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II. Project description.

A. Lending Instrument

13. The lending instrument proposed for the project will be a Specific Investment Loan (SIL) of US$10 million with co-financing of US$ 1.54 million from the Government.

B. Project Development Objective and Key Indicators

14. The project development objectives are to assist in the implementation of the Government's National HIV/AIDS Program by supporting the: (i) deepening of prevention interventions targeted at high-risk groups and the general population; (ii) increasing of access to treatment, care and support services for infected and affected individuals; and (iii) strengthening of program management and analysis to identify priorities for building the capacity of the health sector to respond to the HIV/AIDS epidemic and other priority health problems.

15. Intermediate indicators will monitor the progress in achieving prevention and treatment targets and the availability of timely inputs that contribute to achievement of the project impact and outcomes (see Annex 3) in support of the goal of the national program as specified in the National HIV/AIDS Strategic Plan 2007-2012--to halt and begin to reverse the spread of HIV/AIDS as well as STIs by providing universal access to prevention, care and treatment.

C. Project Components

16. Component 1: Prevention (US$ 3.34 million). Prevention interventions are a high priority of the NHP and need to be scaled up dramatically to halt and reverse the spread of the epidemic. Various implementing entities will intensify prevention activities: the Ministry of Health and the Regional Health Authorities, four non-health line ministries, CSOs and the private sector.

17. Subcomponent 1(a): Prevention Activities by the Ministry of Health (MOH) and the Regional Health Authorities (USS 2.99 million). This subcomponent will strengthen the capacity of MOH and the Regional Health Authorities (RHAs) to provide technical guidance for the national response to HIV/AIDS and to deliver HIV/AIDS related services for prevention through the health care system. Activities financed will include: (a) Support for behavior change communication (BCC) interventions targeting at-risk groups (CSWs, MSMs, in and out of school youth, prison inmates, drug users) and the general population. The activities aim at dissemination of information for adoption of safer sexual practices. Funding will be provided for development of BCC materials, mass media campaigns, peer education, and outreach; (b) Expansion of STI management and blood safety for preventing HIV transmission; (c) Expansion of VCT services for preventing of HIV transmission, scaling up treatment and care and expansion of PMTCT Services. These will include innovative approaches for hard to reach and vulnerable populations, including walk-in and mobile VCT services, and expand provider initiated counseling and testing. Funding will cover training, test kits reagents and supplies, laboratory support, mentioned in Component 2, and minor refurbishment of VCT rooms; and (d) Promotion of increased condom use. Support will be provided for procurement and distribution of condoms and lubricants that will not be financed through the GFATM. Female condoms will be donated by UNFPA.

18. Subcomponent 1 (b): Prevention Activities by the Non-Health Line Ministries (US$ 0.30 million). Strengthening prevention requires scaling up the contribution of the non-health line ministries to make the national response truly multi-sectoral. Four key line ministries have been identified because they can reach important segments of vulnerable and/or at risk population groups through their official mandates: (a) Education (7); (b) Labour and Social Security; (c) Tourism; and (d) National Security. These ministries implemented some HIV/AIDS prevention activities under the first project. They will receive technical support and funding to scale up their activities more strategically based on medium term plans. This subcomponent will finance: annual work programs of three of the four line ministries that include implementing workplace HIV/AIDS policies, BCC, condom distribution and promotion, and advocacy to reduce HIV/AIDS stigmatization and discrimination; and, co-finance staffing costs of the focal points of the non-health line ministries. The national program will finance training, technical and material support for focal points, program officers and their respective ministerial HIV/AIDS Committees.

19. Subcomponent 1 (c): Prevention Activities by Civil Society Organizations and the Private Sector (US$ 0.05 million). This project will finance training and the position of the Civil Society Organizations (CSOs) Coordinator in the PCU who will provide capacity building for CSOs. The GFATM will be the main financing source for CSOs through demand-driven "subprojects" that will target interventions for: (a) Youth, including sexuality education, risk assessment, behavior modeling, and leadership training; (b) Commercial Sex Workers (CSWs), including better access to counseling and health care, skills development for alternative income generation, referral to agencies such as housing and drug addiction/prevention and support for increased involvement of club operators and the tourism services in risk reduction interventions including increased condom use; (c) MSMs by continuing training of trainers on risk reduction among the MSMs, referral to STITHIV test and treatment along with adherence and positive prevention; (d) Adult Males (19-39 years), including scaling up existing experiences in reaching/targeting male dominated occupations such as taxi and bus drivers, the police force and auto-mechanics for risk reduction interventions. The project will also provide works skills training for economically vulnerable populations to assist them in entering the job market. The GFATM has allocated US$5 million to fund CSOs which will allow a dramatic scaling up of the response. This support will encourage community-based activities to strengthen prevention work in rural and in urban areas and work with orphaned and HIV/ADDS affected children. The NHP has developed an organizational structure with standard operating procedures for engaging CSOs and the private sector. Selection criteria are detailed in the Project Operations Manual and include fiduciary and administrative procedures, demonstrated consultation and participatory processes to mobilize and empower target communities, and a system for provision of technical support to the CSOs.

20. Component 2: Treatment, Care and Support (US$1.81 million). This component will provide financing to support the efforts to enhance the following services: (a) Laboratory Diagnostic Services. Refurbishing and equipping the TB Laboratory and the provision of reagents and supplies to support scaling up diagnosis and treatment of TB patients and the detection of HIV in this group; (b) Training for staff in the use of new equipment; (c) Refurbishing of select Treatment Sites as well as the procurement of drugs (not funded through the GFATM), nutritional supplements, substitution infant feeding formula, contraceptive methods and reagents and testing supplies for diagnosing and monitoring HIV; (d) Refurbishing of Regional Laboratories to facilitate decentralization of laboratory services; (e) Training of staff, and health care workers in comprehensive management of HIV/STI/TB,PMTCT, counseling and testing, Public Health Management and BCC and, (f) Curriculum development to support training activities.

21. Component 3: Strengthening Institutional Capacity for Legislative Reform, Policy Formulation, Program Management, Monitoring and Evaluation (US$ 4.26 million).

Subcomponent 3 (a): Policy Formulation for an Enabling Legal and Regulatory Environment and Human Rights (US$ 0.41 million). The new NSP emphasizes the need for a supportive legal and regulatory environment. The project will provide technical assistance in support of the changes to the legislative framework that have been recommended by the legislative review including updating of the Public Health Act to deal with new health challenges such as HIV/AIDS and advocacy for further legislative and policy reform to address stigma and discrimination.

22. Subcomponent 3 (b): Program Management (US$ 3.30 million). This subcomponent will continue to support the coordination and management of the Government's National HIV/AIDS Program. The project will co-finance staff costs for the technical and fiduciary functions of the PCU and the RHAs in supporting the coordination and management of the Borrower's NHP. This includes reviewing work programs from line ministries and proposals from civil society implementing agencies, monitoring and evaluating program progress, and training staff of the PCU, Line Ministries, and CSOs in fiduciary functions.

23. Subcomponent 3 (c): Monitoring and Evaluation (US$ 0.54 million). The M&E Unit of the NHP/PCU in the MOH is implementing a comprehensive monitoring system. The objectives of the M&E system are to provide continuous feedback to monitor the trends in the epidemic and to enhance the delivery of HIV services. The NHP will emphasize: (a) staffing, training and building the capacity of the M&E Unit; (b) an information technology (IT) platform that will: (i) integrate the multiple sources of information and implementing partners; and (ii) complete the procurement of equipment, maintaining the software, training staff and rolling out the Laboratory Information System to the regions; (c) technical assistance, equipment and training to strengthen the M&E system and the decision-making process; (d) harmonizing the information flow from multiple data sources for impact, outcomes, outputs, and inputs; i.e., biological HIV surveillance; behavioral HIV surveillance; (e) conducting surveys, surveillance and research/studies on special populations to inform the national response; (f) integrating the five national and sub-national HIV databases to enable evaluating the impact of the national program; and (g) build local M&E capacity. Most of the indicators for monitoring this project are drawn from the national indicators agreed by all partners and used for reporting to the United Nations Special Session on HIV/AIDS (UNGASS).

24. Component 4: Health Sector Development Support (US$ 2.10 million).

Subcomponent 4 (a) Biomedical Waste Management (US$ 2.0 million). The project will support upgrading and improved management of the biomedical waste management system. This will include: upgrading medical waste treatment facilities; waste disposal supplies and materials in all health regions for enabling proper segregation practices. Interim storage facilities to support the regional collection and alternative treatment systems will be financed by the Government through the National Health Fund. The project will also finance capacity building activities: develop and disseminate medical waste management training material; train healthcare workers in medical waste management and post exposure prophylaxis, including regional 'Training of Trainers' workshops; share best practices; and, train staff for operation and maintenance of new equipment. Finally, the project will finance preparation of facility specific waste management plan, including the creation of a system to support health care facilities in the documentation of infectious waste generation on a continuous basis.

25. Subcomponent 4 (b). Diagnostic Capacity Assessment of the Health Sector (US$ 0.10 million). The 2004 national report prepared by the Planning Institute of Jamaica (PIOJ) noted that Jamaica is behind in attaining some of the MDG 2015 target values. Critical challenges to the capacity of the health sector to deliver quality services are the lack of adequate numbers of staff in all professional categories, an underfinanced public sector, crowded hospitals and underused health centers, periodic shortages of medical supplies, and pockets of violence in certain communities impeding access to health services and constraining the movement of health personnel. This component will finance a comprehensive assessment of the obstacles that limit the capacity of the health sector to deliver quality health care efficiently to those needing it most. The investment and operational cost of the actions identified in the assessment will be calculated and options proposed for financing the cost from national and external sources.

D. Lessons Learned and Reflected in the Project Design

26. There are a number of lessons learned from implementing the ongoing Bank-financed Jamaica HIV/AIDS Prevention and Control Project, as well as from other Bank and donor-financed projects throughout the Caribbean (8).

(a) The ongoing project had a slow start mainly due to unclear financial management and procurement procedures. In particular, differences between country and Bank procurement guidelines took time to resolve. These problems were subsequently addressed through a proactive process involving close coordination between the Bank and the project. With the experience gained by the MOH team, this project will take advantage of greater flexibilities in Bank procedures. The Government continues to review its own procedures especially for procurement.

(b) Other challenges experienced relate to slow involvement of non-health line ministries, CSOs and the private sector in execution of priority interventions especially for prevention. This project will build upon the lessons from the first project to strengthen the procedures and technical guidance to these critical stakeholders to ensure their greater participation especially in reaching at-risk and vulnerable groups.

(c) Overall institutional and implementation arrangements are critical for a multi-sectoral response in line with the NSP. Execution of the previous project and other Government HIV/AIDS efforts underscored the importance of the "Three Ones". This project will support the strengthening of the National ADDS Committee as the "one coordinating national body" to enable it to provide the policy guidance. The project will also support execution of the NSP, "the one national strategic plan" with one "M&E plan".

(d) Prevention. The number one issue posited by the NSP is increasing prevention activities and improving strategic focus. This is consistent with the experience in other Caribbean countries and globally. Activities that lead to behavior change need to be more skillfully designed and intensified to respond to the complex socio-economic factors that are driving the epidemic such as multiple partners, commercial and transactional sex and poverty. This project will contribute through a two pronged strategy: targeting interventions at high risk groups and implementing non-targeted activities for the general population.

(e) Stigma and discrimination in Jamaica, as in most Caribbean countries, is still a major impediment to the response to the epidemic as it prevents people from seeking care and caregivers from giving appropriate care. The project will provide technical assistance through support to efforts to foster an enabling environment through BCC as well as legal and regulatory reforms and policy advocacy.

(f) The fight against HIV/ADDS requires a multi-sector response with buy-in from leadership in Government, key non-health line ministries, the private sector, and participation of a crosscutting range of stakeholders: CSOs, the private sector, community level, household level, religious groups, professional groups and PLWHA. The project will greatly scale up the role and capacity of non-health line ministries, CSOs, and the private sector which were activities under the first project that were not developed pro-actively.

(g) The health system still requires considerable strengthening to enable it to cope with the increased demands for prevention, treatment and care brought on by the HIV/AIDS epidemic: improving physical facilities, diagnostic capacity, and increasing the number and skills of staff. Based on the experience of the first project, this project will refurbish treatment sites and train health workers as indicated under Component 2 and finance a comprehensive assessment to identify and solve the most urgent bottlenecks in service delivery.

(h) The fight against HIV/AIDS is expensive and Jamaica needs additional resources to sustain the momentum it has built. Along with this, it is critical for the NHP to be institutionalized through the establishment of staff positions on the regular public payroll. The Government will need to continue to keep HIV/ADDS as a priority in its expenditure plans as it has done in the past to ensure that the HIV/AIDS response is sustained.

(i) Finally, it is important to note that there is no proven "production function" in responding to HIV/ADDS in a complex epidemic such as the one in Jamaica. Research will be important to continue to identify those areas that contribute the most to addressing the epidemic. The project will support M&E to ensure that the Government continuously adjusts the program to the changing nature of the epidemic.

E. Alternatives Considered and Reasons for Rejection

27. The first alternative considered was to have no follow-on project. The Bank-funded Jamaica HIV/AIDS Prevention and Control Project is scheduled to close on May 31, 2008. The CAS stresses the threat of HIV/AIDS to the country's development prospects. This alternative was rejected. The second alternative considered was to combine a health sector intervention and a repeater project into one operation. This alternative was rejected because the broader needs of the health sector will be better addressed in a separate health sector program and will require diagnostic work that will take some time to complete. The Government was anxious to avoid a gap in financing of the HIV/AIDS response and requested that preparation of the follow-on project be expedited. A third alternative would have been to use the option of additional financing. This option was rejected as it would have restricted the implementation period to three years and the Government team and the Bank task team judged a four year period more appropriate. The selected alternative will be a specific investment loan that will build upon the successful implementation of the first HIV/ADDS Project.
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Publication:Jamaica - Second HIV/AIDS Project
Date:Apr 1, 2008
Previous Article:I. Strategic context and rationale.
Next Article:III. Implementation.

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