III. Implementation.

A. Partnership Arrangements

28. The Jamaica NSP is funded by the Government and a number of external agencies. The GFATM and the Bank provide the most significant levels of funding. Other partners, especially the United Nations Agencies and bilateral donors also provide technical support and some funding for specific interventions. All the agencies provide their funding through the NHP. The project will not have specific co-financing from any other partner. The expanded HIV/AIDS theme group provides a regular forum for coordination. In addition, partnerships have been strengthened around key thematic areas. Section IB. above describes how the two main external financing sources (Bank and GFATM) will complement each other as well as the contributions being made by the other bilateral and multilateral development partners. The project design supports the strengthening of partnership between the key stakeholders: the MOH, non-health line ministries, civil society organizations, the private sector, and external funding agencies. Partnerships with the GFATM, bilateral donors and UN agencies will include: implementation based on one annual work plan of the NHP; regular information exchange/updates, harmonized technical assistance on specific thematic areas e.g. education and coordinated implementation reviews/supervision missions whenever possible, though this may present logistical challenges.

B. Institutional and Implementation Arrangements

29. Institutional Arrangements. The following institutions will be key to the successful implementation of the project: The Council for Health and Social Development (COHSOD) reporting to the Cabinet will be responsible for setting policy, overall coordination, and monitoring and evaluating the performance of the national HIV/AIDS program. The Ministry of Health (MOH) will be the Executing Agency through The Project Coordination Unit (PCU) of the National HIV/STI Program. The PCU will coordinate activities and provide technical and fiduciary support to the implementing entities. Execution of project activities will be handled by divisions of the MOH, the four Regional Health Authorities, four non-health line ministries, CSOs and the private sector.

30. Implementation Arrangements. The project will be coordinated by the PCU within the National HIV/STI Program (NHP) of MOH. The PCU consists of an experienced team of professionals that have coordinated the technical and fiduciary activities of the first HIV/AIDS project. The staff has been trained in World Bank procedures, has performed satisfactorily under the first project and is expected to continue performing well under the follow on project. The Unit is headed by a Senior Medical Officer, who manages a core staff that includes the coordinators for the project components and subcomponents, an M&E officer, a financial manager and a procurement manager and their supporting administrative staff. The fiduciary unit also manages the grant funds from the GFATM. Most of the PCU staff has been paid out of donor funds, including the first World Bank loan. The process to convert some of these positions into permanent establishment posts has been initiated with the intended outcome of creating an institutionalized and sustainable core group of professionals to coordinate and support the implementation of the national HIV/AIDS Program.

31. Implementing Entities. Four types of entities will implement project activities: The MOH through its centralized departments and the four decentralized RHAs; Four key non-health line ministries: Education, Tourism, Entertainment and Culture, Labour and Social Security, and National Security, Civil Society entities including the NGO sector with Community Based Organizations (CBOs), churches and other Faith Based Organizations (FBOs); and the private sector through the Jamaica Business Council, private companies and the media.

32. The implementation strategy is detailed in the Project Operations Manual and is summarized in Annex 6. Implementation of project activities will be preceded by the elaboration of annual work plans for the public sector entities and by proposals for the civil society entities. The Government Ministries will prepare annual work plans which are aligned with the Government annual budgets. CSOs will be funded through a demand-driven process based on the system that has been put in place under the ongoing Bank-financed project. A consolidated annual work plan will be prepared by the PCU and reflected in the MOH's annual budget for submission to the Ministry of Finance and the Public Service (MOFPS). The work plan will include the MOH's own work plan, plans of other Line Ministries and a budget line for subprojects of civil society groups and the private sector. Annex 6 contains a fuller description of the institutional and implementation arrangements including eligibility criteria, selection procedures and funding mechanisms for civil society and the private sector. The Project Operations Manual will contain a detailed description of implementation strategies for line ministries, CSOs and the private sector.

33. Financial Management and Procurement Arrangements. The PCU financed under the first HIV/AIDS project is familiar with the Bank procedures. It will be responsible for financial management and procurement. Latest financial management and procurement procedures will be applied now that there is more capacity within the PCU and within the public administration in general. Detailed guidelines on the financial and procurement management including accountability and transparency provisions are contained in Annexes 7 and 8.

C. Monitoring and Evaluation of Outcomes/Results

34. A full time M&E officer with a supporting staff within the PCU will be responsible for: (i) maintaining the overall M&E plan including manuals, implementation procedures, tools, data flowcharts and a budget; (ii) strengthening the monitoring systems to ensure sound output and process monitoring; and (iii) validating data by random sampling recording and aggregating processes and by examining large variations in historical trends. Evaluation of the outcome and the impact of project performance on achieving the development objectives will be done through periodic behavioral surveys of high-risk groups, household surveys of the general population, workplace surveys of a random sample of companies, and health facility surveys and specific research. Baseline markers and targets will be established for measuring progress. Outcome/impact indicators are listed in Annex 3. Most of the indicators are drawn from the country's national M&E plan and are the basis for the country's regular reporting to UNGASS. Monitoring program performance and productivity of service providers will be done on an ongoing basis using management reporting mechanisms. Service statistics will be collected regularly at the points of service and reported on a monthly basis to document progress being made and to show variations that occur. Input and process indicators are listed in Annex 3.

D. Sustainability

35. The following factors will contribute to program sustainability after project completion:

(a) An enabling policy and legal environment with strong political support and leadership for dealing with HIV/AIDS;

(b) Government's willingness and ability to sustain public awareness of HIV/AIDS issues;

(c) Implementation sustainability: development of broad ownership and a strong institutional coordination mechanism for the expanded response to the pandemic and the involvement of other key stakeholders (line ministries, NGOs, FBOs, local communities, etc.);

(d) Converting some of the PCU positions into permanent establishment posts to create an institutionalized and sustainable core group of professionals to coordinate and support the implementation of the national HIV/AIDS Program;

(e) Financial sustainability will include Government budget allocations to finance the national HIV/AIDS program and continued support from external sources especially the Global Fund; and,

(f) Allocating resources available for HIV/AIDS to the highest priority interventions.

E. Critical Risks and Possible Controversial Aspects for the Proposed Project

     Risk                   Description of risk               Rating
    Factors                                                  of risk

Project           * Expenditures during the first               S
design            project for non-health line
                  ministries and for CSOs accounted
                  for only 8% of total project
                  expenditures.

                  * The first project has been
                  criticized for its centralized
                  approach and has been perceived
                  outside the MOH as a MOH
                  project rather than a multi-sectoral
                  project.

Stigma and        * The country's legal framework               S
Discrimination    remains inadequate. However,
and Human         several reforms have been
Rights            launched over the past years.
                  Major achievements include the
                  National HIV/AIDS Policy
                  approved by Cabinet (2004) &
                  Parliament (2005) and the National
                  HIV/AIDS Workplace Policy
                  submitted in 2003 to and approved
                  by Cabinet in March 2007.

                  * An Amendment to the Public
                  Health Act based on a review of
                  existing legislation and for the
                  purpose of repealing outdated
                  legislation is being drafted.

Implementation    The first HIV/AIDS project invested           S
capacity          in the skills development of a project
sustainability    unit to coordinate the national
                  response. The challenge is to retain
                  this staff.

Financial         * Until now a significant share of            S
sustainability    the Jamaica HIV/AIDS program
                  has been financed mostly with
                  external funds. The GOJ may not
                  be able to assume full financial
                  responsibility utilizing its own
                  resources for the national
                  HIV/AIDS program at the end of
                  this project

Financial         * The Regional Health Authorities             M
management        may not have robust financial
                  management and accounting
                  practices, specifically,
                  maintenance of appropriation
                  accounts, financial reporting and
                  internal auditing.

Procurement       * Compliance with both Bank and               S
                  national procurement procedures
                  could potentially delay project
                  implementation.

Social and        The bio-medical waste                         S
environmental     management program may not be
safeguards        upgraded fully to cope with the
                  current challenges.

Overall Risk:

                                                           Rating of
     Risk                  Mitigation measures              residual
    Factors                                                   risk

Project           * The new project defines ex ante four       M
design            key non-health ministries that will
                  develop their strategy, annual work
                  plans and budgets. CSOs will be funded
                  by the GFATM grant. The project will
                  provide technical support to ensure
                  the participation by the business
                  sector and CSO community through
                  demand-driven subprojects and
                  disbursements against approved plans
                  and contracts.

                  * The four decentralized Regional
                  Health Authorities will be responsible
                  for execution of most of the project
                  activities.

Stigma and        A strong emphasis on IECBCC will             S
Discrimination    mitigate the level of stigma and
and Human         discrimination.
Rights
                  * Under the Project's third component,
                  the project will provide technical
                  assistance for reviewing for drafting
                  a new Public Health Act that will
                  include the rights of people living
                  with HIV/AIDS and other vulnerable
                  populations, including children
                  affected by HIV/AIDS, giving them full
                  equality and dignity under the law,
                  without stigma or discrimination.

Implementation    * The Government has already initiated       M
capacity          a process of institutionalizing the
sustainability    program by establishing the requisite
                  posts and other activities in the
                  Government's establishment in a phased
                  manner over the medium-term to ensure
                  sustainability of the national
                  program.

Financial         * Continuing efforts to secure               S
sustainability    external funding for sustaining the
                  program.

Financial         * A complete financial management            M
management        assessment of the financial management
                  capacity at the RHA level has been
                  conducted. Strengthening of the RHA
                  financial management will be included
                  in the project.

Procurement       * The Government has indicated that it       M
                  will review its own procurement
                  thresholds within the next fiscal year
                  to address some of the current
                  bottlenecks. The Bank team will guide
                  the Government team in taking
                  advantage of flexibilities in Bank
                  procurement procedures

Social and        * The current HIV/AIDS project is            M
environmental     supporting the installation of a
safeguards        biomedical waste plant to serve the
                  south-east region (accounts for 60% of
                  the medical waste generated on the
                  island). The medical waste management
                  plan has been updated in preparation
                  for this project and an action plan
                  has been agreed with priority actions
                  identified for financing. Despite
                  these actions, additional investments
                  will still be needed by the Government
                  to fully address the needs of the
                  country.

Overall Risk:                                                  M

Risk Rating--H (High Risk), S (Substantial Risk), M (Moderate Risk), N
(Negligible or Low Risk).

F. Loan/Credit Conditions and Covenants

Conditions of effectiveness:

N/A

Conditions of disbursement:

N/A