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IV. Appraisal summary.

A. Economic and Financial Analyses

36. There are compelling arguments for public intervention to address HIV/ADDS in Jamaica. Because HIV/ADDS is a communicable disease which inflicts negative externalities on society, a purely private response is unlikely to be optimum socially. Information regarding HIV transmission is imperfect; HIV makes people vulnerable to other infectious diseases including tuberculosis; some individuals (spouses, newborns) cannot control their own risk to HIV infection, which are all reasons for intervention. Prevention/early intervention is necessary to reduce the health costs of treatment and mitigation in latter years. Jamaica faces macroeconomic challenges including a high debt stock. Resources available to combat HIV/ADDS are limited and need to be focused on the most cost-effective interventions.

37. Jamaica has selected a range of internationally recognized cost-effective interventions for implementing its strategic HIV/AIDS plan for the period 2007 to 2012. They include interventions for high-risk groups as well as the general population; voluntary testing and counseling, prevention of mother-to-child transmission, STI management and antiretroviral treatment. The expanded program covering antiretroviral drugs (not available in the last Bank-financed project) was made possible through Jamaica's successful application for grant funds from the GFATM. In the third round of the GFATM, Jamaica secured US$23.3 million. These funds together with the Bank loan of US$15 million (later reduced to US$10.6 million) enabled the Government to expand its program. With the new HIV/AIDS strategic plan, the Government has selected the priority interventions for a comprehensive approach including prevention, treatment, care and support. Funding available includes the US$ 6.9 million balance from the third round grant and US$44.2 million recently approved under round 7 of GFATM (20092013). The availability of the grant over the next five years reduces the recurrent cost implication arising from the Bank financed project which is designed to complement the GFATM grant. The Government will provide US$1.55 million to cover the incremental capital and recurrent costs. The Government has also initiated a process of increasing budgetary allocations to the MOH for staff costs and other related expenses in a bid to initiate medium-term sustainability of the response to the HIV/ADDS epidemic.

B. Technical

38. The Government continues to sustain its commitment to confronting the HIV epidemic with the new multi-sector NSP 2007-2012. The plan was peer reviewed by the UNAIDS/World Bank ADDS Strategic and Action Plans (ASAP) team and was found to be technically sound. The plan identifies the factors that are driving the epidemic: risky behaviors (multiple sex partners, early initiation of sex, involvement in transactional sex, non-use of condoms, low perception of personal risk and commercial sex); economic conditions (including high levels of unemployment and poverty); illegal drug trade; tourism and movement of people; and, social cultural factors especially stigma and discrimination (including a high level of homophobia that drive those most-at-risk underground); gender dimensions that influence prevention options, e.g., women are often at risk because they are unable to negotiate condom use. Services for prevention, treatment, care and support have not reached universal coverage. The NSP builds upon the prior NHP (2002-2006) and all the earlier medium term strategic plans. It reflects lessons learned in Jamaica and globally on what constitutes an appropriate response to the HIV/AIDS epidemic.

39. The NSP selected strategies aim to: decrease stigma and discrimination resulting in increased acceptability and uptake of services; strengthen the multi-sectoral approach through partnerships which will include improvement of capacity of all stakeholders, resulting in increased quantity, quality, availability and access to services; and establish a strong evidence-based approach that complies with local, regional and international guidelines to inform the local response coupled with a strengthened M&E system to pave way for an efficient and sustainable response to HIV. Other guiding principles include: equity, e.g., no person shall be denied access to prevention knowledge, skills and services or treatment, care and support services on the basis of their real or perceived HIV status, sexual orientation, gender, age, disability, religion, socioeconomic status, etc.; participation of PLWHA, promotion and protection of human rights, transparency and accountability, and application of the ILO principles on HIV/ADDS and the world of work.

40. The most cost-effective interventions have been selected to address the strategies of the plan which have been summarized in four priority areas: prevention; treatment, care and support; enabling environment and human rights; and, empowerment and governance. Specifically, the project will contribute to the Government's program in the priority areas of enhancing coverage and quality of appropriate HIV prevention interventions targeting those at high-risk as well as the general population; strengthening diagnosis and treatment; reducing stigma and discrimination associated with the disease and promoting and protecting the rights of infected persons; and improving the collection and use of reliable data to guide and monitor program implementation and to evaluate the impact of the program.

C. Fiduciary

41. Financial Management. A financial management assessment has been carried out (see Annex 7 for details). The financial management aspects of the first project were well managed. The fiduciary arrangements, both financial management and procurement under the project, will be provided by the PCU located within the National HIV/STI Program (NHP), a division of MOH. The overall financial management responsibility under the Project will be coordinated and exercised by the Administrative Unit headed by the Finance and Administrative Officer assisted by three Finance Officers and two Accounting Assistants. MOFPS will issue warrants covering the budget for the project during the year in question. Expenditures incurred that will be financed out of the World Bank loan proceeds will be funded out of the designated account to be opened at a commercial bank. The account under the project will be managed by the PCU. The Regional Health Authorities will maintain individual accounts that will be replenished periodically from the PCU's account. Expenditures by the non-health line ministries, CSOs and the private sector will be funded out the PCU's account.

42. The budget estimates for 2008/2009 include provisions for both the on-going project and the proposed project. The eligible items included in the budget of the proposed project will be retroactively financed from April 1, 2008 for an amount of US$1.3 million. Counterpart funding by the Government will be provided for some items under the proposed loan.

43. Procurement. Procurement for the proposed project will be carried out in accordance with the World Bank's 'Guidelines: Procurement Under IBRD Loans and IDA Credits' dated May, 2004 revised October 1, 2006; and 'Guidelines: Selection and Employment of Consultants by World Bank Borrowers' dated May 2004 revised October 1, 2006, and the provisions stipulated in the Legal Agreement. 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 timeframe are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. Procurement procedures

and Standard Bidding Documents (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.

44. An assessment of the capacity of the implementing agencies to undertake procurement was carried out by the Bank in January 2008. The assessment reviewed the organizational structure for implementing the project and the interaction between the project staff responsible for procurement and the national procurement authorities. The mission focused on the capacity of NHP in contracts management using both World Bank and Government procedures. The main findings and recommendations of the assessment are summarized in annex 8.

45. The joint Country Financial and Procurement Assessment (CFAA/CPAR) carried out by the World Bank and Inter American Development Bank in 2005 and approved in 2006 identified a number of weaknesses in the Jamaican procurement system. Improvements are needed to render the system more transparent. Issues identified in the combined CFAA and CPAR report pertaining to procurement statistics, supplier's registration, procurement performance and monitoring and capacity are still actual and relevant. The discrepancies between the national procurement system thresholds and the World Bank thresholds for projects in Jamaica also impact negatively on the procurement processes and timeframe.

46. Based on the procurement assessment, the following corrective measures have been agreed to improve procurement processes.

* The operations manual has been updated. It includes a specific chapter on procurement, detailing all the procedures and channels of responsibilities and flow of documentation.

* Regular submission to the Bank of a Procurement Plan beginning with the first plan to cover the first eighteen months of the project.

* Training in procurement provided by the Bank to the PCU including regional staff as soon as the loan is approved with further training to be provided during the first year of implementation as part of capacity building.

* Hiring a Procurement Specialist with acceptable qualifications and experience to assist the South East Regional Health authority.

In addition to the above action plan, the procurement thresholds and methods have been set to mitigate the procurement risk. The overall project risk for procurement is moderate.

D. Social

47. Individual behavior to a large extent is shaped by society at large. Annex 4-2 presents a detailed social assessment based on a literature review and field visits. In Jamaica, the early socialization of male and female children, into specific gender roles, sets them up for behaviors and decision-making that puts them at high risk for HIV/ADDS and sexually transmitted diseases. Outside the home, market forces support a diet for sexually explicit media and internet messages that glamorize unprotected sex, multiple sex partnerships and early sexual initiation. Musical artists--in particular dance hall disc jockeys--also glamorize multiple sexual partnerships and express innuendos of violence towards men who have sex with men. The result is male adolescents being lured into risk-taking attitudes and behaviors, which promote "manhood" such as having many partners, and engaging in unprotected and early sex. Female adolescents on the other hand are also bombarded by the pressure to engage in early sex and find less societal resistance to actions such as engaging in transactional sex with older men. Life skills messages supporting responsible behaviors such as delaying sex and using condoms if sexually active are too few to compete with adult entertainment which is within the reach of most adolescents.

48. Poverty, cultural factors and vulnerabilities compromise the ability of women to make safe choices. Some engage in commercial sex work or in multiple partnership relationships. Social and cultural norms also affect access to risk-reduction interventions for MSM through societal intolerance for this sexual practice. In addition, some religious denominations advocate against access to condoms, especially to minors and yet are not adequately engaged in interventions focused on the benefits of the delayed sex message to minors and others. Laws criminalize certain behaviors which fosters stigma and discrimination. Non-accepting attitudes and stigma and discrimination of people living with HIV affect the quality of services provided. There is a need to focus on the needs of specific groups: youth in school (10-14), out of school adults, CSWs, MSM, adult males (19-39), and PLWHAs. The project will support interventions for these groups and will strengthen the capacity of BCC teams and NGOs as well to ensure that services to the general population address the social constraints.

E. Environment. Environmental Category B

49. Safeguard Assessments. The safeguard policy, Environmental Assessment (OP/BP/GP 4.01) is applicable to this project as some additional biomedical waste could be generated by activities supported by the project. The Government has a bio-medical waste management system in place. A number of investments in equipment and staff training have been financed under the ongoing Bank financed project. The assessment of the system has been updated and specific areas for strengthening biomedical waste have been identified. Most project activities are not expected to generate adverse environmental effects. Some medical waste is expected to be generated during the administration of HIV tests and in the management of treatment for PLWHA. In relation to construction, there will also be small-scale rehabilitation of existing health care facilities to ensure appropriate provision of HIV/AIDS services. Measures that the Government will take to mitigate potential environmental effects are detailed in Annex 10. The project will support the Government in implementing those measures. Of particular importance is the need to ensure that health care workers are adequately trained on medical waste management. The project will provide support for: standardizing waste management procedures in all health care facilities; strengthening capacity in health care waste management, including training for health care workers in proper waste management and post exposure prophylaxis; and upgrading of regional medical waste collection systems and treatment facilities with specialized medical waste collection vehicles and alternative technology.

50. On the management of environmental risks of small-scale construction works, the project's coordination unit will incorporate the required Bank environmental guidelines in the project's operations manual and standard bidding documents for civil works.

F. Safeguard policies
Safeguard Policies Triggered by the Project Yes No

Environmental Assessment (OP/BP/GP 4.01) [x] [ ]
Natural Habitats (OP/BP 4.04) [ ] [x]
Pest Management (OP 4.09) [ ] [x]
Cultural ProDertv (OPN 11.03. being revised as OP 4.11) [ ] [x]
In voluntary Resettlement (OP/BP 4.12) [ ] [x]
Indigenous Peoples (OD 4.20, being revised as OP 4.10) [ ] [x]
Forests (OP/BP 4.36) [ ] [x]
Safety of Dams (OP/BP 4.37) [ ] [x]
Projects in Disputed Areas (OP/BP/GP 7.60) [ ] [x]
Projects on International Waterways (OP/BP/GP 7.50) [ ] [x]

G. Policy Exceptions and Readiness

51. No policy exceptions are sought. The Bank has assessed the Government as being ready to implement the proposed new project. The Government is committed to dealing with HIV/AIDS and has recently completed a new National HIV/AIDS Strategic Plan 2007-2012. The plan was prepared in a participatory and consultative process involving all key stakeholders within the Government, Civil Society at the community level, and external donors/partners. This plan builds on the achievements of the previous plan which covered the period 2002-2006. The institutional mechanisms for the national program are in place with overall policy direction provided by the Cabinet through the COHSOD. The National HIV/STI Program within the MOH coordinates the program. The project will be executed by the PCU within the NHP. The PCU has a core of qualified and experienced staff that has managed the previous Bank-funded project and other donor projects notable among them, a grant from the GFATM. The Government counterpart team has led the preparation of the project and all key departments within the implementing agency (MOH), the MOFPS and the PIOJ have been key partners in design of the project. The procedures for execution of the project are in place and are outlined in the Operations Manual (updated from the previous Bank financed project's manual). They specify financial and procurement procedures. The PCU and MOH have been assessed and found to have the capacity to manage the project. Necessary capacity building has been planned for different project stakeholders. A procurement plan to cover the first 18 months has been prepared. Provisions have been made in the budget for the loan and for counterpart funds for the first fiscal year. The MOH has an experienced M&E unit and system in place with the capacity to conduct the M&E requirements for the NHP. Monitoring and results framework has been finalized for the project. It is aligned with the Government's overall M&E framework and includes baseline and target values.
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Publication:Jamaica - Second HIV/AIDS Project
Date:Apr 1, 2008
Previous Article:III. Implementation.
Next Article:Annex 1: Country and sector background.

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