the general population. 61. The new project would ensure that surveillance contributes to: (i) better understanding of sexual behaviors and practices driving the epidemic; (ii) better assessment of trends and status over time; (iii) orient public health actions towards the most vulnerable groups, the stigmatized and marginalized; (iv) measure coverage and quality of care for PLHIV and ST1 patients; (v) assess the impact of HIVIAIDSISTI prevention and control programs; and (vi) plan from data and evidence on best practices. Specifically, the project would carry out: (i) epidemiological surveillance of HIV and AIDS cases, AIDS deaths, & ST1 cases; (ii) prevalence and antimicrobial resistance surveys (HIV and STI); (iii) concomitant and periodic KAP and seroprevalence surveys focusing on vulnerable groups; and (iv) audit of quality of treatment and care for PLHIV and patients with sexually transmitted infections (STI). C. Fiduciary 62. Financial Management (Annex 7). The inherent risk of the operation is rated low because of the transparent fiduciary environment prevailing in Barbados. Barbados generally has high marks from Transparency International (Corruption Perceptions Index score of 6.9 in 2007); and the control risk is also rated low. The Bank loan proceeds would be advanced into a segregated account of the Consolidated Fund (the Designated Account), as required by Bank policy and in order to facilitate project audits. A segregated account would facilitate the preparation of withdrawal applications, which require Bank account reconciliation. Subsequent disbursements would be made for eligible expenditures pertaining to project activities to be implemented by the NHAC, Ministries and other eligible agencies based on projections of expenditures and disbursement criteria stipulated in the sections on results-based disbursements and disbursements in the PAD, and elaborated in the Disbursement Letter; and on actual costs reported by the project. 63. Procurement (Annex 8). The overall procurement risk of the proposed project is low. An assessment of the capacity of the implementing agencies to implement the project was carried out during project preparation. The assessment covered the Central Purchasing Department (CPD), MHNI and MEHR, and reviewed the organizational structures for implementing the project and the interaction between the project's staff responsible for procurement and the agencies' relevant central units for administration and finance. The key issues and risks concerning procurement were identified, including the MHNI's weak records management system. The MHNI would proceed with a consultancy for improvement of its records management system, as many procurement activities under the new project, in particular under Component 1, would be subject to post review, and strong records management would be essential for procurement audits. Under Component 1 due diligence to satisfy the Bank that the funds are used for the purposes intended would be carried out during supervision missions. In particular, the Bank would conduct an annual review of procurement activities subject to post review to ensure that procurement has been carried out in accordance with the Government's procurement procedures, which have been found to be acceptable to the Bank. As part of the annual post review, the Bank would verify that procurement capacity in the NHAC and line ministries remains adequate, and would offer capacity building activities as needed. D. Social 64. Social Assessment (Annex 6). Work has started with some key populations at higher risk, particularly SW, MSM and youth, but much needs to be done to extend preventive and treatment services to these groups. The project would include the development of a plan with strategies to effectively reach key populations at higher risk that would provide information about the size, HIV prevalence and practices of each group, as well as other data that can inform HIV planning and policy making. Consultation meetings with implementing partners have been held regularly during the preparation and implementation process of the new Strategic Plan. However, there is a need to implement a more focused and systematic strategy to increase the levels of active and meaningful participation of vulnerable groups in design, implementation, and M&E of prevention work, through workshops, one-on-one meetings, focus groups and other appropriate methods. E. Environment 65. In Barbados, enforcement of environmental standards is delegated to environmental officers. An Infection Control Department has been instituted at the Queen Elizabeth Hospital (QEH). This unit is instrumental in maintaining sources of infection in check, including those potentially originating from biomedical waste. The QEH has one dedicated Environmental Officer who needs additional support considering the amount of environmental concerns the hospital generates (e.g, from food to biomedical wastes). The MHNI is implementing satisfactorily a Biomedical Waste Management Action Plan agreed with the Bank under the first project. The project would support the Environment Department and the MHNI to ensure proper staffing to keep the Infection Control Department effective through the project. F. Safeguard policies 66. The Environmental Assessment (OPBPIGP 4.01) safeguard policy would not be triggered. Given that this is a follow on project, with no new construction envisaged, no new environmental assessment was required. The environmental assessment was updated in relation to ongoing health care waste management activities. Even though project activities would result in increases in waste, this added volume would be accommodated by the health care waste management system that was put in place with support from the first project. The second project would monitor the proper disposal of health care waste by health care providers. Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OPBP 4.01) [ 1 [ XI Natural Habitats (OPIBP 4.04) [ 1 [ XI Pest Management (OP 4.09) [ 1 [ XI Physical Cultural Resources (OPBP 4.11) [ 1 [ XI Involuntary Resettlement (OPIBP 4.12) [ 1 [ XI Indigenous Peoples (OPIBP 4.10) [ 1 [ XI Forests (OPIBP 4.36) [ 1 [ XI Safety of Dams (OPBP 4.37) [ 1 [ XI Projects in Disputed Areas (OPBP 7.60) [ 1 [ XI Projects on International Waterways (OPIBP 7.50) [ 1 [ XI G. Policy Exceptions and Readiness 67. The proposed project is presented as an exception to the Bank's graduation policy based on the strong public goods and externalities rationale for providing technical and financial assistance to Barbados to prevent and control HIVIAIDS, and Barbados' leadership role in these activities in the Eastern Caribbean. Barbados graduated from IBRD lending in 1993, in line with the Bank's existing graduation policy, which was developed in the early 1980s. A 1997 Memorandum of the Senior Vice President and General Counsel indicates that the Board of Executive Directors can approve loans to graduated members as lon as the proposed operation 8 meets the requirement of Section 4 (ii) of Article I11 of the Articles. This section provides that the Bank must be satisfied that the Borrower would be unable, under the prevailing market conditions, to obtain the loan under terms which the Bank considers reasonable to the Borrower. Approval of the HIVIAIDS project for Barbados would be consistent with the provisions of this Article as Barbados cannot find financing for the HIVIAIDS project on reasonable terms. In making the exception to the graduation policy, the Bank also takes into account the provisions of Section 4 (v) of Article I11 of the Articles which provides that "the Bank shall pay due regard to the prospect that the Borrower will be in position to meet its obligations under the loan; and the Bank shall act prudently in the interests both of the particular member in whose territories the project is located and of the members as a whole". Barbados meets this provision as well, given its prudent macroeconomic management and its BBB+ Standard & Poor's credit rating. Consequently, given the exceptional nature of the Barbados case, making an exception to the Bank's graduation policy would not be inconsistent with the Bank's Articles of Agreement. 68. Similarly to the first project, this project would finance operating costs. However, it would finance total, versus incremental, recurrent costs; on a flat as opposed to declining basis; and at a constant 35% disbursement rate throughout the Project. Bank management granted a waiver of existing Bank policy, which allows only the financing of incremental recurrent costs on a declining basis for countries without approved Country Financing Parameters. As Barbados has graduated from Bank lending, no Country Financing Parameters have been prepared and approved. According to the OP Memo on Specific Eligibility Expenditure and Cost Sharing Requirements for Investment Projects in Countries Without Approved Country Financing Parameters of March 23, 2007, the Bank may finance incremental recurrent costs, when: (i) the country has a serious shortage of budget resources that makes it unable to finance such recurrent expenditures for the project; and (ii) the specific recurrent expenditure is crucial to the success of the project and Bank financing is desirable to ensure timely availability of funds. In the absence of Country Financing Parameters, recurrent costs are normally financed on a declining basis with Bank financing not exceeding 25% in the final year. The first project financed 50% of total incremental recurrent costs. The first project supported the establishment and initial operation of the Barbados HIVIAIDS Program, so in effect all recurrent costs were incremental at the time. In order for the Government to gradually assume responsibility for recurrent costs, the new project would finance a smaller share of recurrent costs (35%). Since Bank assistance under the proposed project would follow a SWAP modality, in which the Bank would finance a share of total program costs defined to include critical Eligible Expenditure Programs (EEPs) as opposed to individual input costs, it would be difficult to isolate recurrent costs from those expenditures which are critical for the Program's success. Finally, the waiver was justified given the social benefits to be expected from Barbados' continued, successful efforts in the control and prevention of HIVIAIDS, and the Project's regional and global public goods nature. Graduation from the Bank, R82-1, January 6, 1982; Memorandum to the President entitled "Statement on Graduation," R84-252, September 6, 1984, adopted by the Executive Directors in their meeting of September 11, 1984; Graduation Policy -Korea, Memorandum from I.F.I. Shihata to James D. Wolfensohn, November 29, 1997; Graduation from the Bank, R82-1, January 6, 1982; Consistency of the Graduation Policy with the Bank's Articles: Opinion of the Vice President and General Counsel, SECM84-213, March 12, 1984; Statement on Graduation, R84- 252, September 6, 1984. Annex 1: Country and Sector or Program Background BARBADOS: SECOND HIVIAIDS PROJECT 1. Barbados is the easternmost country in the Caribbean and has a population of 277,000. Tourism is the most important source of income, followed by offshore financial services. Barbados has enjoyed stable democratic governance since independence in 1966 and strong economic growth (3-5% per year) since the 1990s. GDP per capita was US$12,523 in 2006, and the literacy rate is 95%, the highest in the Caribbean. 2. Life expectancy at birth is 75 for men and 79 for women, and under-five mortality rate is 12 per 1,000. Total expenditure on health per capita is US$1,323 (7% GDP) as compared with an average in Latin America and the Caribbean of about US$250 per capita. The Barbados health system is modeled after the British National Health Service. Care is available for free to all citizens in eight regional polyclinics and one central hospital. 3. Barbados has experienced an epidemiologic shift from infectious diseases to chronic non- communicable diseases. The two exceptions to this are Dengue and HIV. In recognition of the epidemiological transition, the MHNI has made strong policy commitments to preventive services. However, these policy commitments have yet to be translated into significant staffing and funding reallocations. Reasons for this include patient preference for curative care over preventive care and the challenges of altering long-established budget and staffing patterns. 4. In 2000, when the project was designed, HIVIAIDS was spreading rapidly and the Caribbean was - and still is - second only to sub-Saharan Africa in terms of the percentage of adult population affected. Data showed a high acceleration rate, and HIVIAIDS seemed poised to spread beyond key populations at higher risk of infection into the general population. Although many Caribbean governments had developed a response to the epidemic, efforts had not been comprehensive enough to stop the disease's regional trajectory. 5. In response, the Bank launched a horizontal Adaptable Program Loan (APL) to provide rapid assistance across the region. Although Barbados had already graduated from Bank lending, it was one of the first two countries to receive support under the APL. The rationale for Bank assistance was clear. Although Barbados was a middle-income country (MIC), with a well established national health delivery system, it was estimated that over 2% of the population was infected with HIV in 200 1. The country also has a strong leadership role in the region, its health infrastructure is used by smaller neighboring countries, and it has a large, active tourism industry and is a hub for regional transportation. In addition, the country was not able to obtain financing for program expansion from other sources, since international donors were focusing their resources on poorer countries throughout the world. 6. An important factor in the Barbados program was the Government's strong commitment to respond to the disease. In September 2000, Barbados took the lead in organizing the first regional conference on the disease. The same year, the Barbadian Parliament approved increased funding for HIVIAIDS activities, and launched the high-level National Advisory Committee on HIVIAIDS (NACA), which in 2001 became the NHAC, reporting directly to the Prime Minister. At the time of project appraisal, Barbados had already formulated a proactive and multi-sectoral response, and was using antiretroviral treatment (ART), which at the time was cutting-edge. Both the Bank and the GOB saw the opportunity to scale up existing initiatives and to integrate best practices into the national plan. The GOB contributed US$8.5 million for the US$23.65 million project. Main Project Achievements Barbados has put in place a comprehensive prevention and treatment program, with the following main results: AIDS mortality declined by 72% between 2001 and 2006. New AIDS cases declined by 46%. This refers only to AIDS cases, which have declined as a result of treatment. Hospital admissions for treatment of opportunistic infections in PLHIV decreased by 42%. Maternal transmission was kept at very low levels (below 2 cases per year). Blood supply remained safe with 100% testing. Share of people reporting positive attitudes towards PLHIV rose from less than 40% to nearly 80%. The community voluntary counseling and testing program, including training of more than 100 new counselors, was launched and expanded. A world-class testing laboratory was established at Ladymeade Reference Unit. The pharmacy system was strengthened, with all necessary ARV available for all PLHIV who qualify. The project was the first World Bank- financed project to support antiretroviral treatment. Remaining Challenges Estimated HIV prevalence has not been reduced and the number of reported cases continues to rise. This refers only to HIV cases, not AIDS cases, which have declined as a result of treatment. Feminization of the epidemic has been rapidly increasing; the male-to-female ratio now stands at 1. Key groups at high risk of infection (sex workers, beach boys, men who have sex with men, prisoners and others) require better, more effective outreach activities. Condom procurement and distribution to key groups at high risk should be improved. Social care of PLHIV needs to be strengthened. M&E system should be fully functional. Evidence and data should be a key factor in designing future programming. Information flows and reporting should be more robust. Multi-sector institutional roles and relations need to be clarified and solidified 7. Overall, the project had a dramatic impact on ultimate outcomes. The share of persons with advanced HIV infections who are receiving treatment rose from 12% to more than 80%. Annual deaths from AIDS have declined by more than 70%. The share of people reporting positive attitudes toward PLHIV has risen from less than 40% to nearly 80%. Equally important, Barbados has proven the feasibility of providing sustained HIV care and treatment and provided key lessons for its neighbors and other countries. Prevention programs have also grown substantially. Consequently, the project is regarded as having been quite successful. It also disbursed in full. The key challenges for the next phase will be to institutionalize better M&E practices, improve outreach to the key populations at higher risk, and achieve safer sexual practices among young people. 8. There are about 2,100 known PLHIV in Barbados, but MHNI estimates suggest that the total number of infected adults may be significantly higher. The reported HIV and AIDS cases represent the visible part of the epidemic. Studies estimate that approximately one-third of the HIV-positive population does not know their HIV status. 9. In 2006, over 75% of reported infections occurred in the 15 to 49 years age group, and overall this group comprises 77% of all reported cases since 1983. In addition, the feminization of the epidemic has been rapidly increasing, with a male to female ratio of 1:1 in 2006. Until 2004, the highest proportion of AIDS cases was found in the 30 to 39 years age group, but since then the 40 to 49 age group has had a higher proportion of cases. The median age at HIV and AIDS diagnosis has risen overall, from 35 years of age in 2001 to 39 years in 2006 (28 in 1990 to 38 in 2006 in females and 31 to 42 in males). Trends in age at AIDS onset from 1983 to 2006 10. Maternal transmission was kept at very low levels with the number of infants born to HIV infected mothers kept below 2 per year (1 in 37 in 2006). An evaluation study of the PMTCT program in Barbados revealed that there has been a major positive impact through intervention with prophylactic anti-retroviral drug therapy, with a significant decrease in transmission of the HIV. HIV Prevalence (percent) In Pregnant women 11. The blood supply is reported to be safe due to universal HIV screening of all blood and blood products. About 85% of teachers living with HIVIAIDS were allowed to teach in 2005106, The percent of youth able to correctly identify ways of preventing the sexual transmission of HIV, and who had no misconceptions about HIV transmission, increased only from 0.1% in 2001 to 1% in 2006. However, evidence from the 2001, 2003 and 2005 youth KAP surveys indicate that educational messages have been successful in raising knowledge levels but less so in affecting changes in unsafe practices. A BCC strategy was approved under the first project, and would be implemented under the new project. 12. The median age at first sex did not significantly change during the life of the project. Condom use, especially among most young people, is low. About 27% of young men and 16% of young women report using a condom when having had sex with a casual partner. Data show that SW use condoms 80% of the time with clients, and condom use among MSM is reported to have increased. 13. Studies estimate that approximately one-third of the HIV-positive population either does not know their HIV status or are not accessing the comprehensive treatment and support system of the Barbados HIVIAIDS Program. The community voluntary counseling and testing program, including training of more than 100 new counselors, was launched and expanded. A world-class testing laboratory was established at LRU. The percentage of VCT increased 17% from 2002 to 2006. However, a review of the NAP indicated that since the start of the program, the general population is not accessing VCT services significantly. This is especially true for people who National AIDS Program 2007. The HIVIAIDS Situation in Barbados 1984-2006. engage in high risk practices. Surveys show that many have taken a test (46%) at one time for reasons such as pregnancy, insurance, loans or travel, but less than 10% of those who practice inconsistent condom use and have multiple partners seek testing. 14. AIDS-related deaths were reduced by 72% since the beginning of the project in 2001 until the end of 2006, as a result of the policy to provide antiretroviral treatment free of charge; 90% of infected pregnant women received a complete course of ART to reduce the risk of mother-to-child transmission, which kept infection among infants born to HIV+ mothers at very low levels (2.6%). About 85% of adults with advanced HIV infections received ART in 2005, and about 97% of diagnosed adults living with HIV were still alive 12 months after initiation of treatment in 2006. Median survival rates have risen steadily with 81% of those enrolled between 2002 (first full year of ART) and 2006 still alive by the end of 2006. One-year AIDS survival has risen from 65% in 2000 to 95% by the end of 2006. By the end of 2006, 65% of those diagnosed with AIDS years ago were still alive. The most likely reasons for these improvements are the improvement in early detection of HIV and advances and success in ART in prolonging lives of PLHIV. Trends In 12months survivial after AIDS Diagnosis by Gender 1887 1888 1888 1890 1891 1882 1883 1884 1995 1988 1987 1988 1989 2000 2001 2002 2003 2004 2005 Year of AIDS Dlagnorls 15. Key stakeholders and studies attribute the dramatic reduction in mortality to the expanded response supported by the project, including the introduction of ART, and care and support service delivered through the centralized clinic services of the MHNI and the private sector. The project was the first World Bank-financed project to support antiretroviral treatment. The pharmacy system was strengthened, and a world-class testing laboratory was established at LRU. The percentage of lab testing increased 22% from 2002 to 2006. Laboratory capacity was built up, with the LRU Lab being able to test all identified PLHIV for viral load and CD4. The LRU is making arrangements to initiate testing of viral resistance to ART drugs. All necessary equipment has been procured and installed. The government is currently seeking to provide laboratory services at a fee to other countries in the Caribbean. 16. More than 65% of the estimated number of AIDS patients and over 90% of the diagnosed AIDS patients are accessing services. However, this data does not apply to resident non- nationals, who are not eligible for the NAP'S care and treatment services. A Health and Social Services Utilization Study (HASSUS) showed that quality of life of patients receiving treatment and support increased by 14% in the first 18 months of the program. However, the study also showed that PLHIV receiving treatment and support continue to be marginalized from the workplace and from comprehensive health and supportive services as a result of self-stigma and discrimination. According to this study, while a PLHIV may not have been involved in sex work, there is a risk that helshe turns to this form of employment, formally or informally, as a means of generating economic sustainability within their household. A prospective study of women receiving PMTCT services showed that almost 25% of previous HIV positive mothers returned to the service pregnant within 2 years, with a different "father-to-be". Disclosure of HIV status in such situations is not common among HIV positive persons. Construction of the Food Bank for PLHIV was 70% completed, with completion expected for March 2008. However, social care of PLHIV needs to be further developed under the second project. 17. A true multisectoral approach to HIVIAIDS prevention and control has been put in place. The resulting "Barbados Model" successfully built sustainable institutional arrangements. The National Strategic Plan for HIV Prevention and Control 2008-2013 was prepared, reviewed by UNAIDS and ASAP, and approved by the government shortly after project closing. A National AIDS Coordinating Authority, with a broad-based multisectoral mandate, is fully functional, and all participant agencies have increased the awareness of their constituencies over the life of the project. However, progress has been uneven across institutions and a number of shortcomings have emerged that challenge the long-term success of the system. Multi-sector institutional roles and relations, especially between NHAC and key ministries such as the Ministries of Health, Education, Social Transformation, Labor and Tourism, have to be further developed. NHAC continued supporting periodic meetings and technical working groups (TWG), but some TWGs have played only a minor role in the development of new initiatives and institutionalizing systems. 18. Project M&E was established during the first half of the first project and the national M&E framework and operational plan, which includes the strategic flow of information and data, was finalized before project closing to be implemented under the new project. Sentinel surveillance data is being recorded manually at QEH and entered into a database at MHNI. NHAC, MHNI and the Division of Youth Affairs have carried out a number of studies on HIV prevention practices, care and treatment and epidemiological trends. The NHAC submitted an inventory of 32 surveys and other studies that were carried between 2001 and 2007. Out of those, 19 were published, 9 have final reports, and 4 are being finalized. SHIP is a PLHIV database at the LRU, which includes patient information from the time of enrollment, as well as care and treatment. The MHNI does receive information from all health services, but has not structured a health management information system. With the assistance of CAREC and WHOPAHO, the MHNI is strengthening the disease surveillance program to structure a robust and comprehensive information system. Seroprevalence and KAP surveys would be carried out under the new project to enable NHAC to make strategic decisions based on robust evidence. Annex 2: Major Related Projects Financed by the Bank andlor other Agencies BARBADOS: SECOND HIVIAIDS PROJECT 1. There are currently no other World Bank financed projects in Barbados. As one of only three investment grade countries in Latin America (along with Chile and Mexico), Barbados has access to private sector financing for most of its investment needs. However, the Bank is the only external source of funding for HIVIAIDS. 2. UN agencies supported the preparation of the HIVIAIDS Strategic Plan. The Barbados and Eastern Caribbean representative for UNAIDS is based in Barbados since April 2007, and provides technical assistance to the national program. UNAIDS financed and provided technical assistance to the preparation of the HIVIAIDS Strategic Plan, including on health economics, scaling up M&E, and strengthening civil society engagement in the NAP. UNIFEM provided technical assistance on gender issues, and mainstreaming gender on HIV programming, including capacity building. UNFPA provides condoms to the MHNI, although not on a regular basis. PAHO provided institutional strengthening to the CSO CARE Barbados, and technical assistance to the NHAC on M&E. Barbados participates in the World Health Organization's HIVIAIDS Drug Facility. 3. The European Union provided a 10.5 million grant to the MHNI, in the period 2004- 2007, to strengthen the health system, which linked disbursements to achievement of specific results. The EU program has proceeded well, and it is one of the reasons for the GOB to endorse results-based disbursements in the Bank-financed project. The EU program provided additional general budget support to the MHNI. To avoid funding disruptions and harmonize the process as much as possible with existing government mechanisms, financing was coordinated with the government funding cycle, with all disbursement dates predetermined. Disbursements were conditional on the meeting of jointly agreed upon goals, with decisions made at joint bi-annual reviews. Funding could be released based on progress on: (i) sector indicators, with special attention to gender and poverty impact; (ii) implementation of annual programs and related budget; (iii) financial audit by the Office of the Auditor General; and (iv) externalities and unforeseen events. 4. Barbados is a regional leader on confronting the HIVIAIDS epidemic and is active in the Pan-Caribbean Partnership against HIVIAIDS (PANCAP). The Caribbean Epidemiology Center (CAREC) carried out an evaluation of the MHNI surveillance system, and assisted the development of a Surveillance Action Plan aiming at having a fully functional HIV surveillance system in the country. The project would contribute to the implementation of this surveillance plan. Barbados has received occasional small grants from DfID, PSI and the US Ambassadors' Small Grants Fund. DfID is financing projects in the tourism sector and to prevent HIV among sex workers in Barbados. The CSO United Gays and Lesbian against AIDS Barbados (UGLAAB) received technical assistance from the International HIVIAIDS Alliance, funded by USAID, for institutional strengthening. Annex 3: Results Framework and Monitoring BARBADOS: SECOND HIVIAIDS PROJECT Use of Project ProjectOutcome Indicators Outcome Information Adoption of safe Behavior change in the period from 2008 to 2013: Monitor progress in behaviors, in a Maintain the percentage of young people 15-24 years spontaneously meeting targets of particular amongst indicating sexual relations as a way of transmitting HIV at least at 90%. the Barbados most vulnerable a Increase in the percentage of HIVIAIDS Strategic groups. o sex workers who report the use of a condom with their most recent Plan, Behavior client from 80% to 95%. Change Strategy and o MSM who report the use of a condom the last time they had sex PDOs. Access to from 64% to 75%. prevention, o young people 15-24 years reporting the use of a condom the last treatment and social time they had sex with a non-marital, non-cohabitating sexual care, in particular partner, from 2 1% to 31%. for the most Revise strategy and vulnerable groups. Access to prevention,treatment and social care a Increase in the number of people from key populations at higher risk policies based on accessing preventive services from 250 in 2009 to 500 in 2013. evidence. Strengthening of a Maintain the percentage of HIV-positive pregnant women receiving organizational and a complete course of AV prophylaxis to reduce the risk of MTCT Report to GOB, institutional above 95% in the period from 2008 to 2013. UNGASS and Bank. structures that Maintain the percentage of PLHIV on ART with achieving virologic govern the NAP. success in the last 12 months above 70% in the period from 2008 to 2013. Use of quality data NAP Capacity for problem Increase in the funds spent by CSOs under results-based identification, agreementslcontracts with the NHAC to facilitate the strategy definition implementation of targeted program interventions for key and measuring populations at higher risk in the period from 2008 to 2013. results. M&E a Strategic Plan for 2013-2018 prepared taking into account KAP and seroprevalence survey data, and monitoring and BCC evaluation results. Component 1: Preventionand Care (a) National Program Coordinationand Monitoring Intermediate /Use of Intermediate I..~..-..A:-~.. n..b-..-.. Outcomes & I I I L W I I I I W U I Q L I U U L b U 1 1 1 1 Outcome & Output Indicators Outputs Monitoring Strengthening the NAP Capacity Assess progress on ability of the public a Funds budgeted for HIVIAIDS annually from US$9 million in 2008 implementation of and private sectors to US$l lmillion in 2013. the UN Three Ones: and civil society to a EEPs included in the project disburse at least 70% every year. (i) one common coordinate, monitor M&E Framework; (ii) one and evaluate their a Number of implementing partners (public, private and CSOsl) who coordination body; activities and use report annually on program results increases from 8 to 18. and (iii) one M&E data to continually a 20 HIVIAIDS and ST1 key indicators routinely reported on and system. increase the quality validated at least once annually by 2013. of their programs. Number of staff trained in M&E increased from 40 in 2008 to 75 in 2013. (b) Scaling up PreventionEfforts Intermediate Use of Intermediate lntermediateOutcome Outcomes & Outcome & Output Indicators Outputs Monitoring Increasing access to Number of people from key populations at higher risk (SW, Assess effectiveness of, preventive services, MSM, prisoners, PLHIV) reached by prevention programs and improve BCC particularly BCC, increases from 250 in 2009 to 500 in 2013. interventions targeting HIVIAIDS and ST1 Number of targeted intervention programs for key populations at key populations at prevention, higher risk increasing from 2 in 2008 to 9 in 2013. higher risk. treatment and Number of CSOs working with key populations at higher risk condoms to key from 2 in 2008 (UGLAAB and CARE) to 7 in 2013. Revise programs and populations at Number of condoms distributed by targeted interventions among activities based on higher risk. key populations at higher risk from 212,000 in 2006 to 700,000 in evidence 2013. (c) Improving Diagnosis,Treatment and Care Intermediate Use of Intermediate IntermediateOutcome Outcomes & Outcome & Output Indicators Outputs Monitoring Increase Maintain above Assess coverage, - thelength and 85% of PLHIV with advanced infection (CD 4 <200) access, utilization, and quality of life of receiving ART in the period from 2008 to 2013. quality of services for PLHIV. 70% of PLHIV on ART achieving virologic success PLHIV. - PLHIV access to (undetectable viral load 4-6 months after initiation of treatment) from 2008 to 2013. diagnostic services, Assess the capacity of treatment services Number of service providers using the National ST1 Guidelines health facilities to and social care and from zero in 2007 to 125 in 2013. provide care and support Functional Biomedical Waste Management System including treatment Properly functioning incinerator; Biomedical waste controlled, recorded and reported to proper Revise programs and authorities (MHNI and Ministry of Family, Youth, Sports and activities based on Environment); evidence. Supplies for the proper disposal of HCW are sufficient. (Component 2: InstitutionalStrengthening lntermediate Use of lntermediate lntermediateOutcome Outcomes & Outcome & Output Indicators Outputs Monitoring Support the Number of staff trained in Monitor training and implementation of HIV and STI-related areas from 70 in 2008 to 130 in 2013. technical assistance the Strategic Plan M&E from 40 in 2008 to 75 in 2013. activities. through training and KAP Surveys carried out in the beginning, mid-term and end of technical assistance the project. Assess capacity on M&E, Seroprevalence surveys carried out by mid-term and end of the building. management, and project. prevention, BCC Evaluation carried out. diagnosis, treatment Fiduciary capacity of NHAC and CSOs improved. and care of HIVIAIDS and other I National AIDS Program Goals and Indicators TARGETS DATA INDICATORS BASELINE 2009 1 2010 1 2011 1 2012 1 FREQUENCY SOURCE RESPONSIBILITY 2013 0 IMPACT INDICATORS HIV Prevalence SurveilIan 1. Percent of young women and men aged 15-24 who are HIV infected Sero- prevalence I survey 2. Percent of most-at-risk I RDS I MHNI populations who are HIV infected (SW, MSM, prisoners, drug users) I 1 1 1 1 1 HIV Incidence I I IAnnual Sentinel MHNI 1 3. Percent of pregnant women Sentinel Sentinel Sentinel Sentine Surveillan NA <1.0% aged 15-19who are HIV data data data ldata infected Prevention Mother to Child Annual Transmission 4. Percent of infants born to 2.6% Maintain an infection rate below 5% HIV-infected mother who 2006 are infected OUTCOME INDICATORS Strategic Objective 1: Prevention and Control of HIV transmission KAPB - Disbursement 2 years Indicator 5. Percent of young women 94.3% and men aged 15-24 years 200512006 Maintain a knowledge rate of at least 90% spontaneously indicating- sexual relations as a way of transmitting HIV INDICATORS DATA FREQUENCY SOURCE Attitudes WIS, 6. Percent of persons Youth expressing accepting KABP, attitudes towards people Sero- living with HIV and AIDS prevalence as measured by people 89% family; survey saying that they would be 31% food; and willing to care for a family 85% teachers RDS member who became sick 200512006 Study with the AIDS virus; would buy food from a PLHIV; andlor would say that a teacher who is HIV+ should be allowed to continue teachingtattending school. I Prevention of Sexual BienniaVSyears IYouth Transmission of HIV KABP 7. Percent of young women and men aged 15-24who have had sexual intercourse before the age of 15 Condom Use 2 years IRDS 8. Percent of female and male Study 2006 sex workers reporting the 80% FSW use of a condom with their most recent client 9. Percent of men reporting 2years the use of a condom the last 5 years time they had anal sex with a male partner DATA INDICATORS /BASELINE I FREQUENCY RESPONSIBILITY SOURCE 2 years WIS, Indicator Youth 10. Percent of young men and KABP, women aged 15-24 years 21% Sero- reporting the use of a 2005/2006 prevalence condom the last time they I survey had sex with non marital and non cohabitating sexual RDS I Biennial I MEHR aged 15-49 years who had KABP NHAC / MFYSE more than one partner in the BMLS MHNI past 12 months reporting SW the use of a condom during KABP I last sexual intercourse WIS- KABP HIV Counseling and Testing 5 years RDS MHNI 12. Percentage of most-at-risk Study populations who received an HIV test in the last 12 months and who know their results 13. Percent of women and men Youth MEHR who received an HIV test in Biennial KABP NHAC / MFYSE the last 12 months and who BMLS MHNI know their results SW KABP WIS- KABP Prevention Mother to Child Annual HMIS Transmission 14. Percent of pregnant women who receive HIV Maintain a rate above 90% counselling and testing for PMTCT and receive their results I TARGETS INDICATORS BASELINE ci 2009 1 2010 1 2011 1 2012 1 2013 Indicator 15. Percent of HIV positive Maintain a treatment rate above 95% pregnant women receiving a complete course of ARV to reduce MTCT Blood Safety Annual 16. Percent of donated blood Maintain a screening rate above 99% units screened for HIV in a qualitv assured manner Strategic Objective 2: Treatment and Care of PLHIV Anti-Retroviral Therapy Annual 17. Percent of persons with advanced HIV infection (< Maintain a treatment rate above 85% 200 CD4) receiving ARV therapy 18. Percent of PLHIV on ART Annual achieving virologic success in the last 12 months Maintain a virologic success above 70% (undetectable viral load in 4-6 months after initiating treatment) 19. Percent of PLHIV on ART Annual with satisfactory adherence Maintain a satisfactory adherence rate above 85% (90% of the necessary drugs taken in the last month) 20. Percent of adults and Annual children with HIV on treatment 12 months after Maintain a survival rate over 95% initiation of antiretroviral therapy 21. Percent of estimated HIV- Annual positive cases TB cases that Maintain a treatment rate above 90% receive treatment for TB and HIV 2009 TARGETS I I INDICATORS BASELINE 1 SOURCE DATA RESPONSIBILITY 2010 1 2011 12012 1 FREQUENCY 2013 I Strategic Objective 3: Support for PLHIV Care and Support Annual 22. Existence of comprehensive 9/17 HIVIAIDS care and support 10 11 13 15 17 2007 policies, strategies and guidelines I Strategic Objective 4: Program Management and institutional Performance Coordination and Annual I Desk 1NHAC Mainstreaming review 23. Number of line ministries submitting HIV work plans in accordance with national guidelines I Strategic Objective 5: Surveillance, Monitoring & Evaluation and Research Monitoring and Evaluation Desk 24. Percentage of institutions review that have incorporated 8 M&E components into their 2006 workplans (public and private sector, and civil society organisations) OUTPUT INDICATORS I Strategic Objective 1: Prevention and Control of HIV transmission Annual Activity NHAC Transmission Reporting 25. Number of targeted Forms F: m sz-g e, .C 0 8 'a C) !3Lt;t5 ebb.^ ' 9 9 ~ e g ~ i b Z ear - . k ;;; I I INDICATORS I 1 TARGETS ( SOURCE DATA RESPONSIBILITY 2009 1 2010 1 2011 ( 2012 12013 FREQUENCY I Strategic Objective 2:Treatment and Care of PLHlV 33. Functional health care waste Annual Action MHNI management system 30 45 60 75 90 100% Plan Site visits I Strategic Objective 3: Support for PLHIV 34. Number of PLHIV andlor Annual Activity MHNI families accessing social Reporting services, including Food 250 275 300 325 350 375 and Bank Referral Forms I Strategic Objective 4: Program Management and Institutional Performance Sectoral Mainstreaming Annual Workplac AFOB; ILO; 35. Number of organizations e-Based CTUSAB; NUPW; 8 with developed workplace 10 12 14 16 18 Survey BEC 2007 policies and programs for HIV and AIDS National Commitment, Annual Smart NHAC Leadership and Coordination US Stream - Disbursement us us us us Indicator $8.5 million US Desk $9.5 $10 $10.5 $11 36. Amount of national funds 2006-07 $9m Review m m m allocated by government for HIV programs National Commitment, Annual Treasury NHAC At At Leadership and Coordination At reports least At least least - Disbursement Indicator At least 2006-07 least Smart US $6.3 US us us 37. Amount spent on US $6.9 m US $7 Stream $6.65 $7.35 m $7.7 HIVIAIDS in the past 12 m Program m m months Reports 38. Amount of funds spent by us Annual Activity NHAC civil society organizations 0 US $ US US Reporting MSCU $502 under results-based 2007 150k $229k $312K $418K Forms MFYSE agreements I I TARGETS DATA INDICATORS , FREQUENCY RESPONSIBILITY 2011 1 2012 2013 SOURCE I I ,,-0 I 39. Number of CSO working 2~I)CS'p5 Annual Desk NHAC 7 with most-at-risk 0 4CSO CSO 6 CSO Review LUU1 CSO populations 40. Number of CSO signing ..- -. I ACtlVlry ""AC N H results-based / 0 1 1 1 2 3 1 4 1 6 1 A n n u a l 1Ineporung I 1.'- I a~reementslcontractswith --..-.A :..- IVISU ~ o k s- MFYSE the NHAC --- 4I. Number of CSO grantees Annual Activity NHAC .Malnraln 2007 I I I who report at least annually '... ,,n",. Reporting MSCU allL ~ U S rc:porting annually on their HIVIAIDS program Forms MFYSE results I I I I Strategic Objective 5:Monitoring & Evaluation and Research Monitoring and Evaluation Quarterly Desk NHAC 39 42. Number of people trained in 15 20 25 30 35 Review 2007 M&E at different levels 43. Number of implementing Quarterly1 Desk NHAC partners (public, private and 8 Annual Review 10 12 14 16 18 CSOs/) who report annually 2006 on program results. Arrangements for Results Monitoring 1. Monitoring and evaluation are viewed as fundamental to the management of the Project. The M&E framework focus on strengthening and developing existing information systems to measure indicators that track activities carried out by the program and the project, the quality of services, and their outputs and outcomes (i.e., access to and utilization of prevention, treatment and social care, adoption of safe behaviors, new HIV and AIDS cases and mortality). Information for project indicators is collected, analyzed and reported on an annual or biennial basis. The system is developing a management cycle that would ensure that information is routinely used for management decision-making and strategic planning. M&E reports would be the basis for evidence-based reviews of project progress and results every semester, for making tactical and strategic changes when necessary, and for reporting to GOB, UNGASS and Bank. 2. The NHAC has the main responsibility for program and project M&E, with the assistance of the MHNI and other local implementing partners. The NHAC monitors and ensures the quality of the data collected and entered into the program database; oversees the overall design and sample selection of special surveys; and carries out the overall analysis, triangulating information from the different sources, and reports to GOB, UNGASS, Bank, public and other stakeholders. 3. Implementation of an effective M&E system is a team effort requiring the commitment of the NHAC and implementing partners. The current M&E capacity is limited. The M&E system design emphasizes the empowerment of program managers to obtain data that assists them in identifying and improving issues. The capacity of the NHAC and implementing partners to use data for decision making would be strengthened. 4. The M&E conceptual framework and operational plan included in the Project Operational Manual describe how M&E would be carried out under the project, including human and financial resources required. The M&E system relies on several systems and sources of information, which would be further developed under the project as described below. 5. NHAC Management Information System (NHAC-MIS). Under the project, the NHAC would strengthen its management information system to collect and analyze data provided by the MHNI and other line ministries, CSOs and private sector, and to produce reports for the Government, UNGASS, Bank, public and other stakeholders on the progress of the project and program implementation, and their respective results. 6. Health Management Information System (MHNI-MIS). The MHNI has the responsibility for routine health data collection, analysis and reporting. The MHNI-MIS is a public health planning and information system that tracks a number of national health indicators based on the data provided by the health facilities. Information from each health facility is filled out daily and summarized on monthly tables. The MHNI produces quarterly bulletins and annual reviews per fiscal year. Under the project, the MHNI would strengthen its health management information system to collect and analyze data on HIVIAIDS and STIs, and produce reports for the NHAC on implementation progress of HIVIAIDS prevention, treatment and care activities, and their respective results. The system would also collect and analyze HIVIAIDS and ST1 data from private health facilities within the catchment area of each MHNI health facility. 7. HIVIAIDS and ST1 Surveillance. HIVIAIDS Surveillance has been implemented since 1986, and would continue throughout project implementation. The VCT sites, the QEH, the LRU and the MHNI Barbados HIVIAIDS Impact Project (BHIP) are involved in data collection, analysis and reporting. The BHIP collates the VCT data forms received from VCT sites. Health facilities (QEH and polyclinics) provide HIV and ST1 data to the LRU, which aggregates it at national level. Information is analyzed and HIVIAIDS and ST1 surveillance reports are issued quarterly and annually. The MHNI HIV Program has developed a protocol for sentinel surveillance in antenatal care, ST1 and VCT services. The specific objectives of sentinel surveillance are to: (i) monitor the trends of HIV infection at sentinel sites; (ii) provide estimates of the burden and distribution of HIV infection in the general population, by extrapolating from prevalence in sentinel sites; and (iii) support the dissemination of sentinel surveillance information in order to plan more effective HIV prevention and care services. Under the project, routine HIVIAIDS and STIs surveillance would be strengthened, and complemented by data from periodic behavior and seroprevalence surveys carried out among key populations at higher risk, youth and general population. The combined information would provide complementary information about the epidemic, its drivers and adoption of safe practices among vulnerable groups and the general population. 8. Sero-Prevalence Surveys among Key populations at higher risk and Population- Based. Seroprevalence surveys would be carried out among key populations at higher risk and general population, on the second and last year of the project. The overall purpose of these surveys is to track epidemic trends and its drivers. A Respondent Driven Sampling (RDS) Survey of Hard-to-Reach Populations would be conducted among key populations at higher risk (SWs, MSM, prisoners). The population-based survey would be conducted among the general population with an oversampling for youth. 9. Knowledge, Attitudes and Practices Surveys (KAP). Information about KAP has been collected on a biennial basis among youth by the Ministry of Family's Division of Youth Affairs. Under the project, the NHAC would also carry out KAP surveys among key populations at higher risk, and among the general population that would provide baseline information, and data at project mid-term and by the end of the project. The M&E Technical Working Group would advise on the sub-populations to be targeted. Among other issues, the surveys would aim at determining the knowledge levels about HIVIAIDS and STIs among different key populations at higher risk, youth and general population; patterns of condom use among SWs and their clients, patterns of seasonal migration of sex workers; proportion of MSM who engage in SW; non-injecting behaviors; and ST1treatment practices. 10. Logistic Management Information System (LMIS). The purpose of this system is to ensure an uninterrupted availability of lab reagents, ARV drugs, condoms and other essential drugs and medical supplies in public health facilities. Under the project, NHAC and implementing partners would track stocks and distribution of basic commodities. Essential data would include: stocks; rate of usage; and losses/adjustments. This system would allow the MHNI to produce reports on condoms including information about: (i) number of condoms distributed free of cost to clinics or purchased by private sector companies for free distribution to users/clients or workers in those organizations; and (ii) number of condoms distributed to the end users by each facility. This also enables the MHNI and health facilities to project stock needs for the next reporting period and submit orders appropriately. 11. Health Facility Survey (HFS). Health Facility Surveys would report on the overall capacity of health services to provide basic counseling, testing and management of HIV positive cases. This survey would be carried out in the beginning of the project, at mid-term and by the end of the project. The survey would focus on quality of case management, health information, existence of essential medicines and supplies and IECIBCC materials, equipment and referral systems, counseling and staff training, among others. 12. Environmental Health Assessment. Indicators on the proper functioning of the Biomedical Waste Management System would be monitored annually by the MHNI under the project. These indicators include: (i) properly functioning incinerator; (ii) biomedical waste controlled, recorded and reported to proper authorities (MHNI and Ministry of Environment); and (iii) supplies for the proper disposal of HCW are sufficient. 13. Independent Technical and Financial Reviews of Project Results. As part of the results-based design of the project, technical reviews would be carried out twice during the project by an independent agency. Reviews would focus on analyzing project results, especially those linked to loan disbursements. These reviews would help the NHAC verify the accuracy of reporting mechanisms, and contribute to ensure the quality of the project and program. Possible candidates to carry out the reviews include regional research centers, international private firms and international organizations with experience on HIVIAIDS program implementation and M&E. Annex 4: Detailed Project Description BARBADOS: SECOND HIVIAIDS PROJECT 1. The Barbados HIVIAIDS I1 Project would co-finance the GOB'S National HIVIAIDS Program through a Sector Investment Loan (SIL) of US$35 million to be disbursed in five years (2008-2013). The project would follow a Sector Wide Approach (SWAP). The Bank would co- finance a percentage of eligible expenditures of the government program. For Component 1, on Prevention and Care, loan funding would be pooled with government funding to finance the NAP. For Component 2, on Institutional Strengthening, loan funding would be disbursed against approved contracts. Bank financing would contribute to the implementation of agreed policies and programs, and to the achievement of specific results, which would trigger disbursements as explained below. The loan would be incremental to government funding. Project development objective and key indicators 2. The project would support the implementation of the 2008-2013 National Strategic Plan for HIV Prevention and Control, specifically to increase: Adoption of safe behaviors, in particular amongst key populations at higher risk7. Access to prevention, treatment and social care, in particular for key populations at higher risk. Capacity of organizational and institutional structures that govern the NAP. Use of quality data for problem identification, strategy definition and measuring results. Project Development Indicators Behavior change Maintain the percentage of young people aged 15-24 years spontaneously indicating sexual relations as a way of transmitting HIV at a level of at least at 90% from 2008 to 2013. Increase the percentage of o sex workers who report the use of a condom with their most recent client from 80% in 2008 to 95% in 2013. o MSM who report the use of a condom the last time they had sex from 65% in 2008 to 75% in 2013. o young people 15-24years reporting the use of a condom the last time they had sex with a casual partner from 21% in 2008 to 31% in 2013. Access to prevention, treatment and social care Increase in the number of people from key populations at higher risk accessing preventive services from 250 in 2009 to 500 in 2013. 'InBarbados, key populations at higher risk include male and female sex workers (SW); men who have sex with men (MSM), prisoners and drug users (DU); people living with HIVIAIDS (PLHIV) and with disabilities; youth, especially out-of-school; and unemployed women (Annex 6 includes detailed information about these groups). r Maintain the percentage of HIV-positive pregnant women receiving a complete course of AV prophylaxis to reduce the risk of MTCT above 95% in the period from 2008 to 2013. r Maintain the percentage of PLHIV on ART achieving virologic success in the last 12 months above 70% in the period from 2008 to 2013. NAP Capacity Increase in the funds spent by CSOs under results-based agreements with the NHAC to facilitate the implementation of program interventions for key populations at higher risk from 2008 to 2013. M&E An evidence-based Strategic Plan for the period of 2013-2018 prepared before project closing, taking into account surveillance and M&E data available under the project. Project components 3. The proposed Project aims to build on the successful increase in access to HIVIAIDS testing, treatment and care accomplished by the Barbados NAP with Bank assistance. The new project would further expand this success into increased knowledge and effective, sustainable behavior change. An additional major focus would be to improve M&E of the HIVIAIDS epidemic and program, and its ability to make mid-course corrections. 4. The project would have two components with the same focus, but different implementation and disbursement arrangements. The first component would follow a SWAP approach by financing a percentage of the Barbados HIVIAIDS Program and having funds pooled with those from the GOB. The second component would provide technical assistance and training following Bank procurement guidelines. The GOB and Bank would review annually the budget execution of key programs included in Component 1, aiming at guaranteeing at least 70% execution, and achievement of agreed results. Necessary adjustments would be made by the project Mid-Term Review. Component 1: Prevention and Care (US$89.65 million, US$31.4 million loan) 5. This component would contribute to the implementation of the National Strategic Plan for HIV Prevention and Control 2008-2013, specifically of the following three EEPs: 6. National Program Coordination and Institutional Strengthening. This program aims at strengthening the ability of the public sector, private sector and civil society partners to co- ordinate, monitor and evaluate their activities and use data to continually increase the quality of their programs. Specific activities would include: (i) Building capacity that would help the GOB and civil society increase their ability to formulate a vision, policies, strategies, and plans of action; mobilize financial resources; and conduct operations relevant to HIVIAIDS. These activities would address issues in intra- and inter-agency communications and coordination, leadership, division of labor and adequate work practices and management practices. An existing Public Sector-CSO Grant System would be further developed under the project. This is described in Annex 6 and in more detail in the Project Operational Manual. (ii) Strengthening surveillance, including the following: (a) continue to routinely report on identified HIV and AIDS cases and AIDS deaths, with close attention to confidentiality matters; (b) routinely report other STIs cases (Syphilis, Gonorrhea and Chlamydia); (c) Continue to carry out sentinel surveillance on pregnant women attending antenatal care and blood donors, to monitor general population prevalence; (d) carry out periodic seroprevalence surveys among key populations at higher risk; (e) carry out periodic KAPB studies of high risk behaviors among key populations at higher risk, looking for changes in behavior which may lead to spread of HIV infection, concentrating on behavior links between members of these groups and the general population; and (f) carry out audits of quality of treatment and care for PLHIV and ST1patients. (iii) Addressing the critical issue of M&E within the HIVIAIDS Program. Additional M&E staff would be hired within the NHAC and MHNI and a system would be set up to ensure a pool of trained M&E personnel in the country. A consultant would be hired to provide technical assistance and coaching to the new staff. The current M&E system would be redesigned to more effectively gather high quality data on a smaller number of critical indicators. The new system would facilitate the sharing of data with NHAC, the MHNI, and all relevant partners. Analysis and action on data would also be strengthened via new institutional arrangements and training. In addition, the safe storage of data to prevent loss or breaches of confidentiality would be improved. M&E capacity would be increased in the MHNI and other agencies. Capacity building includes training in implementation of the M&E plan, training in specific technical areas such as questionnaire design and data analysis, and translating results into action. Capacity would also be built through the procurement of needed computer systems and software. Implementation of the M&E strategy would include collection of baseline data for planned activities, monitoring of ongoing work, and final evaluation of the HIVIAIDS programming at the end of the project. 7. Scaling up Prevention Efforts. This program aims at increasing access to preventive services, especially among key populations at higher risk, and including BCC and provision of condoms. Prevention activities would be implemented in close cooperation between public agencies and CSOs. Among other activities, the BCC Strategy would be implemented as follows: (i) Evidence-Based BCC Design. High quality research would be conducted to determine the KAP of key populations at higher risk regarding HIVIAIDS practices. In addition, research would be conducted to determine proximal determinants of behavior as well as barriers and enabling factors. The results of the assessment of the most vulnerable groups (sex workers, men who sex with men, prisoners, youth) would be used to create and test multi-channel high-impact BCC programs tailored to each of the key populations at higher risk, as well as to the general population. (ii) Implementation of BCCprograms. BCC programs would be implemented over the course of the five years to reach key populations at higher risk. Promising existing BCC programs in Barbados and the Caribbean would be identified, tested and fine- tuned to ensure that they are appropriate for the Barbados context. The interventions would be multi-channel including peer communications, counseling, mass media, and social marketing. Management of the BCC strategy. The NHAC manages the BCC strategy and in addition to program design and implementation, it is responsible for needed policy changes and reporting. The BCC unit is currently understaffed and does not have the capacity to meet the challenge of effective BCC. This subcomponent would be responsible for the recruitment and hiring of a senior behavior change officer, a junior behavior change officer responsible for edutainment, and a junior behavior change officer responsible for advocacy. Given the multi-sector nature of Barbados HIVIAIDS response, the success of the new BCC program requires the training and coordination of the partners including civil society, faith-based organizations (FBOs), PLHIV groups, the Ministry of Education, and the Ministry of Tourism, among others. 8. Improving Diagnosis, Treatment & Care. The goal of this program is to increase the length and quality of life of PLHIV. The program aims at increasing PLHIV access to diagnostic services, treatment services (ART and treatment for 01s) and social care and support (counseling, support groups, drug addiction therapy, and home care), as follows: (i) HIV Testing services would be expanded into community organizations, including those working with vulnerable groups. The HIV testing training program would be adjusted to the new rapid testing protocol, and training would be condensed and made available at more convenient times for private providers. The LRU's laboratory would be strengthened so that it can offer viral loads and CD4 counts not only for Barbados but for other Caribbean countries at cost. (ii) Treatment would be decentralized on a phased basis to the polyclinics that provide free government health services to the entire island. This would help eliminating the stigma currently associated with the LRU in the MHNI, and would seek to integrate HIV services with other services provided at the polyclinics. The subcomponent would provide HIVIAIDS training for health care workers and social workers in the polyclinics. Training would also be made available for private providers. In addition, a quality control system would be introduced to ensure that the decentralization of care does not compromise the quality of outcomes. (iii) Referral systems to social care would be strengthened, including assigning each PLHIV to a social worker. A protocol for systematic evaluations of social care needs would be instituted. Counseling for drug use would be made available to PLHIV and other highly vulnerable individuals. Component 2. Institutional Strengthening (US$4.47 million, US$3.6 million loan) 9. The objective of Component 2 is to provide institutional strengthening via training and technical assistance that would not be funded under the SWAP component. While routine surveillance, seroprevalence and behavioral surveys, and quality audits would be carried out under Component 1, the second component would include non-routine training and technical assistance to review the surveillance system, put in place sero- and behavior surveillance and quality audits and assist with standardization of data collection methodologies, particularly in the case of behavior surveillance. This component would finance training and technical assistance on M&E, management, surveillance, prevention, diagnosis, treatment and care of HIVIAIDS and other STIs, to support the implementation of the Strategic Plan. -.- -. --" Comqonent 2: Technical Assistance and T r a i n i n g-- J Surveillance /Seroprevalence surveys among key populations at higher risk and general population Behavior surveys among key populations at higher risk, youth and general population Trend study: vulnerable groups, estimate incidence and prevalence Development of Strategic Plan 2014-2019 Management NHAC Management Information System Procurement, FM NGO Fiduciary Capacity Technical audits - - Prevention BCC technical exchanges - BCC Evaluation Diagnosis, Training health care providers to improve diagnosis, treatment and Treatment & care Care Training for drug abuse issues Palliative and Social Care EEPs, PDOs, PDIs and Disbursement Milestones and Indicators PDOs PDIs Project Milestones and DLls Increase in Increase in hnds spent by CSOs under results-based Agreed NAP Budget. Coordination and Capacity of organizational and agreements with the NHAC to facilitate the Institutional institutional structures that govern implementation of targeted program interventions for key 70% EEPs execution. Strengthening the NAP. populations at higher risk from 2008 to 2013. Use of quality data for problem Evidence-based Strategic Plan for the period of 2013- identification,strategy definition and 2018prepared before project closing, taking into account measuring results. surveillance and M&E data available under the project. Scaling up Adoption of safe behaviors, in In the period from 2008 to 2013: In the period from 2008 to 2013: Prevention Efforts particular amongst key populations at higher risk. Maintain at least at 90% the percentage of young people Maintain at least at 90% the 15-24years spontaneously indicating sexual relations as a percentage of young people 15- Increase access to prevention, in way of transmitting HIV. 24 years spontaneously particular for key populations at indicating sexual relations as a higher risk. Increase in the number of people from key populations at way of transmitting HIV. higher risk accessing preventive services from 250 in 2009 to 500 in 2013. Increasethe percentage of young men and women 15-24years Increase the percentage of people reporting use of a using a condom the last time condom as follows: they had sex with a non-marital, - SW with their most recent client from 80% to 95%. non-cohabitating sexual partner - MSM the last time they had sex from 65% to 75%. from 21% to 31%. - young people 15-24 years the last time they had sex with a casual partner from 21% to 31%. Maintainthe percentage of HIV- positive pregnant women Maintain the percentage of HIV-positive pregnant women receiving a complete course of receiving a complete course of AV prophylaxis to reduce AV prophylaxis to reduce the the risk of MCT above 95%. risk of MTCT above 95%. Improving Improve access to treatment and Maintainthe percentage of PLHIV on ART achieving Diagnosis, social care, in particular for key virologic success in the last 12 months above 70% in the Treatment & Care populations at higher risk. period from 2008 to 2013. Annex 5: Project Costs BARBADOS: SECOND HIVIAIDS PROJECT Project Cost By Component and/or Activity Local Foreign Total us us $million $million US $million Component 1 88.06 88.06 EEP 1 Management 10.68 10.68 Surveillance, M&E and Research 2.11 2.11 Capacity Building 4.00 4.00 CSO Grants 1.61 1.61 EEP 2 Prevention & BCC 16.08 16.08 EEP 3 Treatment 44.48 44.48 Care & Support 9.11 9.11 Component 2 Surveillance, M&E and Research Behaviour Change Communication Diagnosis, Treatment & Care Management Total Baseline Cost Physical Contingencies Price Contingencies Total Project costs' Interest during construction Front-end Fee Total Financing Required 94.39 94.39 0 0 `"" N m 2 N `0 - m w - Y2 .-a0 .-c +E - 00 m 3 t - V V T - N t- o\ o\ 5 Y m 00 rr) rr) o\ N V , N b 0 0 0 rr) 2 2 rn f 2 3 % t-- g- z r- w o\ 3 N 2 3 o\ t % ? ? g : P C . O 3 3 3 3 3 $1 -5 - 3 (z Q\ m :-2 - E" z* o\ w rn w 8 2 2 ; 2 0 c? 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Y"Y 0 3 L 3 9 cl! r Z 6 . 2 4 .S ":zo3: r . b B u C Q, 2 '?gz & $ & ; a s a Z < P ' $ a ( d o 0 * M b '; .,z " 9 " ' ;;j; u ggu W 3r nm o o U ~ O a a m Sector Budget Budget Item 2008 2009 2010 2011 2012 Total Code Prevention - Legal matters OAG 8308 226 30,000 31,500 33,075 34,729 36,465 165,769 Prevention - Industry workers & MFAFI 8319 212 Staff 18,466 20,358 21,376 22,445 23,567 106,212 Prevention - Staff & Transport MTW 8309 212 11,750 12,455 13,602 14,282 14,997 67,086 Prevention - Staff MFEE 8317 212,752 10,865 11,408 11,979 12,578 13,206 60,036 Prevention Port & Airport Staff - MTW 8306 212 3,535 3,712 3,898 4,092 6,139 21,376 Prevention - Industry Workers MTIC 8318 212 3,500 3,850 4,235 4,659 5,124 21,368 EEP3 Improving Diagnosis, Treatment& Care 5,852,466 8,429,973 10,996,618 12,979,816 15,324,000 53,582,873 Treatment & HIV Testing MHNI 0397 101,102,103,206,20,2 08,209,2 10,211,2 12,7 4,565,777 6,945,728 9,235,958 10,885,745 12,842,683 44,475,890 51, 752,753,755 Health Care- Elroy Phillips Centre MHNI 8701 101,102,103,206,207, for PLHIV (residential Care) 208,209,2 10,2 11,2 12, 775,041 930,049 1,116,059 1,339,27 1 1,607,125 5,767,545 223 -- Social Care- Support for PLHIV MSCU 8304 485,06 1 514,315 584,780 665,069 739,595 2,988,820 Care -Prisoners MHA 8704 209,2 10,2 12, 26,587 39,88 1 59,82 1 89,73 1 134,597 350,616 TOTAL 10,630,451 14,116,654 17,685,773 20,939,724 24,686,644 88,059,246 Annex 6: Implementation Arrangements BARBADOS: SECOND HIVIAIDS PROJECT 1. Institutional capacity to implement the National Strategic Plan for HIV Prevention and Control 2008-2013 is satisfactory. Institutional and implementation arrangements for the Barbados HIVIAIDS Project I1 would be similar to those for the first project. At the political level, the MFYSE is responsible for HIV matters, and sets the political strategy guiding the implementation of the NAP of which the project is a sub-set. The NHAC's Secretariat would perform the functions of Project Coordination Unit. 2. Social and institutional assessments were carried out during project preparation to identify beneficiaries and their needs, assess the institutional arrangements in place to fill those needs, and identify necessary institutional changes for successful project implementation. Below, is a summary of both assessments and agreements regarding arrangements to put in place prior to project effectiveness and during project implementation. Beneficiary Assessment 3. In Barbados, key populations at higher risk include SW; MSM, which includes self- identified gay, bisexual, transgender or heterosexual people; prisoners and drug users; PLHIV and persons with disabilities; and young people, especially single unemployed and dependent women (SUDW). In addition, tourists, foreign sex workers visiting the island as tourists, and temporary foreign residents (owners of holiday houses, workers in outsourcing and regional trading companies, tourism and construction workers, exchange students, etc) make up a large percentage of the population living in the island. Table 1. Estimates on Key populations at higher risk in Barbados 2007 Yo HIV Highly Vulnerable Group Number Population Prevalence Female Sex Workers (estimate) 400-1,600 0.6-2.24% NA Male Sex Workers NA NA 1,296 1% 1,016 0.4 NA NA PLHIV 2,100 People with disabilities (2000) 13,142 4.6 NA Single, Unemployed and 4,200 1.5 NA Dependent Women (SUDW) Youth 15-24 years old 34,100 12.3 1.3 4. Barbados is a relatively small country, with close-knit family and social networks, where people are often reluctant to identify as being part of a vulnerable group, and avoid government services due to their perceived lack of confidentiality. This is particularly the case for sex workers and MSM. Existing legislation criminalizes sex work, anal sex and drug use. Work has started with some key groups, particularly SW, MSM and youth, but much needs to be done to extend preventive and treatment services to them. Available evidence shows that although some advances have been made in behavior change, the gap between knowledge and behavior is still large. The project would include the development of a plan with strategies to effectively reach key populations at higher risk that would provide information about the size, HIV prevalence and practices of each group, as well as other data that can inform HIV planning and policy making. Consultation meetings with implementing partners have been held regularly during the preparation and implementation process of the current Strategic Plan. However, there is a need to develop a more focused and systematic strategy to increase the level of active and meaningful participation of vulnerable groups in design, implementation, M&E of prevention work through workshops, one-on-one meetings, focus groups or other appropriate methods. Available evidence and participation of the different key populations at higher risk of HIVIAIDS and ST1in strategic planning and decision-making is reviewed below. 5. Sex Workers (SW). The illegal nature of the sex trade, and the fact that sex workers move frequently among islands, complicates attempts to reach them. A soon to be released report with the results of a baseline study carried out by the sex workers project of the MHNI among 44 sex workers shows that the use of condoms by female and male sex workers with their clients is relatively high, but this percentage is much lower with regular partners. The study found that those sex workers who migrate between countries are of particular concern, requiring specific interventions. Following this baseline study, the MHNI is implementing a project targeted at sex workers. The CSO United Gays and Lesbians against AIDS Barbados (UGLAAB) has also formed a successful outreach program using innovative mechanisms aimed at reaching sex workers and MSM. However, because of a lack of institutional capacity and resources, their reach is limited. In addition, due to denial, stigma and discrimination and existing legislation, many male sex workers do no want to be associated with UGLAAB. 6. Men who have sex with Men (MSM). In 2007, there was an overwhelming public outcry against recommendations to decriminalize anal sex among adultss, since it was mostly seen as the decriminalization of homosexuality, which is socially regarded as immoral. The Barbados Men's Lifestyle Survey 20079interviewed 540 Barbadian male residents ranging from age 15 and over, of which 7% was classified as MSM. In this group, about 42% indicated that they had always used a condom with a non regular partner, while only about 22% of men classified as heterosexual indicated the same. Almost two thirds of MSM have two or more sexual partners. Men in general make limited use of health services; 68.5% only visit a doctor when they have a health problem, and 15% report never seeing a doctor. This would be due to provider stigma and discrimination in some settings, with those who can afford it visiting local Walrond ER 2004. Legal, Ethical and Socio-economic Issues relevant to HIVIAIDS. Review of HIVIAIDS legislation and socio-economic impact commissioned by the Office of the Attorney General in February 2004; and Global Rights and the International Human Rights Advocacy Seminar at the University of Virginia School of Law. Shadow report on lesbian, gay, bisexual and transgender rights in Barbados. Year of publication unknown. NHAC and Associates for International Development. Barbados Men's Lifestyle Survey 2007. private physicianslO.Demand for condoms among UGLAAB members is reported to have risen up in recent years. Representatives from the gay and MSM community consider their participation in the planning process of the National Strategic Plan for HIV Prevention and Control 2008-2013 satisfactory. The Program Officer of UGLAAB is a member of the prevention committee of NHAC, and has therefore a direct input in policy making concerning prevention. UGLAAB has found an effective way to sensitize its members about HIVIAIDS strategies. 7. Prisoners. Key stakeholders suggest that not enough attention is paid to analyzing how prisoners are infected or affected by the epidemic. There is limited information about the high risk sexual practices inside and outside the prison (for recently released prisoners). However, a study1' carried out in Barbados indicates that a comprehensive program addressing prisoners while incarcerated, as well as after their release, could result in a high percentage of PLHIV released prisoners following up with medical care, or making contact with community-based drug treatment programs. Effective prevention programs for inmates require collaboration between inmates, staff, public health, and community-based service organizations. Reportedly, a high percentage of prisoners are serving time due to drug related crimes. Research carried out on drugs, HIVIAIDS and inmates in 2005 by the National Council on Substance Abuse suggest a strong relation between drug and alcohol use and high-risk sexual practices. This is an area that deserves further investigation. In addition, a more integrated approach targeting prisoners should be established through inter-sectoral coordination and collaboration in terms of prevention programming among the NHAC, Ministry of Home Affairs, MHNI, and the National Council on Substance Abuse. 8. Drug Users (DU). Injecting drug use (IDU) is not an important way of transmission of HIV in Barbados, unlike what happens in other countries. However, drug use is prevalent, and it may be associated with high risk sexual practices. Stakeholders indicate that not enough attention is paid to analyzing how drug users are infected or affected by the epidemic. Drug users' representatives indicated that strategies, especially prevention efforts, are too centralized in Bridgetown and do not cover the most important locations for drug trafficking and use: beaches, drug holes and bars. The Psychiatric Hospital reports that 70% of the women treated for drug addiction are HIV positive and many are occasional sex workers. However, due to the social perception that drug abuse is a male problem, addicted women are practically excluded, or exclude themselves due to stigma and discrimination, from treatment. The Psychiatric Hospital is the only centre that offers in-house rehabilitation for women. 9. People living with HIV (PLHIV). A study12 aimed at investigating the reasons for hospitalizations and its outcomes in the country indicated the prevalence of a high degree of stigma and discrimination in Barbados, and highlights the consequent occurrence of late diagnosis of HIV. The CSO UGLAAB reports that hospitalization of PLHIV is less frequent now than in past years due to ART. PLHIV are represented by CARE Barbados in the network of l oNHAC 2007. The HIVIAIDS Situation in Barbados from 1984 to 2006. I 'Best A, Innocent-Ituah I, Sukhaseum D 2004. HIVI AIDS Prevention and Control Project in Glendairy Prison, Barbados. l 2AIDS Research and Therapy 2007 4:4. Trends in the HIV related hospital admissions in the HAART era in Barbados 2004-2006. Available at http://www.aidsrestherapy.corn/content/4/1/4, Barbadians infected and affected by HIV. However, membership is very limited compared to the number of registered PLHIV in the MHNI. This is mainly due to stigma and discrimination PLHIV face in their communities, the workplace and the society at large, as well as the limited outreach capacity of the organization. CARE Barbados main concern refers to the difficulties in the coordination between MHNI and CARE, which has not received condoms since May 2007, and reports that health care providers in clinics do not refer people to CARE Barbados due to discrimination of PLHIV. 10. People with Disabilities. People with disabilities are underrepresented in national planning and strategies although they are represented by various CSOs and groups according to their type of disability. Their under-representation is partly due to internal coordination problems between the different groups, as well as the perception that people with a disability are not sexually active, although they are at increased risk as they are often victims of sexual abuse. An important step to address this group is the pilot project Planned Approach to Community Health (PATCH) to be implemented by the MHNI in collaboration with the National Disabilities Unit from the Ministry of Social Care, Constituency Empowerment and Urban Development. The representatives of persons with disabilities indicated a need to distribute more information in Braille and use sound for the vision and hearing impaired; and for policy makers to sensitize the general public about persons with disabilities and discrimination, as much of their risk related to HIV stems from myths from within and outside the community of disabled people. 11. Single Dependent Unemployed Women (SDUW). This group includes women who are single heads of households, low income earners and unemployed. The National Strategic Plan for HIV Prevention and Control 2008-2013 indicates that single dependent unemployed women are a key group at higher risk, and will be specifically targeted by the Program. This group is already targeted by the Bureau of Gender Affairs in coordination with the Welfare Department and Poverty Alleviation Bureau. The inclusion of a gender component in the Strategic Plan is regarded as a positive step forwards in targeting the feminization of the HIVIAIDS epidemic observed in Barbados. 12. Youth. Information about youth awareness, understanding of, and attitudes, vis-a-vis the epidemic is available from the National Youth KAPB survey^'^. While 94.3% of young women and men aged 15-24 years spontaneously indicated sexual relations as a way of transmitting HIV; only 21% reported the use of a condom the last time they had sex with non marital non cohabitating sexual partner. Behavior change of this group is one of the main areas of focus of the Strategic Plan. Evidence from the UWI HIVIAIDS Response Program suggests the need to pay particular attention to the sexual behavior of students from overseas, who are reportedly more likely to engage in high-risk practices than local students due to anonymity and reasons that should be further investigated. Youth are represented on community groups at the community level and on the Youth Committee of the NHAC. The NHAC Youth Committee is actively involved in creating innovative and creative prevention strategies including song contests, interactive internet sites and peer education programs, as it considers crucial to update prevention messages for young people. "MES. National Youth KAPB Survey on HIVIAIDS 2004-2005. 13. To address the needs of the key populations at higher risk under the project, the NAP would: A Carry out studies to identify the size, HIV prevalence and behavior of each group, as well as gather other data and information about key populations at higher risk that can inform HIV planning and policy making. This would include research to determine the dynamics of the sex work networks and its relation with tourism; and analysis of power relations between men and women in gender mainstreaming as this influences behavior. A Carry out a continuous compilation and analysis of existing initiatives by government agencies and CSOs that target key populations at higher risk. A Continue to advocate for decriminalization of sex work and homosexuality, as existing discriminating laws have far reaching consequences in terms of identifying and reaching key populations at higher risk, learning about their behavior and determining prevalence, which prevents policy makers from formulating targeted programs and plans. A Develop a strategy that encourages the active and meaningful participation of key populations at higher risk in design, implementation, M&E of prevention work to ensure a more structural and continuous participation of these groups. Their active participation will serve two purposes; the first is an increase of ownership and self-esteem, which may ultimately contribute to behavioral change; the second is the systematic collection of updated data on the changing dynamics of the epidemic that will inform programming in planning. This strategy should include the following elements: The first step would be to hold meetings with representatives of each group to involve them in the design of the participation plan. This can be done through workshops, one-on-one meetings, focus groups or other appropriate methods to meet vulnerable groups to learn about their concerns, needs and interests. These meetings should also be used to involve key populations at higher risk in the design of prevention messages. Upscale and strengthen the Sex Workers Project to increase their level of implementation in the Strategic Plan and their participation in future planning. Improve coordination efforts with the Ministry of Home Affairs to develop a comprehensive HIVIAIDS strategy for the prisoners, and increase their level of implementation in the Strategic Plan and their participation in future planning. Integrate drug rehabilitation centers and NCSA in program planning and implementation efforts. Strengthen CSOs so that they can scale up and increase their outreach programs to key populations at higher risk. Update information, education and communication strategies for key populations at higher risk constantly, as the dynamics of the epidemic change and groups are dynamic and not homogenous. Support peer education programs as these have reportedly been very effective amongst prisoners, youth and other vulnerable groups. Support the establishment of self-help and support groups by and for key groups. Engage people from key groups in the preparation of plans and policies to increase the effectiveness of prevention efforts. Raise awareness and train medical staff about confidentiality and stigma and discrimination. Institutional Assessment 14. This study assessed the institutional capacity of NHAC, ministries, public health services and relevant CSOs and private sector to tackle the epidemic. Institutional capacity to implement the national HIVIAIDS Strategic Plan was found to be satisfactory. A multi-sectoral framework is in place and the NAP is considered a flagship program in the region in terms of technical capacity. The HIVIAIDS strategy has been mainstreamed within key ministries. Key populations at higher risk and Government and Civil Society Partners Welfare Department UGLAAB Bureau of Gender Affairs MSM MHNI UGLAAB Welfare Department Bureau of Gender Affairs Ministry of Community Abuse Addiction Support Alternatives MHNI (CASA) Verdun House Prisoners Ministry of Home Affairs None (education and VCT) MHNI PLHIV MHNI CARE Barbados Ladymeade Reference Center Queen Elizabeth Hospital Youth and Sports Departments in Teachers' Union the Ministry of Family Single Bureau of Gender Affairs National Organization of Women unemployed Welfare Department women Ministry of Social Care, Constituency Empowerment and Urban Development try of Tourism Barbados Hotel and Tourism tourism staff Association 15. Unlike some other parts of the world, in Barbados the fight against the HIVIAIDS epidemic is mainly led by the Government. Global evidence indicates that CSOs have direct access to highly vulnerable, hard-to-reach groups, and a potential to expand their outreach if strengthened. Although CSOs lack a solid strategic planning framework, and have very limited skills in proposal writing, fundraising, reporting and administration -- there is experience of the public sector partnering with established CSO to implement public-sector sponsored initiatives. Some key populations at higher risk (for example, SWs and prisoners) are not organized or represented by any CSO. There are approximately 11 CSOs working on HIVIAIDS-related issues in the country. The majority has been recently established and faces challenges in terms of their organizational and institutional capacities, staffing and resources. 16. Some level of social tension has been observed between key populations at higher risk on one side, and CSOs that represent them and public institutions on the other, as some vulnerable people do not identify themselves with the CSOs that represent them. This is the case for MSM and the CSO UGLAAB, as well as PLHIV and the CSO CARE. This would be mainly due to underlying prejudices that accompany the HIVIAIDS epidemic in Barbados and the criminalization of sex work and homosexuality. UGLAAB indicates that many male sex workers and gay men (for example beach boys) do no want to be associated with the organization due to stigma and discrimination. Involvement of UGLAAB in outreach programs for beach boys may therefore be counterproductive and other innovative strategies may have to be found to reach them. CARE Barbados has encountered the same problem as their outreach efforts to PLHIV have had little result in involving a significant number of PLHIV. Similarly, the main reason given is that PLHIV are fearful of being openly associated with the organization. 17. An important advance has been the engagement of FBOs and the private sector in the implementation of HIVIAIDS strategies. NHAC has managed to get FBOs from different religions engaged in prevention efforts, which has contributed to decrease social tension. Church leaders are considered a critical ally in the Barbadian context. Several national and regional events about HIVIAIDS were held with FBOs in 2007, which contributed to increased dialogue and understanding between religious groups. As the leader of the largest religious group, the Anglican Church, mentioned "AIDS has brought us together as nothing else has ". Some of these groups, including the Roman Catholic Church no longer publicly oppose condom use, as was the case in the past, and religious organizations seem to increasingly organize prevention efforts with and for their members. Led by organized trade unions and the International Labor Organization with support from the Barbados Employers' Confederation, approximately 11 private businesses now have workplace programs in place. Some other private businesses are currently volunteering staff through their corporate social responsibility programs or are exploring possibilities to finance the implementation of prevention programs in the workplace. 18. National HIVIAIDS Commission (NHAC). The lead institution for HIVIAIDS in Barbados is the NHAC. The Commission is responsible for overall coordination of the response to ensure complete coverage, without gaps and unnecessary duplication in the implementation of the National AIDS Plan. This Board is responsible for determining the strategic content and direction for implementing the NAP. The NHAC advises Government on HIV policy, advocates and promotes the active involvement of all sectors and organizations in implementing HIV management actions, creates partnerships to broaden the national response to HIV, mobilizes resources internationally and locally to support the efforts, and monitors the successful implementation of the Program. The composition of this board includes representation from PLHIV, youth, CSOs, private sector, medical doctors and nurses, the media, and UN and bilateral agencies. The structure of the NHAC is reflected in Chart 1. 19. Several ministries, CSOs such as UGLAAB, and various community and religious groups, work in partnership with the NHAC. No significant challenges or issues were found on decision-making lines, cooperation, coordination, and information flow. Within the NHAC, the Chairman is ultimately responsible for decision making on policy. NHAC partner organizations have the opportunity to be engaged in decision-making and are invited to consultations to provide inputs on strategic planning, policy documents and other relevant documents or issues. Communication between partners and the NHAC and vice versa is fluid and smooth. The NHAC7s Deputy Director has regular contact with the partners through email, phone and monthly coordination meetings. The monthly meetings are considered by partners as an excellent opportunity to get updated about the work being implemented by their colleagues, which allows for more efficient planning and coordination of activities. Staff members also regularly attend local community events, symposia or fora organized by other entities. The challenges that the NHAC currently faces are lack of physical office space for its team and insufficient staff in the areas of M&E and BCC (currently there is one staff member in M&E and the BCC officer responsible recently resigned). For the implementation of the project, NHAC plans to recruit additional staff members. However, it may take over 2 years to recruit new staff due to slow and cumbersome administrative procedures for the establishment of Service positions. In the meantime, local and foreign consultants would be hired to ensure adequate implementation of project activities. 20. Key Ministries. The ministries have the technical capacity to implement the National Strategic Plan for HIV Prevention and Control 2008-2013 through the designated HIV Coordinators in key Ministries -- Ministries of Education, Labour, Tourism, Home Affairs, Community Development and Culture, and Social Care, Constituency Empowerment and Urban Development. Each of the participating Ministries and their attendant agencies have established their own programs to promote behavior change, and contribute to the prevention of HIV transmission among the populations and target groups that they normally serve. Each ministry is responsible for the design, work plans, budgeting, procurement, implementation, and M&E of its own activities. The NHAC and MHNI provide technical assistance as needed. Each Ministry organizes its work through an HIV Core Group (Minister, Permanent Secretary, relevant technical officers, representatives of the Ministries7 constituencies, and a representative of PLHIV), which is managed by a designated full-time HIV Coordinator, who is responsible for consolidating the Ministry's HIV work plan, supervising its execution, and coordinating its efforts. Core groups hold quarterly meetings and the HIV coordinator reports quarterly to NHAC. For planning and monitoring purposes, the HIV Coordinator organizes the development of the work plan and budget covering the Ministry's expected contribution to the project, coordinates these plans with the Commission's Secretariat, and upon inclusion in the national work plan, assures its implementation. However, there are few dedicated posts of HIV Coordinators (5 have been established and 4 have been filled), and some Coordinators have other responsibilities in addition to their HIV-related tasks, and lack staff and resources. This is further compounded by bureaucratic obstacles, which restrict the full utilization of AIDS program funds. Under the project, HIV Coordinator positions would be fully resourced. Chard I Managemend Sfmc&re for &e Ebjecd p----- I Cabinet ! IFamihr. Youth Affairs. Sports andEnvironment I :National HWlAIDS Commission j I I I Secretariat 4 4 4 A ! i ! I ! I Ministry HIVjAIDS ! ! ! i C'oorduintion Uiiits ! ! ;-----+ 5 ! ! ! ! Health(inc1udingM) ! ! i ! ! i Education ! ! 1 Social Care ! ! i Labour ! ! i ! I i Tourism ! ! i Office of Atorney I ! i General ! I i Home Affairs I ! i ! ! ,gm*-mm-,ma-,o+- Government Jnformation ! ! Service ! I Other Minishes ! ! ! ! I I t ! I ! Key of Relationships ! Local NGOslCSOs ! 1.-.-.-.-.- 11.111.1IIIp. ! Co-ordination q-+ ! - I Contractual ,,,., Policy Advice - - - - m PolicyOversight --- Reporting 21. Ministry of Health, National Insurance and Social Security. The MHNI is responsible for the health of the population of Barbados, and is the executing agency for the delivery of health care. The Ministry has a steering role, and the Chief Medical Officer is the Ministry's technical head. In the MHNI, the HIVIAIDS program structure for prevention, care and support is led by the Chief Medical Officer and a Program Manager. The MHNI is the major provider of health care services in Barbados. There are 8 polyclinics and 2 satellite clinics throughout the country. Emergency, secondary and tertiary health care is provided at the Queen Elizabeth Hospital (QEH). This is the only public hospital in the island, and it is a teaching hospital affiliated with the University of West Indies School of Clinical Medicine and Research. Mental health services are provided at the QEH and the Psychiatric Hospital, with additional limited outpatient mental health services offered at the polyclinics. Residential services are offered for men with drug addiction at two privately managed drug rehabilitation centers that have a contractual arrangement with the Government. The private health sector is expanding, but focusing on highly profitable services such as cosmetic surgery and in-vitro fertilization. 22. A major challenge is the weak surveillance and M&E system. HIV testing carried out in public spaces during special events (World AIDS Day, University Campus) has been very successful. However, the downside is that capacity to provide counseling, analyze samples and follow up after results are given back does not keep up with the generated demand. In addition, HIV testing services are currently centralized, which means people may not get tested due to the fear of being stigmatized and discriminated. The program is working to decentralize HIV testing services. CSOs such as UGLAAB are planning to introduce testing services in their offices, making it more accessible for key groups. 23. Outpatient care for PLHIV is centralized in the LRU, which some patients may bypass as they do not want to be seen in a clinic associated with HIV. A studyI4describes the profile of the HIV-positive people who are hospitalized in the QEH. HIV-related hospitalizations constituted a significant proportion of all medical admissions in adults. Over the period of the study, there were 431 adult admissions to the medical wards of the QEH; 60% were in persons known to be HIV positive prior to the current admission. The majority of the patients were heterosexual males in the age group 31-50 years; 92% of patients were Afro-Caribbean, and their median age at the time of hospitalization was 41 years (range 16 - 71 years). Of the 352 adults who were admitted during the study period, and who had HIV infection as one of the discharge diagnosis, about 59% were males, 14% were MSM, 13% smoked marijuana and/or cocaine, and none were intravenous drug users (IDU); 15% of the patients had multiple admissions and accounted for 30% of all the admissions. l 4AIDS Research and Therapy 2007 4:4. Trends in the HIV related hospital admissions in the HAART era in Barbados 2004-2006. Available at http:/lwww.aidsrestherapy.com/contenti4il/4, Project Implementation Arrangements 24. To strengthen the Program's institutional capacity under the project, the NHAC would: A Continue to hold monthly meetings and maintain communication and information flows smooth and fluid, ensuring that follow-up is given to all views and needs expressed by partners and service providers and that these are channeled appropriately. A Continue to engage partners, especially CSOs in decision-making as this leads to more ownership and responsibility to upscale and strengthen prevention, care and support efforts. A Encourage dialogue between key populations at higher risk, CSOs, public institutions and other entities through the organization of forums, symposiums etc, and continue maintaining good relations with religious leaders as they are critical allies in the Barbadian context. A Provide ministries, CSOs and private sector with additional incentives to report to NHAC on their activities or results. A Establish a more integrated approach for prisoners through coordination between the Ministry of Home Affairs, MHNI and the National Council on Substance Abuse. A Further develop a Grant Mechanism for eligible CSOs, including an institutional strengthening program for organizations that work with hard-to-reach populations. 1UpscalesurveillancemechanismsintheMHNI,andM&EintheNHAC. A Decentralize treatment and healthcare for PLHIV. A Establish and fill non-established HIV Coordinator positions in participating Ministries. A Recruit additional staff for the implementation of the project. 25. Project Management. The daily work of coordinating the NAP and project is executed through the NHAC Secretariat. Coordinated by the Secretariat, significant aspects of the project would be implemented through the efforts of several Ministries. According to the Bank's project implementation arrangements classification criteria, the proposed project rates as integrated in each of the three key features: staffing composition and salary structure, operational responsibility, and reporting relationship. This unit has been established as a government department and has its own budget approved by the Parliament. It is managed by a Director, appointed at the level of a Department Head in the Public Service. In addition to the regular duties of a Department Head, the Director performs the following functions: Advises the Commission on the formulation of national programs and policies for HIV management. Assures the development of the overall HIVIAIDS prevention and control work programs and coordinates its implementation through various Ministries' implementation plans, CSOs and the private sector. Advises on budgetary allocations to be made to line Ministries for HIVIAIDS activities and reports on the financial performance of Ministries, CSOs and private sector in relation to HIVIAIDS. Assures the sound financial management of the project, and is responsible for project procurement. Monitors and evaluates the performance and results of actions implemented by Ministries and other stakeholders. 26. The Secretariat is staffed, inter alia, with a Deputy Director, an Assistant Director, Behavioral Change Communication Specialist, and a Senior Accountant responsible for: HIV prevention programs and programming, including guiding the design and implementation of education, training, and BCC; Policy, planning, research and M&E to maintain the focus on the activities on key target groups in a cost-effective manner; Financial management related firstly to the management of resources as these become available (resource allocation, accounting, disbursements); and secondly to monitor and advise on the uses and needs for financing Ministries' and CSOs activities; and Procurement management. 27. Public Sector CSO Grant System. The CSO community is represented on NHAC and - participates in strategic and policy management of the national Program. CSOs would be integrally involved in the implementation of the project. As part of the efforts to reach key populations at higher risk, as well as to build the capacity of civil society, grants would be awarded to CSOs. The project would further develop an existing Public Sector-CSO Grant System (PCSP) to expand the establishment of self-help and support groups by and for key populations at higher risk. This grant system is described in more detail in the Project Operational Manual. The CSO community in Barbados is nascent and can benefit greatly from institutional capacity building including volunteer recruitment and training, strategic planning, fundraising, and general management. The NHAC would also develop, as part of the grant model, an institutional strengthening program for CSOs that work with hard-to-reach populations. Organizations would be identified and selected according to previously established quality criteria. 28. When preparing their annual plans, the sector ministries involve the related civil society groups and private sector agencies in developing proposals, which once approved are implemented together. CSOs also submit proposals directly to the NHAC, which reviews and endorses some of these proposals for funding based on pre-determined criteria. Some Ministries would identify a role for CSO within their own areas of responsibility, and proactively solicit their participation. Such solicitation would be on the basis of well-defined tasks, with clear monitoring expectations, and an expected time frame and budget. Secondly, CSOs would be encouraged to develop proposals that may address themes that are not aligned with specific Ministry responsibilities, and submit these to the Secretariat directly for funding. 29. The granting system would develop the pre-existing system successfully established by the Division of Youth Affairs and the Community Development Department. The Secretariat, with guidance from the Ministry of Social Care, Constituency Empowerment and Urban Development and the Youth Department, adapted guidelines that were used to support community groups in the area of social development for Ministries wishing to engage non- governmental partners. These guidelines are included in the Project's Operational Manual. The process of soliciting and selecting CSOs would be jointly shared between the Ministry concerned and the Commission's Secretariat. The RFPs would be advertised via several different channels, including the Government Information Service, local media houses, and print and electronic media. In addition, the NHAC, Division of Youth Affairs, and Community Development Department are in direct contact with all CSOs, and will distribute the RFP through these networks. Applications would be accepted and reviewed on a rolling basis. The approval committee would be chaired by the NHAC Deputy Director and include the HIV Coordinator from the Ministry of Social Care, Constituency Empowerment and Urban Development, and a member of the NHAC Commission. Public Sector - CSO Grant System Who would be eligible to participate? All recognized Barbadian CSOs with HIVIAIDS and ST1programs, including FBOs. What types of subprojects would be financed? Sub-projects covering Epidemiological hotspots. Key populations at higher risk: sex workers, MSM, prisoners, drug users, unemployed, dependent women; and young vulnerable groups: out of school, unemployed youth. Voluntary Counseling and Testing. Prevention of ST1among key populations at higher risk. Condom distribution among key populations at higher risk and social marketing of condoms. Drug use prevention and treatment. BCC about drug use, HIVIAIDS and ST1for youth. Advocacy for PLHN and support of human rights. What would grants finance? Goods, consulting services, training, resources for sub-projects, and operating costs. Who would evaluate the subproject proposals? The NHAC would evaluate all proposals submitted for funding. 30. CSOs that are either invited or proposing to contribute to the project would meet criteria to establish their technical competence, managerial capacity, financial accountability, and credibility in the eyes of their constituencies. The completed applications would include content on proposed activities, objectives, targets, detailed budget, co-funding (if any), capacity (employees or volunteers and their skills), and prior experience of the organization. The grant proposals would also specify the task, accountabilities and monitorable deliverables and outcomes, and the time and resources proposed to perform the task. Part of the subproject would be to offer technical assistance to community groups and others in capacity building through institutional strengthening activities. This would have the effect of broadening the commitment to and ownership of the prevention and treatment agenda, as well as increasing its reach. To ensure that the funding is properly spent, each proposal would be judged against a list of quality criteria. Criteria for Selection of HIVIAIDS Subprojects Assessments Selection Criteria Value O/O Technical Clear and well-prepared time-based proposal Targets epidemiological hotspots and/or groups Consistent with AIDS Program policies Complements existing activities Includes M&E indicators Social Clearly identifies beneficiaries Involves key populations at higher risk Institutional Organization's previous experience 30 Proposed staff qualifications Cost Overall Quality 100 31. Grant sizes would range from US$5,000 to US$10,000 over 18 months with the possibility of a one year extension. Tasks assigned to these partners would normally not cost more than 20% of the cost of projects that the organization has typically managed. The standard contract has been modified to reflect the results-based nature of these grants. Recipients with successful programs would be eligible to apply again for more funding. Progress on the activities funded via these grants would be monitored both internally within the CSOs, as well as externally by the NHAC. Each organization that receives funding would be required to set up a three person monitoring committee. Grant recipients would report to the NHAC quarterly and at the end of the funding on: (i) number of activities conducted; (ii) number of people reached; and (iii) funding spent. Further receipt of grant funds would be dependent on an organization having submitted quarterly and end-grant reports in a timely manner. The NHAC would monitor the progress of activities via a monitoring committee composed of the NHAC Deputy Director and Assistant Director, the HIV Coordinator from the Ministry of Social Care, Constituency Empowerment and Urban Development, and a member of the Commission. The monitoring committee would provide feedback and arrange technical assistance as needed to the CSOs to facilitate the successful completion of the funded activities. HIVIAIDS Grant Indicators Satisfactory grant Funds granted and disbursed annually as Existing statistics scheme and subproject planned performance At least 75% of grantees express Project statistics satisfaction with-project grant mechanism (MIS) , At least 75% of beneficiaries of grants express satisfaction with the subprojects Subproject M&E BARBADOS: SECOND HIVIAIDS PROJECT Institutional Capacity vis-his key populat ons at higher risk of infection Sex workers Strengths Weakness o The MHNI in conjunction with the Ministry of oSex work is criminalized in Barbados. Tourism is implementing a project targeted at male oUGLAAB lacks institutional and organizational and female sex workers. capacity, staff and resources, and their quantitative o UGLAAB has formed an outreach program using outreach is limited. innovative mechanisms including visits to bars, nightclubs, private gay parties and organization of chat rooms aimed at SW, MSM and heterosexuals. o UGLAAB has direct access to SWs and can gain their confidence more easily than government institutions, which are often considered to lack confidentialitv. Opportunities Threats o The UK AIDS Alliance through a grant from USAID o There are several subgroups: beach boys and sex is financing the institutional and organizational workers who work in clubs; house sex workers; street strengthening of UGLAAB, the only CSO that sex workers; high-end tourism sex workers (escorts). represents SWs. Some of these are employed and are also involved in occasional SW. Escorts and house sex workers are the most difficult to identify and reach. o Sex workers who migrate between countries are of particular concern; short stays make it difficult to reach them and for those who test positive getting treatment may be an issue as access for foreigners is decided on a case by case basis. o University students, especially those from neighboring islands, engage in occasional SW to pay university fees. I Strengths Weakness MSM o UGLAAB represents this group. I o There is limited data on the number and practices of o UGLAAB has direct acce's to MSM and can gain their confidence more easily than government o UGLAAB lacks institutional and organizational institutions that are often considered to lack capacity, staff and resources, and their outreach is confidentiality. Opportunities Threats o The UK AIDS Alliance through a grant from Io Many men do not want to be associated with a USAID is financing the institutional and "gay'' organization, for example beach boys. Due to organizational strengthening of UGLAAB. stigma, discrimination and the illegal nature of anal o ILO in coordination with the Pan Caribbean sex between consenting adults, many MSM do not Partnership against HIVIAIDS (PANCAP) will start consider themselves gay or bisexual. Some of these an analysis of the legal framework in the region. men are married or in a relationship with a female partner. Prisoners Strengths Weakness o There is currently an HIVIAIDS Counselor working o No prevalence data or information about high risk in prison who regularly organizes workshops on a sexual practices of prisoners is currently available. range of issues, including HIVIAIDS for prisoners, o Prisoners are not seen as persons with human rights o The drug rehabilitation counselor (psychologist) but as people that should be punished and therefore appointed by the National Council on Substance have no say in anything that concerns them. Abuse also works with the prison population on o In Barbados, a high percentage of prisoners are HIVIAIDS issues. serving time due to criminal offenses that are drug related (for example drug trafficking) or drug induced crimes (burglary, trespassing e t ~ . ) ' ~ . Opportunities Threats o The NHAC is aware of the need to strengthen o The rates of HIV infection among inmates of coordination with the Ministry of Home Affairs and prisons and other detention centers in many NCSA in order to strengthen prevention and VCT countries are significantly higher than those of the efforts for prisoners and released prisoners. general population (UNAIDS'~). o UNAIDS global studies have shown that providing HIV prevention services in prisons increases knowledge of how to prevent sexual transmission and increases protective behaviors including after release. Substance Strengths Weakness users o The NCSA represents the substance abusers and is o Substance abusers are not organized as a group. carrying out research on the link between drug and o The NCSA feels disconnected from the NHAC. alcohol abuse and high risk sexual behavior in vulnerable groups and the general population. Opportunities Threats o One of the two private drug rehabilitation centers o Research carried out on drugs, HIVIAIDS and (Verdun House) is looking into the possibility to inmates in 2005 by the National Council on open an in house rehabilitation facility for female Substance Abuse suggest a strong relation between drug and alcohol addicts. drug use and high-risk sexual practices. o Due to the social perception that drug use is a male problem, addicted women are practically excluded, or exclude themselves from rehabilitation. PLHIV Strengths Weakness o PLHIV are represented by CARE Barbados, a Io There is no legislation that protects PLHIV from network of ~arbadiansinfected and affected by discrimination in ~arbados; HIV. o CARE has 20 affiliates only. o United Gays and Lesbians against AIDS Barbados o CARE and UGLAAB lack institutional and (UGLAAB) targets PLHIV through care and organizational capacity, staff and resources, and support activities (home and hospital visits etc.). their quantitative outreach is limited. o CARE has direct access to PLHlV and can gain their confidence more easily than public agencies that are often considered to lack confidentialitv. Opportunities Threats o The UK AIDS Alliance through a grant from Io PLHIV are often marginalized from the workplace USAID is financing the institutional and and from comprehensive health and supportive organizational strengthening of UGLAAB. services as a result of self-stigma or discrimination. o There are 11 HIVIAIDS workplace programs in place as a result of 3-year ILONSDOL project. o ILO in coordination with Pan Caribbean Partnership against HIVIAIDS (PANCAP) will start an analysis of the legal framework in the region. People with Strengths Weakness disabilities o These are represented by two umbrella Io People with disabilities have an increased risk of organizations --Barbados Council for the Disabled HIV infection as they are often victims of sexual and Barbados National Organizations for the abuse. Many victims are afraid to speak out due to Disabled (BARNOD) -- and other smaller groups discrimination and lack of understanding from the that are subsidized by Government. people surrounding them. o People with disabilities are underrepresented in national planning and strategies. This is partly due l 5National Council on Substance Abuse l 6http:llwww.unaid~.org/en/PolicyAndPracticeKeyPopulations~eoplePrisonl to coordination problems between the two umbrella organizations that seem to duplicate efforts. Opportunities Threats o An important step to address this group is the - . o The general public has misconceptions about people planned pilot planned Approach to Community with disabilities that may not be easily changed, Health (PATCH). such as that persons with disabilities ire not- o The NDP is scaling up its HIV Prevention sexually active, while on the other hand they are Programs. regarded as highly sexual. o Caretakers and parents often do not know how to handle the sexuality of a mentally challenged person. Youth Strengths Weakness o Youth are well represented on Community o There is a large gap between knowledge related to Committees and on the Youth Committee of the HIVIAIDS and practices in the age group 15-24 NHAC, which actively participates in planning and years old. implementation of activities for young people. o Youth that test negative may return to risky o The Youth Affairs Division has 32 Youth practices. Commissioners. o Even though the NHAC promotes condom use, o FBOs such as the Barbados Christian Council strategies focus in large part on abstinence for (BXC) and the Barbados Evangelical Association young people thereby ignoring the fact that young (BEA); and community organizations such as the people have their first sexual relation at a young age Parish Independence Committees, focus on young as shown by KAPB studies. people. The UWI HIVIAIDS Response Program has integrated HIVIAIDS in the curriculum of various courses and trained peer educators on campus. o VCT campaigns at University Campus have been very successful. Opportunities Threats o Behavior change amongst youth is one of the main o There is a need to pay particular attention to the components of the Strategic Plan. sexual practices of young students, especially those o UWIHARP is encouraging the establishment of from other islands who would be more likely to support groups for students who test negative. engage in high-risk sexual practices and sex work These groups could play a key role as peer than local students. educators. UWIHARP is seeking funding for research on sexual behavior of university students. Women Strengths Weakness o The National Organization of Women (NOW) is an o There are many subgroups that require tailor made, umbrella organiiation of women's groups. specific interventions. Women may be part of o The inclusion of a gender component in the several key populations at higher risk. Strategic Plan is seen as a positive step toward o Not enough attention is given to specific needs of targeting the feminization of the HIV epidemic women and the uneven gender power relationships observed in Barbados. that mav. for examole. influence condom use. Opportunities Threats o Women in general, and especially unemployed o In 2006, the male to female ratio of HIV cases was young single women, are specifically targeted by the 1:1, while women accounted for almost 40% of Bureau of Gender Affairs in coordination with the reported AIDS cases. The lower ratio in AIDS Welfare Department and Poverty Alleviation cases reflects the lag in the epidemic as it Bureau. transitioned from MSM activity driven to being driven by heterosexual intercourse". "NHAC 2007. The HIVIAIDS situation in Barbados 1984 to 2006. Annex 7: Financial Management and Disbursement Arrangements BARBADOS: SECOND HIVIAIDS PROJECT 1. A Financial Management Capacity Assessment (FMCA) was carried out during project preparation, with the following results: (i) The financial management arrangements for the project are characterized mainly by a decentralized approach in the implementation of the project's activities whereby most of the activities would be implemented by the following Ministries: (i) Family, Youth Affairs, Sports and Environment; (ii) Health, National Insurance and Social Security; (iii) Education and Human Resource Development; (iv) Social Care, Constituency Empowerment and Urban Development; (v) Tourism; (vi) Labor and Civil Service; (vi) Home Affairs; and (vii) Community Development and Culture. (ii) The overall financial management responsibility under the project would be coordinated and exercised by the NHAC's senior accountant, directly assisted by an accountant, an assistant accountant and a clerical officer. At the level of each Ministry, the Financial Management team would comprise a finance officer and the above-mentioned positions. The FM team would operate in conjunction with the coordinator of the HIVIAIDS Unit of the Ministry. (iii) Loan funds would be channeled through a segregated account of the Consolidated Fund (CF) (the Designated Account) , and would be used and managed by the Ministry of Finance in accordance with the GOB Financial Management and Audit Act 2007. Disbursements under the first component would be report- and results- based. Loan funds would be advanced to the Designated Account based on the projected work program and provided the implementation targets are achieved; and based on actual costs reported by the project. (iv) The Government recently updated the computerized public accounting system SMART STREAM, which is now fully operational in all Ministries. However, some FM team members are still being trained in its use, but training is expected to be completed by project effectiveness. Risk Assessment and Mitigation 2. The inherent risk of the operation is rated low because of the transparent fiduciary environment prevailing in Barbados. Barbados generally has high marks from Transparency International (Corruption Perception Index score of 6.9 in 2007) and the control risk is also rated low despite some areas of concern pertaining to the flow of funds. The rational behind this rating is as follows: (i) Entity risks. The rating is low. The principal project implementing agencies - the NHAC and the MHNI - are already knowledgeable about Bank fiduciary requirements. Some risks in the flow of fund arrangements related to the results-based disbursements were identified, but these are being satisfactorily mitigated by consulting and involving the implementing agencies in the flow of funds design and carefully choosing the parameters on which disbursements would be based, thus leading to a low residual risk. (ii) Project risks. The rating is low due to the existence of public financial procedures manuals including internal controls largely mitigating risk factors. (iii) Control risks. The control risk is low, and relates to the implementation of SMART STREAM, on which some staff members have not been fully trained. A training program is planned to make the FM Teams proficient in World Bank disbursement and-financial management requirements. Risk Residual Risk Mitigating Measures Condition of Risk Incorporated into Project Negotiations, Rating Design Board or Effectiveness Inherent Risk L . Country Level L , Entitv Level L . Project Level L Control Risk L .Budgeting L . Accounting L Appointment of FM staff completed in all Y I implementing Agencies . Internal L N Control . Funds Flow M Participating Ministries and the NHAC were 1 consulted. Performance-based disbursements could be a challenge initially .Financial L Y Reporting . Auditing L Y 3. Flow of Funds. The loan proceeds would be advanced into a segregated account of the Consolidated Fund (the Designated Account) in United States Dollars. A segregated account would facilitate the preparation of withdrawal applications, which require bank account reconciliation. At project effectiveness, two disbursements would be made (reimbursement and advance) to cover the six month period starting with the Government fiscal year on April 1, 2008. Subsequent disbursements would be made for eligible expenditures pertaining to project activities implemented by the NHAC, Ministries and other eligible agencies based on projections of expenditures and disbursement criteria stipulated below in the Disbursement section, and elaborated in the Disbursement Letter. The segregated account of the Consolidated Fund (the Designated Account) should be established by project Negotiations. Payments would be made for goods and services procured to finance Ministries' action plans, from the Designated Account for the Bank's portion of the expenditures. The funds to beneficiaries and mechanisms for disbursements, and the scaling up of successful subprojects, would be managed by the Accountant-General's Department in accordance with eligibility standards and implementation procedures as described in the Project Operations Manual. For each category of applicants, there would be clear eligibility criteria, thresholds for assistance, as well as requirements for contributions. A Flow-of-Funds is presented in Chart 2. 4. Staffing. The NHAC and Ministries would have financial management staff with the right mix of qualification and experience. The Commission's Secretariat has ample experience managing the first Barbados HIVIAIDS Project and meets Bank requirements with regard to financial management. The levels of FM staffing in the participating Ministries, except for the Ministry of Social Care, Constituency Empowerment and Urban Development, are adequate. Two additional FM staff should be appointed at the Ministry of Social Care, Constituency Empowerment and Urban ~ e v e l o ~ m eton tbring the FM team there up to standards. The ~ a n k recommends that staffing be in place by effectiveness. 5. Budgeting Process. A budget process exists that would be followed by all project implementing agencies. The fiscal year starts on April 1 of each year and ends on March 31 the following year. While there are no physical targets for budget activities, a budget review commission is held quarterly between the technical departments and the Ministry of Finance. Guidelines are provided to each ministry to meet their budget targets and avoid overruns. With respect to the proposed project, the budget allocations (estimates) for the project have already been made and the monitoring of expenditures under the project would follow the Government's guidelines. 6. Accounting Procedures. The project would use the existing Government accounting system, which has been installed in all Government agencies. The Accountant-General Department would be required to confirm the full integration of all participating Ministries into the public financial management and accounting system (SMART STREAM). NHAC would consolidate financial management information to produce the financial reports required by the Bank. The accounting system has been assessed td meet the minimum req;irements of the Bank and can produce reliable interim un-audited financial reports as required under the project. 7. Disbursement Arrangements. Disbursements under Component 1 of the Project would be report and results-based. Disbursements under Component 2 would be report-based. Under Component 1, agreement was reached on the results that would be attained in the three programs included in Component 1: National Program Coordination and Monitoring; Scaling up Prevention Efforts; and Diagnosis Treatment and Care. In addition, two program milestones would be tracked for disbursement purposes: (i) annual increase in the HIVAIDS Program budget from about US$9 million to US$11 million per year from 2008 to 2013; and (ii) at least 70% budget expenditures would have to be confirmed prior to disbursement of the loan funds for the following period. The Bank would disburse into a segregated account of the Consolidated Fund (the Designated Account) for a specific share of expenditures incurred under the Component 1 as indicated in the tables below. Project Loan Allocation Loan Allocation Financing Percent Million US $ Component 1 31,412,500 35% Component 2 3,500,000 79% Front-end-fee 87,500 Total 35,000,000 39% Component 1and 2: Government Expenditures and Loan Disbursements (US$)* Component 1 10,630,451 14,116,654 17,685,773 20,939,724 24,686,644 88,059,246 Component 2 926,715 890,715 682,715 804,715 1,080,215 4,385,075 Project Total Cost 1 1,557,166 15,007,369 18,368,488 21,744,439 25,766,859 92,444,321 Loan Component 1 3,720,658 4,940,829 6,190,021 7,328,903 8,640,325 30,820,736 Loan Component 2 732,105 703,665 539,345 635,725 853,370 3,464,210 Loan Contribution 4,452,763 5,644,494 6,729,366 7,964,628 9,493,695 34,284,946 * Base costs 8. Requests for replenishments would be accompanied by a summary report in the form of interim unaudited financial reports which were agreed at negotiations and included as an attachment to the Disbursement Letter. Disbursement applications would be submitted every semester (March and September of each year). Documentation of withdrawal applications utilizing interim unaudited financial reports used for financial reporting would include cash forecast for the next reporting period. The documentation of expenditures would be reconciled with information contained in Client Connection. 9. Loan disbursements under Component 2 would be report-based. The Commission's Secretariat would submit quarterly interim unaudited financial reports consistent with the agreed format and content within 45 days of the end of each reporting period. To support disbursement, the interim unaudited financial reports would be accompanied by the following additional information: Designated Account (DA) activity statement, DA bank statements, summary statement of the DA expenditures for contracts subject to prior review and a statement reconciling the category balances in the Commission Secretariat's books with those in Client Connection. Disbursements for Component 2 would be in US dollars. 10. Reports and Monitoring. The NHAC would prepare interim un-audited financial reports every semester during project implementation for Components 1 and 2. The content, reporting format and periodicity would be confirmed during Project Negotiations and would be documented in the Project Operations Manual. The periodic interim un-audited financial reports and annual project financial reports would cover all activities financed under the project regardless of the source of funding. The periodic progress reports would cover financial management, procurement and physical progress monitoring. 11. Internal Audit. Under the Financial Management and Audit Act (FMAA) 2007, the responsibility of the internal audit falls under the purview of the Accountant-General's Department with its functions clearly defined. Under the new FMAA, internal audit units would be established within the project implementing agencies. 12. External Audit. The segregated account of the Consolidated Fund (or Designated Account) ,through which the loan funds would be channeled, together with the project accounts would be subject to annual audit by the Auditor-General's Office in accordance with the Government regulations. The Designated Account would be held in the Central Bank and would be denominated in US Dollars. The financial statements for the entire project would be kept at the NHAC so that the main audit of the project accounts would be undertaken there. The audit of the project accounts could be sub-contracted to the private sector under terms of reference (TORS)acceptable to the Bank. 13. The following agreements were reached during Project Negotiations: (i) Establishment of the segregated account or Designated Account. (ii) The content, format and periodicity of the interim un-audited financial reports. (iii) Appointment of NHAC and Ministry of Social Care, Constituency Empowerment and Urban Development project financial staff. (iv) The terms of reference of the annual independent audits. 14. Financial Covenants. Bank's standard financial covenants apply to this project. They include the requirement to maintain adequate financial management systems so that the project is capable of preparing reliable periodic interim un-audited financial reports; and submit annual audit reports of the project's account statements not later than six months after the end of each fiscal year. 15. Supervision Plan. Project risk is low. This is due to the fact that: (a) Barbados has built strong financial management and procurement capabilities; (b) NHAC responsibility on the overall financial management has been shared by the Accountant-General's Department and the implementing agencies. The supervision of the NHAC and other implementing agencies would focus on: (i) number and qualifications of the staff working on the project, (ii) quality, reliability and timeliness of reports produced, (iii) the processing speed of administrative and financial matters, particularly payments processing. Bank supervision would also include government agencies and CSOs involved in project implementation, to evaluate how these entities manage and account for project resources. Given the above and the results based disbursements, the project requires intensive financial management supervision during the first year, which should be budgeted for. Supervision missions should be undertaken at least every four months with the first mission occurring within three months after credit effectiveness. The timeliness of the audit would be monitored closely to ensure that it covers all relevant aspects and provide enough confidence on the appropriate use of funds by recipients. Financial Management Action Plan I I I I Tasks Responsibility Appoint a Finance Officer for the NHAC. MFYSE August 1,2008 Appoint 2 FM staff in consultation with the Ministry of Social Care October 15, 2008 Bank. Establish Internal Audit Units within the NHAC and Participating August 1, 2008 Project Implementing Entities Ministries Prepare a Training Program for FM staff in NHAC and Participating Project Launch each implementing agency Ministries Annex 8: Procurement Arrangements BARBADOS: SECOND HIVIAIDS PROJECT A. General 1. Procurement for the proposed project would be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004, revised October 2006; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004, revised October 2006, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the loan, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan would be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. 2. Procurement of Works. No works are envisaged under the project. However, if works were envisaged under this project, the procurement would be done using the Bank's Standard Bidding Documents (SBD) for all ICB and National SBD agreed with or satisfactory to the Bank. 3. Procurement of Goods. Goods procured under this project would include drugs, laboratory equipment, pharmaceuticals, and small equipment. The procurement would be carried out following the Bank's SBD for all ICB and National SBD agreed with or satisfactory to the Bank. 4. Procurement of Services. Consulting services would be provided for HIVISTI Surveillance, and Behavior Surveillance Survey, Sex Workers Project, HIVIAIDS Impact Study, and IT Platform. Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. Procurement of non-consulting services is not envisaged under the project. 5. Operating Costs. The project would finance operating costs as it finances a percentage of the NAP. These may include NHAC expenditures related to human resources, training, conferences and meetings, and stipends for the Advisory Board; and MHNI expenditures related to prevention, diagnosis and treatment, and program management. 6. Others, Grants ranging from $5,000 to US$10,000 over 18 months would be awarded to CSOS, FBOs and private sector organizations working on HIVIAIDS prevention. 7. The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, are presented in the Project Operations Manual. B. Assessment of the agency's capacity to implement procurement 8. The NHAC would be the implementing agency and is staffed by a Director, a Deputy Director and appropriate technical, administrative and support staff. Procurement activities would be carried out by the MHNI's HIVIAIDS Program Management Unit, the Barbados Drug Service (BDS) and participating ministries, e.g., the Ministry of Education and Human Resource Development (MEHR). The procurement function in MHNI's HIVIAIDS Program Unit is staffed by a procurement officer, assisted by an executive officer and an administrative officer. MEHR has a line-item budget to support its individual HIVIAIDS activities and the Ministry's accounting and finance staff follow the Government's procurement procedures. These HIVIAIDS activities would fall under Component 1 and are expected to be below the prior review thresholds established by the Bank. As it was the case under the closed HIVIAIDS project, pharmaceuticals funded under the proposed project would be procured by BDS, which is staffed with a procurement officer. 9. The overall project risk for procurement is low. An assessment of the capacity of the implementing agencies to implement procurement actions for the project was carried out during project preparation. The assessment, which included the Central Purchasing Department (CPD), MHNI and MEHR reviewed the organizational structures for implementing the project and the interaction between the project's staff responsible for procurement and the agencies' relevant central units for administration and finance. The key issues and risks concerning procurement for implementation of the project have been identified and include MHNI's weak records management system. The corrective measures which have been agreed are that MHNI would proceed with the consultancy for improvement of its records management system, as many procurement activities under the new project, in particular under Component 1 would be subject to post review and strong records management would be important when carrying out procurement audits. C. Procurement Plan 10. The Borrower developed a procurement plan for project implementation, which provides the basis for the procurement methods. This plan was agreed between the Borrower and the Bank project team prior to Negotiations and would be available at NHAC and MHNI in Barbados. It would also be available in the project's database and in the Bank's external website. The procurement plan would be updated in agreement with the Bank annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. D. Frequency of Procurement Supervision 11. In addition to the prior review supervision to be carried out by the Bank, the capacity assessment of the implementing agency has recommended one supervision mission per year to visit the field to carry out post review of procurement actions. Under Component 1, due diligence to satisfy the Bank that the funds are used for the purposes intended would be carried out during supervision missions. In particular, the Bank would conduct an annual review of procurement activities subject to post review to ensure that procurement has been carried out in accordance with the Government's procurement procedures, which have been found to be acceptable to the Bank. As part of the annual post review, the Bank would verify that procurement capacity in the NHAC and line ministries remains adequate, and would offer capacity building activities as needed. E. Details of the Procurement Arrangements Involving International Competition 1. Goods, Works, and Non Consulting Services (a) List of contract packages to be procured following ICB and direct contracting: 1 2 3 4 5 6 7 8 9 Ref. Contract Estimated Method P-Q Domestic Review Expected Comments No. (Description) Cost Preference by Bank Bid- US$ (yestno) (Prior / Post) Opening Date 01 ARV Drugs 2,000,000 ICB N N Prior June 2008 (b) If envisaged, ICB contracts for works estimated to cost above US$3,000,000 equivalent per contract, ICB contracts for goods estimated to cost above US$250,000 equivalent per contract and all direct contracting would be subject to prior review by the Bank. 2. Consulting Services (a) List of consulting assignments with short-list of international firms. 1 2 3 4 5 6 7 Ref. No. Description of Estimated Selection Review Expected Comments Assignment Cost Method by Bank Proposals US$ (Prior / Submission Post) Date 01 Behavior 160,000 QCBS Prior June 2008 Surveillance Survey (b) Consultancy services (firms) estimated to cost above US$100,000 equivalent per contract and single source selection of consultants (firms) for assignments estimated to cost above US$50,000 equivalent would be subject to prior review by the Bank. (c) Short lists composed entirely of national consultants: Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. Barbados Second HIVIAIDS Project Thresholds for Procurement Methods and Prior Review (US$ thousands) Expenditure Contract Value Procurement Contracts Subject to Category (Threshold) Method Prior Review US$ thousands 1. Works 113,000 ~ICB l ~ l l 150-3,000 NCB None I50 I C B I A I I I <50 Shopping None Pharmaceuticals Direct Contracting First 3. Consulting I Services Firms QCBS, QBS, LCS, CQS, FBS I QCBS, QBS, LCS, CQS, TOR only (by TTL) FBS Individuals Comparison of 3 CVs in All (by TTL) accordance with Chapter V of the Guidelines ITOR only (by TTL) ICB =International CompetitiveBidding; NCB = National Competitive Bidding QCBS Quality-and Cost-Based Selection;QBS Quality-Based Selection; = = LCS = east-cost Selection;CQS = Selectionbased on ~onsultants'Qualifications; FBS =Selection under a Fixed Budget Annex 9: Project Economic and Financial Analysis BARBADOS: SECOND HIVIAIDS PROJECT 1. This annex presents the summary results of the cost-benefit analysis of the Barbados Second HIVIAIDS Project, based upon the project's costs and the expected, measurable economic benefits flowing from the successful implementation of the proposed project. Project benefits were analyzed in terms of lives saved, disease prevented or ameliorated, disability avoided or diminished, work absenteeism avoided, and health care costs saved. The project would yield a net present value of benefits, after investment and recurrent costs, of more than US$68 million, and produce an internal rate of return (IRR) above 32% over a 10-year period. Table 1. Estimated Costs and ~enefits" 5 vears 10 vears 1 NPV 1 -30.2 1 68.1 1 (US$ millions) IRR 32% Benefit1 1.O I Cost Ratio I I I Cost Benefit Analysis 2. The economic analysis of the project aimed at quantifying health gains and translate these into estimates of the direct benefits and indirect benefits. The present analysis uses several indicators of the expected savings to the health care system as proxies to measure the net direct economic benefits of the project. The analysis is based on sophisticated modeling techniques. Two scenarios were developed: (i) The "do nothing" case where the existing program is maintained and no new initiatives provide prevention and treatment to new cases identified; (ii) Strengthening of the existing programs for prevention, testing and counseling, and treatment for a higher effect on the reduction of the burden of the disease. 3. The analysis is based on the following assumptions: The risk of infection for SW and MSM who have unprotected sex with infected persons is 3% 19. Successful condom use during sex reduces the risk of infection to 0.5%. Another group at high-risk for infection is children born to HIV+ mothers. In Barbados, 0.9%of all mothers are HIV+. Epidemiologically, about 27% of babies born to infected mothers contract the disease through vertical transmission, but in Barbados this rate has been reduced to 2.5% with the use of AZT. l 8NPV Benefits equals direct and indirect benefits minus total project costs (in US$ millions); BenefitiCost equals total benefits divided by total costs; IRR was calculated based on net benefits over 10 years. l 9Satten GA, Mastro TD, Nopkesorn T, Sangkharomya S, Longini I. Int Conf AIDS. 1993 Jun 6-1 1; 9: 649, Centers for Disease Control, Atlanta Though the number of SW in Barbados is unknown, this analysis estimated that 25% of 2.24% of the female population 15-49 years old engage in sex work; and that SW have about 7 partners per week on average2'. People over the age of 15 represent approximately 71.4%of the population. Discount rate: 10% HIVIAIDS prevalence rate: 1.5% Cumulative AIDS cases 1984-2008:2,060~' Cumulative AIDS deaths 1984-2008: 1,24822 Cost (current ARV) per person per year (US$): 2,260.7 Cost (new ARV treatment) per person per year (US$): 5,249 Total cost (inpatient and outpatient) per person per year (US$): 7,509.7 Barbados population 2008 (estimate): 281,968 4. Direct Benefits. The direct benefits were estimated based on the effect on the health system of decreased morbidity. A cost study of inpatient and outpatient costs estimated the total cost per case at $7,509.7 per year. The total cost per case includes expenditures for pharmaceuticals, labor, infrastructure, overhead and other materials. The total direct cost savings were calculated by multiplying the annual treatment costs by the annual number of cases averted. The direct costs savings were then discounted at 10% to determine their present value. The direct cost savings would increase from US$34,000 in 2008 to approximately US$5.8 million in 2017. The net present value of the direct cost savings is estimated at US$9.5 million. This is the result of preventing nearly 2,500 cases of AIDS and of the corresponding savings in the health system. Table 2. Direct Benefits 2008 7,510 5 34,023 34,023 2009 7,510 16 119,178 108,343 2010 7,510 37 275,239 227,470 2011 7,510 70 525,054 394,481 2012 7,510 119 895,004 611,300 2013 7,510 188 1,415,543 878,941 2014 7,510 283 2,121,822 1,197,713 2015 7,510 407 3,054,417 1,567,399 2016 7310 567 4,260,176 1,987,404 2017 7,510 771 5,793,215 2,456,889 2,463 Total PV 9,463,963 Total 5 years 2,254,559 5. Indirect Benefits. The proposed project would result in substantial indirect benefits related to the cost savings associated with decreased morbidity and mortality and the impact on 20Horizontal Technical Cooperation Group, 2007 - Guyana. "UNGASSCountry Report2008 22Idem the quality of life, as well as the positive economic benefits associated with lower costs of illness and death of working age adults. To estimate the present value of the indirect cost of AIDS, it was assumed that each case avoided would live 10 years more on average, and this productivity savings were valued using the current GDP per capita in Barbados of US$9,80023as a proxy for the marginal product of labor, or the value of each productive year of life lost. The indirect benefits would increase from US$0.5 million in 2008 to US$75.6 million in the year 2017. The total indirect costs prevented over a 10-year period would total US$241 million, which represents a NPV of nearly US$124 million. Additional indirect cost savings can be expected as a result of reductions in the incidence of sexually transmitted infections (STI), which were not be calculated in the present analysis. Table 3. Indirect Benefits 2008 5 45 443,996 443,996 2009 16 159 1,555,238 1,413,853 2010 37 367 3,591,801 2,968,431 2011 70 699 6,851,829 5,147,881 2012 119 1,192 11,679,588 7,977,316 2013 188 1,885 18,472,492 11,469,964 2014 283 2,825 27,689,256 15,629,863 2015 407 4,067 39,859,388 20,454,168 2016 567 5,673 55,594,256 25,935,131 2017 771 7,714 75,600,031 32,061,793 Total 2,463 24,626 241,337,876 123,502,396 6. Investment Costs. The third step in the cost benefit analysis is the estimation of the present value of the investment and recurrent costs of the proposed project. This information is critical to determine overall net benefit. The present value of the proposed investment and recurrent costs was estimated at US$49 million over a five-year period. While the investment costs are clearly identified in the project costs, the recurrent costs are estimated at 10% of the total investment costs during the 5 years of the project. Annual investment and recurrent costs are shown in table below on the estimated costs and benefits of the project. 23Barbados Economic and Social Report 2006. Table 4. Investment Costs 2008 1 1,875,000 I 1,875,000 7,000,000 7,000,000 18,875,000 18,875,000 2009 11,875,000 10,795,455 7,000,000 6,363,636 18,875,000 17,159,091 2010 11,875,000 9,814,050 7,000,000 5,785,124 18,875,000 15,599,174 201 1 11,875,000 8,921,863 7,000,000 5,259,204 18,875,000 14,181,067 2012 11,875,000 8,110,785 7,000,000 4,781,094 18,875,000 12,891,879 2013 5,937,500 3,686,720 5,937,500 3,686,720 20 14 5,937,500 3,351,564 5,937,500 3,351,564 2015 5,937,500 3,046,876 5,937,500 3,046,876 20 16 5,937,500 2,769,888 5,937,500 2,769,888 2017 5,937,500 2,s 18,080 5,937,500 2,518,080 Total 89,062,500 64,890,280 35,000,000 29,189,058 124,062,500 94,079,338 7. Cost Benefit Analysis. The overall investment in HIVIAIDS prevention and treatment was determined in the context of the relative cost effectiveness of the proposed project vis-a-vis alternative investments. According to conservative estimates, the stream of benefits yields a net present value in excess of US$68 million with an internal rate of return of over 32%. The stream of benefits and costs takes into account the recurrent costs of maintaining the programs that would produce the savings. The table below displays the summary results of the quantitative returns of the project. Table 5. Cost-Benefit Analysis 2008 11,875,000 2009 11,875,000 2010 11,875,000 2011 11,875,000 2012 11,875,000 2013 5,937,500 2014 5,937,500 2015 5,937,500 2016 5,937,500 2017 5,937,500 Total 89,062,500 NPV (10% discount rate) 68,076,079 1 IRR 32% Financial Analysis 8. In 2006, total health care spending in Barbados was approximately US$350.6 million, or 6.5% of GDP, with health spending of US$1,280 per capita. The proposed project spending is roughly 2.5% of the amount spent by the MHNI annually, or nearly US$8.4 million. Table 6. Health Care Spending in Barbados Expenditure category US% Gross Domestic Product (GDP) (Millions US$) 5,383.7 National Health Sector 2006/2007 (Millions US$) 350.6 Project (Millions $US) 8.4 Public health spending per capita ($US) 1,279.6 Project spending per capita ($US) 30.7 9. The project would account for US$ 9.4 million per year in recurrent costs, which corresponds to a maximum of 2% of current national health sector expenditure, a figure that is entirely manageable in the context of stable economic indicators and fiscal expenditures sustainability. This analysis did not consider private sector spending, as it was assumed that the public sector will continue to be responsible for the majority of the spending on HIVIAIDS given the public goods nature of expenditures. The assumptions for this analysis include annual spending increases equal to the projected growth of GDP; and public health spending would continue to account for approximately 6.5% of GDP over the next 10 years. Table 7. Projected AIDS Program Allocations and Expenditures 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Gross Domestic Product (GDP) 5,823.0 6,055.9 6,298.2 6,550.1 6,812.1 7,084.6 7,368.0 7,662.7 7,969.2 8,288.0 National Health Sector 200612007 (US$M) 379 394 410 427 444 46 1 480 499 519 540 Project (USSM) 9.1 9.5 9.8 10.2 10.6 11.1 11.5 12.0 12.5 13.0 National Health Sector Spending as a % of GDP 6.5% 6.5% 6.5% 6.5% 6.5% 6.5% 6.5% 6.5% 6.5% 6.5% Project as a % of NHS spending 2.4% 2.4% 2.4% 2.4% 2.4% 2.4% 2.4% 2.4% 2.4% 2.4% National Health Sector Spending Per Capita (US$) 1.384.0 1,439.3 1,496.9 1,556.8 1,619.1 1,683.8 1,75 1.2 1.821.2 1,894.1 1.969.8 Project Spending Per Capita (US%) 33.2 34.5 35.9 37.4 38.9 40.4 42.0 43.7 45.5 47.3 Loan (US$) 7.0 7.0 7.0 7.0 7.0 Government Project Costs (us$) 11.9 11.9 11.9 11.9 11.9 9.4 9.4 9.4 9.4 9.4 Total Project Costs (US$) 18.9 18.9 18.9 18.9 18.9 9.4 9.4 9.4 9.4 9.4 Recurrent expenditures (US$) 11.9 11.9 11.9 11.9 11.9 9.4 9.4 9.4 9.4 9.4 Total project costs as a % of National Health Sector expenditures 5.0% 4.8% 4.6% 4.4% 4.3% 2.0% 2.0% 1.9% 1.8% 1.7% Loan costs as a % of National Health Sector expenditures 1.8% 1.8% 1.7% 1.6% 1.6% Recurrent exoenditures as a % of ~ationaiHealth Sector Expenditures 3.1% 3.0% 2.9% 2.8% 2.7% 2.0% 2.0% 1.9% 1.8% 1.7% 10. Fiscal Impact. The analysis showed that the Government has a great opportunity to fulfill the needs of key populations at higher risk without compromising the fiscal stability of the country. Estimates of the fiscal impact were based on a model developed to evaluate the expected fiscal expenditures and revenues that are projected as a result of the project. The following assumptions were used for the model: a. Estimates of growth rates of main categories of analysis were based on official figures from government operations from 2002 to 2007. b. Growth rates for main categories of revenues and expenditures were used to project fiscal behavior for the period when the project would be implemented and the government would make payments. c. The category amortization expenditures was used from 2016 to 2030 for repayment of the loan (interest and capital). d. Tax collection at the average growth rate estimated from 2002 to 2006. One of the benefits of the project is a total of 269 lives saved. Those people would contribute additional tax payments starting in 2008. e. Loan disbursements and advances were estimated according to expected disbursements in the 2008-2013 period. f. GDP grows at a rate of 3.9%. Table 8. Projected Fiscal Impact (US$ million) Category 2008/2009 200912010 2010/2011 201112012 2012/2013 201312014 201412015 2030/2031 Current Expenditure 1,384.8 1,480.1 1,582.0 1,690.8 1,807.1 1,931.5 2,064.4 6,060.3 Amortization 180.1 192.5 205.8 220.0 235.1 25 1.3 268.5 852.9 Other 1,204.7 1,287.6 1,376.2 1,470.9 1,572.1 1,680.2 1,795.8 5,207.4 Current Revenue 1,349.3 1,455.9 1.571.6 1,697.0 1,833.0 1,973.4 2,133.1 7.514.5 Tax 1,315.5 1,423.8 1,541.0 1,667.9 1,805.3 1,954.0 2.1 15.0 7,508.1 Non-Tax 26.9 25.2 23.6 22.1 20.7 19.4 18.2 6.4 Loans and Advances 7.0 7.0 7.0 7.0 7.0 0.0 0.0 0.0 Current Surplus/ Deficit -35.5 -24.2 -10.4 6.2 25.8 41.9 68.8 1,454.2 Capital Expenditure and Net Lending 93.4 85.0 77.4 70.5 64.2 58.4 53.2 12.0 Capital Expenditure 92.9 84.6 77.1 70.2 64.0 58.3 53.1 12.0 Lending 0.5 0.4 0.3 0.2 0.2 0.1 0.1 0.0 Total Expenditure 1,478.2 1,565.1 1,659.3 1.761.3 1,871.3 1,989.9 2,l 17.6 6,072.3 Total Financing Requirements1 Overall Fiscal Deficit -128.9 - 109.2 -87.8 -64.3 -38.3 -16.5 15.6 1,442.3 Overall Deficit as % GDP -1.8% -1.4% -1.1% -0.8% -0.5% -0.2% 0.2% 8.5% Source: Estimates based on data from the Ministry of Finance of Barbados 11. Table 8 displays the main results of the fiscal impact analysis. The results are projected to 2030 to accurately reflect the full repayment of the loan. As the table shows, the project would not raise a fiscal issue in Barbados. The trend for the overall deficit is to decrease over the years, and this would not change after disbursements and repayments of the loan take place. The projections show that after year 7 of the project, the fiscal deficit would disappear and become a surplus. This situation would be due to the increasing trend on tax collection and the flow of benefits that the project would cause. Sensitivity Analysis 12. The analysis assessed to what extent project benefits would be affected by risks leading to: (i) delays in implementation; or (ii) direct reduction in benefits. Lower benefits could result from either the selection of poor-quality interventions and subprojects, resulting in lesser cost- effectiveness and fewer cases averted, or from implementation difficulties, which would minimize expected benefits. Both of the above alternatives were considered assuming a 30 and 50% reduction in overall benefits. Assuming total savings were 30% lower than expected, the net present value of the savings over a 10 year period would be reduced to nearly US$28 million, with a rate of return of about 21%; while in the extreme case of 50% fewer benefits than expected, the project would remain almost unsustainable. The table below shows that a 3 year delay in project implementation would have a profound effect on the overall returns to the project. In case of a 2 year delay, project benefits would be reduced by about US$59.7 million and the rate of return would be reduced from 32 to 16%. Table 9. Sensitivity Analysis Base Case 68.1 31.9% Benefits reductions: 30% reduction in benefits 28.2 20.6% Annex 10: Safeguard Policy Issues BARBADOS: SECOND HIVIAIDS PROJECT 1. This is a follow-on project, which would finance activities for prevention and care and institutional strengthening. No new construction and/or rehabilitation of facilities is anticipated. While these activities would result in increases in health care waste, it has been assessed that the health care waste management system, which implementation started under the first project, would be capable of its proper disposal. Considering this assessment, it was only necessary to update the existing environmental assessment in relation to ongoing health care waste management activities. In order to ascertain the proper disposal of health care waste by health care providers supported by this project, supervision would include monitoring activities including indicators to this effect. 2. A number of activities are anticipated in the continued implementation of the Health Care Biomedical Waste Management system. These activities include but are not limited to: 1) implementing a rigorous manifest system (first in the QEH and subsequently across the country); 2) establishing a capacity building program which is continuous (accommodate new staff and introduce new knowledge on HCWM to current staff); 3) preparing a practical manual with national guidelines on HCWM; 4) holding a stakeholder forum on HCWM (include representatives from the entire chain of the health care waste stream - from doctors to janitors); 5) installing the incinerator; and 6) enforcing health care waste separation. These activities would provide monitorable results, which would contribute to an improved health care waste management system in Barbados. Annex 11: Project Preparation and Supervision BARBADOS: SECOND HIVIAIDS PROJECT Planned Actual PCN review 10/1612007 1011812007 Initial PID to PIC 11/3012007 12/12/2007 Initial ISDS to PIC 11/30/2007 1211212007 Appraisal 02/28/2008 Negotiations 0311912008 06/24/2008 BoardiRVP approval 08/07/2008 Planned date of effectiveness 09101/I2008 Planned date of mid-term review 03101/2011 03/01/2011 Planned closing date 1 1/29/2013 11/29/2013 Key institutions responsible for preparation of the project National HIVIAIDS Commission Ministry of Health, National Insurance and Dr. Carol Jacobs, Chair Social security HIVIAIDS Program - Dr. Alies Jordan, Director Dr. Anton Best, Senior Medical Officer of Health 4nd Floor East, Warrens Office Complex (CD) Warrens, St. Michael BB 12001 BARBADOS Ministry of Health, Jemmotts Lane, Tel(246)-310-1008; Fax (246)-421-8499 St. Michael, BB 1 1 156 BARBADOS Email: ajordanahiv-aids.gov.bb Tel (246) 467-9439140; (246) 437-8215/25 (at the LRU) Fax (246) 429-5953 Email: antonbest@caribsurf.com Project Preparation Team Members ROLE GOB IBRD Team Leader Alies Jordan (NHAC) Joana Godinho PLHIV Consultant Patricia Phillips (CARE B'dos) M&E Nicole Drakes (NHAC) Marcelo Castrillo Carolyn Estwick (MHNI) Data Analyst Shaawna Crichlow (MHNI) PWAIDS Specialist Anton Best (MHNI) Katherine Tulenko Nicholas Adomakoh (MHNI) Environmental Sp. Ricardo Marshall (MHNI) Gunars Platais Dave Thorne (MHNI) Operations Javier Jahnsen Procurement Specialist Esther Williams (MHNI) Judith C. Morroy Horace Williams (MHNI) Financial Mgmt Claudia Clarke (NHAC) Emmanuel N. Njomo Specialist Francina Springer (MHNI) Administration Rhonda Greenidge (NHAC) Maria Lourdes Noel Daphne Kellman (MHNI) Lawyer Representative from Solicitor-General's Office Rolande Simone Pryce Michael Sabazan (NHAC) Economist Dale Foster (NHAC) James Cercone Sarah Adomakoh (Consultant) Rodrigo Briceno Social Scientist Marilyn Sealy (NHAC) Noortje Denkers Library Research Claire Guimbert Bank funds expended to date on project preparation: 1. Bank resources: US$130,000 2. Trust funds: 3. Total: US$136,990.80 Estimated Approval and Supervision costs: US$240,000 Remaining costs to approval: US$10,000 Estimated annual supervision cost: US$90,000 (including fixed and variable costs) Annex 12: Documents in the Project File BARBADOS: SECOND HIVIAIDS PROJECT Government of Barbados. National Strategic Plan for HIV Prevention and Control, 2008- 1013. Bridgetown. MHNI 2008. HIV Surveillance Report January-June 2007. MHNI: Bridgetown. National HIVIAIDS Commission 2008. Barbados National HIV Policy: A Framework for Action. World Bank 2001. Financial and Economic Analyses. World Bank 2001. Financial Management Capacity Assessment. World Bank 2001. Procurement Capacity Assessment. World Bank 2001. Project Concept Note. World Bank 2001. Social and Institutional Assessments World Bank 2008. Updated Environmental Assessment. Annex 13: Statement of Loans and Credits BARBADOS: SECOND HIVIAIDS PROJECT Difference between expected and actual Original Amount in US$ Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd PO75220 2001 BARBADOS - CARIBBEAN HIVIAIDS I 15.15 0.00 0.00 0.00 0.00 1.22 1.22 0 00 Total: 15.15 0.00 0.00 0.00 0.00 1.22 1.22 0.00 BARBADOS STATEMENT OF IFC's Held and Disbursed Portfolio In Millions of US Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. Total portfolio: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Approvals Pending Commitment FY Approval Company Loan Equity Quasi Part~c. Total pending commitment: 0.00 0.00 0.00 0.00 Annex 14: Country at a Glance BARBADOS: SECOND HIVIAIDS PROJECT Barbados at a qlance siZM)7 Key Davelop~~~nt Indicators 12006) Pow olton mid-yew(milrasl Surface ores i'housandso hvi Poo?lla'ton ~ r w i hlahi UNOI' pwu~atim,% d 10% pop~~atimi Gtll *'a3 ileW00 LS9j 011mris 37 52% GNI ~r coplta Qt'ns n'ethod -551 ?t' 46' GtJl aer capm ~PPPlrtwrntwna 5 ?470' GDP g m m 1%) GDP w csp~tagrmth i%) Poverty heedcount ram at 51 a day rPPP % Poverty headcountmdoat 52 a day IPPP, %' LifetxpeCtancy ai bm{para) Infantmwtailly (per 1,000 live bKmsj Chf d mahrutmon(%or chrldrm under 51 &duttItteracy,n~slet% of age5 15 and order1 Grow pnnuty enrollnEnt feme 1% of age jmup' L C C ~'oarS .W,OIEC ~ *ate( SOLICI Z of POD., anon LCCOP)'a r-pr?.ea wntsteol t3c ,:es % af WDJBINO 0Barbl2cr Ungh Income Net Aid Flows rUS6 mtii*oos Net ODA an0 off%c!oaa Groarh of GDP and GOP per cnplta 1%) V p 3 oo~oncrr~n 2x5 i Wlrlted K-m V~i~ted SBtet Canada Long-Term Economic Trends n s oc m Cunwmer ances jannbal "A cbanpei GDP implcit dsflstor (annbolX changer -OD' G D P per cap,^ 4grlcutture Industry Manutacrur~ng SdPIICeS tiweehaid fiml comumptlonexpextfiurc Genera$wvl flna eonsumptm3exwdlture Gross cepm fwmathon E x W s ofgo&s and semcea Impartsof goodsarad sewjces Gmas wvkngs Note Flgurw In dalss are fcr year9 omsr than thou, sprc~fied 2OOE dam are ofbiinnnt?ry mdlcntoadata are not DvaIlaDle a 4rd data are for 305 Deveomen! Ecmonucs 3arelopnimt Deta Group iOECDGi Page 2 of 2 Barbados Balarlce of Payn~etlZsand Trade BOO 2006 Governancerndlcalors, 2000 and 2006 rUS5 rnshunsj T&?I Ilerchai>Olseexpcdts (fob Total nwrchardise miports (cifl '/>Ice 3rd aowuntab nl Net Ircrde 10 gooas and seivsces Current accourt balance asa%cfGDP Coneol d conptton Reserves, mclud~nggold 473 6?& 0 Z! K 75 tm 2006 Ccunnyr penelhe rsnk O-IOCI Central Government Finance .?Coo I@?UYaWS lMifW '*WZ 1% oB GDP) Revunw Spua Kauinm-Kraay-htasl-JUI @aridPm Tax revenue Expense Tedrnology and Infrastrt~ctvre 2000 2005 Cash surplus/defc~t Pavedroads ,% OFiota \ Hlghesrmargma,tax rate I%, F~xedlire and mub le ohare lndvidual suascr~bers(per 1 OUC' peosde C.orporate Hlgh techno cq) exports (% cqf nmanufacture.: erwnsl External Debt and Resoilrce Flows (US%mrrDoosl T&l debt outstanding&nd disbursed Ogncultumi land 1% of land area: 44 M Total debt service Forestarea (% of landarea) 4 7 4 7 Debt relsef (HIPC,MDRI) Natron8llyprotectedareas (*h of landarea 0 0 T&l debt (% of GDP) 215 214 Fnshweter resourcesper cap& (cu nletersi 37 1 Total debt serv8ce (% OfcmWtsi 4 1 4 7 Freshwaterwthdrawal 1% of tr*tmai renoraces 90 0 Fweapndlrect ln'u'estment(net ln0ows1 19 62 C02 maslans per capb !mt 1 Portfol~oequaty !net mflows; 0 -5 GDP per unit d energy use 121330PPP % per kgof 04 equlvalmt! Composittot~of total external debt, 2005 Energy use ger capita ikg of oi equrvalent; World Bank Group portfolio 2000 2008 IBRD Total debt Wtotandlw and dlslwrwd Dobursenients Pnnclpalrepaynwts Interestpaynlerits U9S n lliona IDA Totaldebt wtotandlng and disbursed D&urseme~?ts Private Sector Developnient 2000 2006 Total debt WMCC T~nwrequrredtostart a buslnese (dmys - 1FC (fisc~lyeorl Cost lostart a tnrsmess :%of OW1per capital Total drmursed and wtstandmfqporffollo 1 0 r~nlerequlredto regrsterpropefrj !day8 -- of rvtuch IFC maccaunl 1 0 D~sbursanients IFC own account tor 0 0 Rankedas a major constraint to bwrness Pmorw wiles. prepaymentsand i% managerssuweyedwhoagrea of repaymentsfar IFC own accounl 0 0 n a n a MlGA Gross exposwe S4& manet caprtaltzationf% ot GDP) 65.4 178 4 New guarantees Bank caoltalto asset rabo(%I Note Figures~nbtaltcsare for years olherthen those s p e o f ~?OD6 data are orel~mrnary Y128.637 mdlcatesdata are not svallabie - od~cateaderdation 19not app(lcaWe Devebpment Economics. Development Data Group (DECDG) IBRD 33369 59°45' 59°30' BARBADOS SELECTED CITIES AND TOWNS NATIONAL CAPITAL RIVERS Archer'sBay North Point MAIN ROADS 13°30' 13°30' PARISH BOUNDARIES Crab Hill Spring Hall Harrison Point S T. L U C Y This map was produced by the Map Design Unit of The World Bank. Gay'sCove The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. Portland SixMen's Bay Greenland Speightstown S T. P E T E R S T. A N D R E W AT L A N T I C Bruce Vale O C E A N Westmoreland Mount Hillaby Bathsheba (336 m) S T. J A M E S Hillaby S T. J O S E P H CongorBay Holetown S T. T H O M A S Blackmans Coach Consett Bay Hill Bennetts S T. J O H N 13°15' Ragged Point 13°15' Thicket Payne'sBay Belair Prospect S T. G E O R G E Warrens Freshwater S T. P H I L I P Bay S T. M I C H A E L Bulkely Workhall Six Cross Turnpike ur Roads Crane Bay Crane BRIDGETOWN C H R I S T CarlisleBay C H U R C H Sargeant Needhams Point Saint Oistins Lawrence OistinsBay Long Bay South Point BARBADOS AT L A N T I C O C E A N 13°00' 13°00' 0 1 2 3 Kilometers 0 1 2 3 Miles 59°45' 59°30' DECEMBER 2004