Document of The World Bank Report No: ICR2783 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-75560) ON A LOAN IN THE AMOUNT OF US$10 MILLION TO JAMAICA FOR A SECOND HIV/AIDS PROJECT September 30, 2013 Human Development Sector Unit Caribbean Country Management Unit Latin America and the Caribbean Regional Office CURRENCY EQUIVALENTS (Exchange Rate Effective: August 27, 2013) Currency Unit 1.00 JMD = US$0.01 US$ 1.00 = $101.48 JMD FISCAL YEAR (April 1 – March 31) ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Clinic ART Antiretroviral Therapy ARV Antiretroviral CAS Country Assistance Strategy CBO Community Based Organizations CSW Commercial Sex Workers DALYs Disability-Adjusted Life Years FM Financial Management GDP Gross Domestic Product GFATM Global Fund for HIV/AIDS, TB and Malaria GOJ Government of Jamaica HIV Human Immunodeficiency Virus IBRD International Bank for Reconstruction and Development ICR Implementation Completion Report IOI Intermediate Outcome Indicators KABP Knowledge, Attitude, Practices and Behavior LIS Laboratory Information System M&E Monitoring and Evaluation MARP Most at-risk Populations MOH Ministry of Health MSM Men-having Sex with Men MTR Mid-term Review NHP National HIV/AIDS Program NPC National Planning Council NPHL National Public Health Laboratory NPV Net Present Value NSP National Strategic Plan OIs Outcome Indicators PAD Project Appraisal Document PCU Project Coordination Unit PDO Project Development Objectives PLWHA Persons Living with HIV/AIDS P(MTCT) Prevention of (Mother to-Child Transmission) R/F Results Framework RHA Regional Health Authority SIL Specific Investment Lending ii STD Sexually Transmitted Disease STI Sexually Transmitted Infections SW Sex Workers SWAp Sector Wide Approach TB Tuberculosis TA Technical Assistance UNAIDS United Nations Program on HIV/AIDS UNGASS United Nation General Assembly Special Session on HIV/AIDS USAID United States Agency for International Development Vice President: Hasan A. Tuluy Country Director: Sophie Sirtaine Sector Manager: Joana Godinho Project Team Leader: Shiyan Chao ICR Team Leader: Rianna Mohammed-Roberts iii JAMAICA Second HIV/AIDS Project CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Profile 1. Project Context, Development Objectives and Design ......................................... 1 2. Key Factors Affecting Implementation and Outcomes ........................................ 3 3. Assessment of Outcomes ...................................................................................... 9 4. Assessment of Risk to Development Outcome................................................... 15 5. Assessment of Bank and Borrower Performance ............................................... 16 6. Lessons Learned ................................................................................................. 18 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .... 19 Annex 1. Project Costs and Financing .................................................................... 20 Annex 2. Project Components and Outputs by Component ................................... 21 Annex 3. Economic and Financial Analysis ........................................................... 25 Annex 4. Bank Lending and Implementation Support/Supervision Processes ...... 34 Annex 5. Beneficiary Survey Results ..................................................................... 36 Annex 6. Stakeholder Workshop Report and Results............................................. 37 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ............... 38 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ................. 51 Annex 9. List of Supporting Documents ................................................................ 52 MAP JAM 33423…………………………………………………………………55 iv v DATA SHEET A. Basic Information Jamaica Second Country: Jamaica Project Name: HIV/AIDS Project Project ID: P106622 L/C/TF Number(s): IBRD-75560 ICR Date: 09/30/2013 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: SIL Borrower: JAMAICA Original Total USD 10.00M Disbursed Amount: USD 9.65M Commitment: Environmental Revised Amount: USD 10.00M B Category Implementing Agencies: The Ministry of Health, Non-health line ministries, Regional Health Authorities, Civil Society Organizations; and the Private sector. Cofinanciers and Other External Partners: N/A B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 10/30/2007 Effectiveness: 09/23/2008 09/23/2008 Appraisal: 03/17/2008 Restructuring(s): 05/22/2009 Approval: 05/13/2008 Mid-term Review: 10/25/2010 05/30/2011 Closing: 11/30/2012 03/31/2013 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Moderately Quality at Entry: Government: Satisfactory Satisfactory Quality of Moderately Implementing Moderately Supervision: Satisfactory Agency/Agencies: Satisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Satisfactory Performance: Satisfactory vi C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Quality at Entry Project at any time No None (QEA): (Yes/No): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 5 10 Health 63 63 Other social services 13 13 Solid waste management 19 14 Theme Code (as % of total Bank financing) HIV/AIDS 33 33 Health system performance 17 17 Participation and civic engagement 16 16 Population and reproductive health 17 17 Tuberculosis 17 17 E. Bank Staff Positions At ICR At Approval Vice President: Hasan A. Tuluy Pamela Cox Country Director: Sophie Sirtaine Yvonne M. Tsikata Sector Manager: Joana Godinho Keith E. Hansen Project Team Leader: Shiyan Chao Mary T. Mulusa ICR Team Leader: Rianna L. Mohammed-Roberts ICR Primary Author: Rianna L. Mohammed-Roberts F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The Project development objectives are to assist in the implementation of the Government’s national HIV/AIDS program through support to: (i) deepening of prevention interventions targeted at most at-risk populations (MARP) and for the vii general population (ii) increasing of access to treatment, care and support services for infected and affected individuals; (iii) strengthening of program management and analysis to identify priorities for strengthening the health sector capacity to respond to the HIV/AIDS epidemic and other priority health problems. Revised Project Development Objectives (as approved by original approving authority) The Project Development Objectives were not revised. (a) PDO Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years % of young people aged 15-24 reporting the use of a condom the last time they had Indicator 1 : sex with a non-regular sexual partner. Value Men: 76% Men: 80.0% Men: 85.0% Men: 79.3% quantitative or Women 66% Women: 75.0% Women: 70.0% Women: 57.0% Qualitative) Date achieved 05/13/2008 11/30/2012 06/16/2009 12/30/2012 Comments Partially achieved. The percentage of men reporting the use of a condom increased (incl. % slightly by 3.3% and the percentage for women decreased by 9 percentage points. achievement) Indicator 2: % of infants born to HIV infected mothers who are HIV infected. Value quantitative or 10.0% <5.0% NA 1.4% Qualitative) Date achieved 12/30/2006 11/30/2012 12/30/2012 Comments (incl. % Achieved. achievement) % of people expressing accepting attitudes towards persons living with HIV/AIDS Indicator 3: (PLWHA), of all people surveyed aged 15-49. Value Men: 41.4% Men: 46% Men: 36.5% quantitative or N/A Women: 34.3% Women: 40% Women: 33.8% Qualitative) Date achieved 05/13/2008 06/16/2009 12/30/2012 Comments (incl. % Not achieved. achievement) viii (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or Target documents) Values Years Component 1: Prevention Activities % of young women and men aged 15 - 24 who both correctly identify ways of Indicator 1: preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission. Value Men: 37.4% Men: 70% Men: 45% Men: 35.6% quantitative or Women: 42.3% Women: 80% Women: 50% Women: 51.3% Qualitative) Date achieved 05/13/2008 11/30/2012 06/16/2009 12/30/2012 Comments Partially achieved. The indicator for women has improved by 9 percentage (incl. % points. achievement) Indicator 2: % of sex workers (SW) reporting condom use with their most recent client. Value quantitative or 90% > 92% Maintain > 90% 91% Qualitative) Date achieved 05/13/2008 11/30/2012 06/16/2009 12/30/2011 Comments (incl. % Achieved. achievement) % of SW who received HIV testing in the last 12 months and who know the Indicator 3: results. Value quantitative or 43.0% 50% 50% (SW) 59.2% Qualitative) Date achieved 12/30/2005 11/30/2012 12/30/2011 Comments (incl. % Achieved. achievement) % of men who have sex with men (MSM) reporting the use of condom the last Indicator 4: time they had anal sex with a male partner. Value quantitative or 74.0% 78.0% 80% 75.5% Qualitative) Date achieved 12/30/2007 11/30/2012 06/16/2009 12/30/2011 Comments Partially achieved. The % of MSM reporting the use of condom the last time (incl. % they had anal sex with a male partner improved by 1.5 percentage point. achievement) Number of commercial sex workers (CSW) and MSM reached through Indicator 5: prevention activities. Value CSW: 7790 CSW: 14,955 CSW: 40,445 quantitative or NA MSM: 7832 MSM: 14,059 MSM: 22,145 Qualitative) Date achieved 12/30/2007 06/16/2009 12/30/2012 Comments (incl. % Achieved. achievement) ix Indicator 6: % of inmates reached through prevention activities. Value quantitative or < 1% NA 15% 19% Qualitative) Date achieved 05/13/2008 06/16/2009 03/30/2013 Comments (incl. % Achieved. The target was surpassed by 4 percentage points. achievement) Component II: Treatment, Care and Support % of adults & children with HIV still alive 12 months after initiation of Indicator 7: antiretroviral therapy (ART). Value quantitative or 75.0% 90% 92.0% 75.6% Qualitative) Date achieved 12/30/2006 11/30/2012 06/16/2009 12/30/2012 Comments Not achieved. Compliance to ART has been affected by a number of issues: (incl. % transportation costs, food availability, stigma and discrimination, and challenges achievement) in tracking and identifying patients at risk. Number of men, women & children with advanced HIV receiving antiretroviral Indicator 8: combination therapy according to national guidelines. Value quantitative or 3,000 9,000 NA 10,469 Qualitative) Date achieved 12/30/2007 11/30/2012 12/30/2012 Comments (incl. % Achieved. achievement) % of HIV positive pregnant women receiving a complete course of antiretroviral Indicator 9: (ARV) prophylaxis to reduce the risk of mother to-child transmission (MTCT). Value quantitative or 84.0% 100% Maintain ≥80.0% 85.8% Qualitative) Date achieved 12/30/2007 11/30/2012 06/16/2009 12/30/2012 Achieved. Comments (incl. % achievement) Indicator 10: % of antenatal clinic (ANC) clients that are counseled and tested for HIV. Value quantitative or 95% 100% Maintain >90% >95% Qualitative) Date achieved 12/30/2007 11/30/2012 06/16/2009 12/30/2012 Comments (incl. % achievement) Achieved. x Component III: Strengthening Institutional Capacity for Legislative Reform, Policy Formulation, Program Management, Monitoring and Evaluation Indicator 11: % of reported cases of HIV-related discrimination receiving redress. Value quantitative or >50% 70% NA 100% Qualitative) Date achieved 12/30/2011 11/30/2012 12/30/2012 Comments (incl. % Achieved. achievement) Indicator 12: Percentage of institutions/organizations reached adopting HIV/AIDS policies. Value quantitative or 31% 93% NA 100% Qualitative) Date achieved 12/30/2007 11/30/2012 12/30/2012 Comments (incl. % Achieved. achievement) Indicator 13: Completion of computerization for Regional Labs. Value Systems completed for 3 quantitative or 0 NA 0 regional labs Qualitative) Date achieved 12/30/2007 11/30/2012 12/30/2012 Comments (incl. % Not achieved. achievement) Component IV: Health Sector Development Support Alternative treatment technology for biomedical waste management established Indicator 14: in the Western Health Region. Value quantitative or NA 1 NA 1 Qualitative) 03/30/2013 Date achieved 12/30/2007 11/30/2012 Comments Due to the financial crisis, the GOJ decided to expand and upgrade the existing (incl. % plant rather than building a new one as originally planned. The expanded facility achievement) could handle 83% of medical waste from public health facilities in Jamaica. Environmental management and monitoring plans for each plant dealing with Indicator 15: biomedical waste developed and being implemented. Value quantitative or 1 2 NA 1 Qualitative) Date achieved 12/30/2007 11/30/2012 12/30/2012 Comments The facility is implementing a monitoring and management plan based on the (incl. % National Guidelines. achievement) xi Indicator 16: Assessment of Health sector obstacles to delivery of quality care. An analytical Value report with quantitative or NA Report available. NA recommendations Qualitative) for improvement Date achieved 12/30/2007 11/30/2012 12/30/2012 Comments (incl. % Achieved. achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 06/30/2008 Satisfactory Satisfactory 0.00 2 12/12/2008 Satisfactory Satisfactory 0.00 3 06/19/2009 Satisfactory Satisfactory 0.85 4 12/03/2009 Satisfactory Satisfactory 1.80 5 06/28/2010 Moderately Satisfactory Moderately Satisfactory 2.65 6 02/23/2011 Moderately Satisfactory Moderately Satisfactory 3.19 7 08/09/2011 Satisfactory Satisfactory 3.28 8 03/22/2012 Satisfactory Satisfactory 5.39 9 10/28/2012 Moderately Satisfactory Satisfactory 7.09 xii H. Restructuring ISR Ratings Amount Board at Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Restructuring Date(s) Key Changes Made PDO Change in USD DO IP millions To revise Project indicators in order to better reflect the reality of the epidemic (including updated data) and 05/22/2009 No S S 0.85 to allow for better tracking of Project progress towards implementation of the National HIV/AIDS Strategic Plan. To allow the Project to complete the activities that started late due to delayed budget allocation resulting 09/24/2012 No S S 7.09 from the negative impact of the global economic down- turn on the Government’s budget. I. Disbursement Profile xiii 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Jamaica is the third largest island in the Caribbean, with a population of 2.7 million. During the past three decades, Jamaica has continued to face significant challenges: low growth, high debt, crime and violence; and high vulnerability to exogenous shocks and natural disasters. These factors have contributed to economic stagnation and volatility. 2. At appraisal in 2008, AIDS and sexually transmitted infections (STI) were the second leading cause of death among the 15-24 year age group. It was estimated that 25,000 (1.5 percent) adults aged 15-49 years were infected with HIV, with the majority (65 percent) of reported AIDS cases falling within the 20-44 year age group. Jamaica displayed features of both a generalized and concentrated HIV epidemic. Heterosexual transmission was reported by 90 percent of persons with HIV. The prevalence varied across population groups, with a high prevalence among men who have sex with men (MSM, 20-30 percent), commercial sex workers (CSW, 9 percent), STI clinic attendees (4.6 percent) in 2005; and prisoners (3.3 percent) in 2006. 3. A complicated and intertwined set of cultural, economic, social, and behavioral factors was identified as driving the epidemic: risky behaviors such as multiple partners, participation in commercial and transactional sex, and failure to use condoms with non-regular partners; early initiation of sexual activity; gender inequity and gender roles; poverty; and stigma and discrimination, which negatively affected appropriate health-seeking behaviors. 4. The national response was guided by a series of medium-term HIV/AIDS strategic plans, the 2002-2006 HIV/AIDS National Strategic Plan (NSP), and the 2007-2012 NSP. The NSP identified four priority areas: (a) improved access to quality prevention services; (b) comprehensive treatment, care and support services; (c) enabling environment and human rights; and (d) empowerment and governance. The Government of Jamaica (GOJ) estimated that a substantial increase in funding would be needed to scale up the National HIV/AIDS Program (NHP) to finance the implementation of the NSP. As such, the GOJ sought to increase domestic resources to address the epidemic, as well as complimentary resources from external partners including the World Bank (WB). 5. This Project was a follow-on project to the Jamaica HIV/AIDS Prevention and Control Project (P074641, Loan No. IBRD-71120), which was successfully completed on May 31, 2008. As such, it built upon the support provided under the first WB financed operation. The Bank’s comparative advantage rested in its accumulated technical expertise in the implementation of HIV/AIDS projects both in the Caribbean, and across the world. The Project was aligned with the FY2006-2009 Country Assistance Strategy (CAS) (Report #31830-JM), which itself was aligned 1 with the Government’s Medium-term Socio-economic Policy framework for 2004- 2009, which stressed the threat of HIV/AIDS to the country's development prospects. 1.2 Original Project Development Objectives (PDO) and Key Indicators 6. The Project Development Objectives (PDO) were to assist in the implementation of the Government’s national HIV/AIDS program through support to: (a) deepening of prevention interventions targeted at most at risk populations and for the general population; (b) increasing of access to treatment, care and support services for infected and affected individuals; (c) strengthening of program management and analysis to identify priorities for strengthening the health sector capacity to respond to the HIV/AIDS epidemic and other priority health problems. 7. The Project’s original indicators included four outcome indicators (OIs), and nineteen intermediate outcome indicators (IOIs). The OIs related to the PDO, as defined in the Project Appraisal Document (PAD) were: (a) % of CSWs who are HIV infected; (b) % of MSM who are HIV infected; (c) number of men, women & children with advanced HIV receiving antiretroviral combination therapy according to national guidelines; and (d) number of institutions adopting policies to address HIV. 1.3 Revised PDO and Key Indicators, and reasons/justification 8. The Latin America and the Caribbean Regional Vice Presidency approved second order restructuring of the Project on May 22, 2009. Restructuring involved changes to the Results Framework (R/F) to make the indicators more realistic and reflective of new knowledge and information (arising from a 2008 National Knowledge, Attitudes, Behavior and Practices (KABP) survey and a 2007 MSM survey), and better aligned with national priorities. One change involved replacing the four original OIs with three new OIs which were deemed to be more appropriate for measuring the Project’s achievements. The new OIs were: (a) % of young people aged 15-24 reporting the use of a condom the last time they had sex with a non- regular sexual partner; (b) % of infants born to HIV infected mothers who are HIV infected; and (c) % of people expressing accepting attitudes towards PLWHA, of all people surveyed aged 15-49. In addition, four new IOI were added, six IOIs were removed, and a number of indicators and targets were refined based on data availability, and the appropriateness of the indicators in reflecting the reality of the epidemic and in tracking Project progress. 1.4 Main Beneficiaries 9. Project beneficiaries included: (a) most at-risk populations (MARP) - with an emphasis on CSW, MSM, in and out of school youth, prison inmates, and drug users- who would benefit from targeted interventions; (b) persons living with HIV/AIDS (PLWHA) who would benefit from better access to treatment, care and support interventions, and efforts to develop an enabling environment; and (c) the entire population in Jamaica who would benefit from, inter alia, improved prevention services. 2 1.5 Original Components 10. The Project had four components (detailed description of project components in Annex 2). 1.6 Revised Components 11. No changes were made to Project components or proposed activities. 1.7 Other significant changes 12. In addition to the first restructuring in May 2009 (Section 1.3), a second Project restructuring was approved by the Country Director on September 24, 2012, to provide the Project with the additional time needed to complete activities that had been delayed due to the negative impact of the global economic down-turn on the Government’s counterpart funding. Approved changes involved: (a) reallocating funds among project categories of expenditures to reflect the actual costs of activities supported by the Project; (b) extending the Closing Date by four months to March 31, 2013; and (c) extending the grace period from two to four months. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 13. The background analysis for this Project was sufficient. This follow-on Project was prepared as part of the GOJ’s emergency response to HIV/AIDS, and in support of the financing gap needed to implement the NSP. The Government was committed to meeting the Millennium Development Goals, with HIV/AIDS one of the high priorities in the country’s development agenda. The NSP was developed in a participatory manner based on consultations with a wide range of stakeholders, and included cost-effective interventions in priority areas: prevention; treatment, care and support; enabling environment and human rights; and empowerment and governance. 14. Project Preparation and Design. The Project was prepared in approximately eight months. There were no conditions of effectiveness. The Project design built upon the lessons learned from the previous project, and took into account the priorities identified in the NSP. The Project design recognized that there was no proven "production function" to respond to HIV/AIDS in a complex epidemic such as the one in Jamaica. As such, the importance of research and M&E were considered critical in identifying the areas driving the epidemic, and the effectiveness (or not) of interventions, to continuously adjust the program to the changing nature of the epidemic. 15. Lessons reflected in the Project design. The Project design benefitted from a number of lessons learned from implementing the previous Bank-financed project, as well as from other Bank and donor financed projects throughout the Caribbean. These included: (a) the need to improve the strategic focus of prevention activities, by ensuring that behavior change efforts are skillfully designed to respond to the 3 complex socio-economic factors driving the epidemic; (b) the importance of TA in supporting efforts to foster an enabling environment, legal and regulatory reforms, and policy advocacy; and (c) the importance of a multi-sectoral response involving a cross-cutting range of stakeholders. 16. Lending Instrument. The lending instrument was a Specific Investment Lending (SIL) of US$10M with co-financing of US$1.54M from the Government. By Project closing, actual counterpart funding was US$2.24M, or approximately 145 percent of the appraised amount. 17. Assessment of risks and their mitigation. At appraisal, important risks were identified, with the overall risk rating assessed as Moderate. The risk mitigation measures were generally adequate as reflected in the design. Two key risks, however, and their corresponding mitigation measures were not identified: (a) insufficient counterpart funds, despite the fact that Jamaica had persistent issues with budget deficits and a major fiscal space constraint; and (b) the socio-cultural environment, which posed a persistent challenge in reaching MARP, in particular MSM. 2.2 Implementation 18. The Loan Agreement for the Project was signed on June 10, 2008, and became effective on September 23, 2008. Project implementation benefitted from the capacity built during the first HIV/AIDS Project, including a competent management team. As such, Project implementation commenced in April 2008 - in advance of both Project signing and effectiveness - due to retroactive financing. In addition, Project funds were pooled with other donor funds managed by the NHP, configuring a Sector Wide Approach (SWAp). This approach was never formalized in Bank documents, but was crucial to a coordinated and programmatic response to the epidemic. Notwithstanding achievements, a summary of implementation challenges is outlined below. • The global financial crisis substantially affected the availability of resources for implementing the NHP. In particular, the budget allocated to the NHP was reduced from approximately US$4.98M in 2009 to US$1.46M in 2010. Consequently, the GOJ used the Bank loan as its counterpart funding to meet an agreed condition of the Global Fund for HIV/AIDS, TB and malaria (GFATM) grant. The project funding was mainly used to support staffing cost to implement the activities under the NHP financed by the Global Fund. There was no funding allocated to implement the activities planned under Component 4 until 2011, when the funding situation improved, and the GOJ actually allocated additional funds to allow the Project to catch up with the delayed activities. Even though the Bank disbursement was low in the first few years of project implementation, the ISR ratings were based on the overall progress made under the NHP, which the project supported. • At the individual level, it can be inferred from global evidence that the global financial crisis also led to, and exacerbated risky behaviors. The available data indicated an increase in transactional sex; informal/ multiple 4 partnerships and reduced condom use by both men and women during the economic downturn from 2008 to 2012. This finding is consistent with the findings from a number of studies on the HIV/AIDS epidemic in sub-Saharan Africa, which show that poverty and income shocks negatively influence sexual behaviors. 1 Seeking financial and social security under an economic hardship could drive up risky behaviors. • Stigma and discrimination continued to be a challenge - as it was under the first operation - despite the scaling up of prevention interventions. Despite efforts such as the revision of the National Workplace Policy, as well as other initiatives in some Ministries, key populations at higher risk for HIV continue to face stigma and discrimination. • Development of an enabling environment was challenged by a number of factors, including: (a) limited support from the high level Officers of the Court, barriers to the proposed legislative amendment, and inadequate interest by legislators; and (b) the sensitization period required to gain the support of newly appointed Permanent Secretaries. • Limited capacity. While the implementation capacity of the NHP was strengthened under the first project, this changed during implementation of this project, with the turnover of almost all key Project Coordination Unit (PCU) staff members mainly due to the unforeseen future of the Project. The Government considered cancelling the Project several times as a means of reducing expenditure and the debt to Gross Domestic Product (GDP) ratio. This turnover led to a gap in both knowledge and institutional memory, and had a negative impact on implementation. In addition, relatively weak capacity at the regional and community levels proved to be a major concern, although this situation was partially addressed through the recruitment of procurement and financial management specialists in the four RHAs. 19. Due to initial delays in the Government budget allocation for Project implementation, a mid-term review (MTR) of the Project was conducted in May 2011, when the Project had disbursed US$4.5M, or 45 percent of the loan. The MTR was conducted jointly with development partners, and included a review of the Jamaica National HIV/STI Program. Prior to the MTR, several assessments on the performance of the National HIV/STI Program and the Bank-supported Project were conducted. The overall conclusion of the MTR was that while significant achievements had been made, AIDS remained a major threat in Jamaica, with the sustainability of efforts in prevention and treatment of AIDS, particularly among key populations, persisting as a challenge. The project performance further improved after the MTR. 20. The Bank provided important technical assistance to Jamaica under this Project. The Bank assisted Jamaica in developing new NSP 2012-2017. The Bank conducted jointly with the GOJ and UNAIDS an important study on the sustainability of the National HIV Response. The study results have helped the GOJ prepare a 1 Dinkelman et al.2007 & 2008; Robinson and Yeh 2011 & 2012. 5 sustainability plan for its National Response. The study has also served as a model for Caribbean countries for strengthening the sustainability of their national HIV responses. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 21. Design. By Project appraisal, the HIV/AIDS M&E system was well developed. 2 Most of the indicators in the results framework were drawn from the country's national M&E plan, which also served as the basis for the country's regular reporting to the United Nation General Assembly Special Session on HIV/AIDS every two years. However, the targets for a number of indicators had already been achieved; some targets were unrealistic; some indicators could not be tracked due to the absence of an appropriate data collection instrument; and a number of baseline and target indicators related to MSM were not defined. Consequently, discussions on revising the results framework were initiated during the first supervision mission in Sept 2008. The revised indicators were deemed to be: (a) more appropriate for attributing the Project’s achievements; (b) consistent with global knowledge on monitoring the epidemic at the Project-level; and (c) better linked to the priority areas of the Project. That said, the prevention outcome indicators (OIs #1 and #3) remained overly ambitious, as at the time it was not possible to anticipate the significant impact of the financial crisis in both maintaining gains achieved under the previous project, and in influencing further change. Also, as Project implementation later evolved into a SWAp Approach, there was an associated emphasis in monitoring programmatic NHP indicators. 22. Implementation and Utilization. Guided by the M&E Plan, the M&E system collected data and produced information to support and guide the national HIV/AIDS response. The results from the 2008 KABP, and 2007 MSM and 2008 CSW surveys, were used to develop targeted interventions to reach a higher percentage of key populations at higher risk for HIV. 3 Specific achievements in the area of HIV/AIDS M&E under the Project include: (a) development of the HIV M&E Plan 2012-2017 (which underpins the NSP) through an extensive participatory process; (b) support to making the HIV/AIDS M&E database web-based to allow direct inputting of data and reports electronically by key actors; (c) strengthening of the Laboratory Information System (LIS) at the National Public Health Laboratory (NPHL); (d) M&E capacity building for staff from each RHA, CSOs, Government ministries and the NHP, as well as pharmacies and treatment sites; and (e) increased operational research to guide program management and implementation. 2 (a) an HIV/AIDS tracking system had been established since 1989; (b) ANC/STI clinic attendees sentinel surveillance and second generation surveillance on SW were being carried out routinely, along with nationally representative surveys to obtain information on subgroups such as SW and MSM; and, (c) national KABP surveys were conducted every 4 years to monitor progress. 3 The term MARP has been recently replaced by “key populations at higher risk for HIV”. This term is considered to be more politically correct by the Joint United Nations Programme on HIV/AIDS. 6 23. Notwithstanding achievements, there were also a number of challenges: • Data collection and dissemination. Disaggregated data on some key indicators remained unavailable, limiting understanding of access to services by key populations at higher risk for HIV and the general population. In addition, gaps in collecting data from private health care professionals remained, along with ad hoc dissemination of data. Published data was often limited to surveillance data. • Databases. Interrupted power supply, inadequate human resources, and both limited buy-in by stakeholders and non-linkage of many HIV related databases, limited the usefulness of databases, and reduced the accuracy of data captured. Also, having purchased the licensing rights to implement the LIS nationwide, funds to train and equip staff were not available. • Limited capacity. Lack of capacity among key implementing agencies at sub- national levels to use available data for decision-making. • Partnerships. A lack of clarity about the services and deliverables expected from the NHP at the national level, coupled with limited coordination of M&E training between the M&E Unit of the NHP, and other training entities. 2.4 Safeguard and Fiduciary Compliance 24. Safeguards. The Project triggered OP/BP/GP 4.01 - Environmental Assessment - due to additional biomedical waste that would be generated from activities supported by the Project. The Government's Environmental Impact Assessment for the Southeastern Regional Medical (infectious) Waste Treatment Facility, which was publicly disclosed in Jamaica on September 13, 2007, was reviewed and considered valid for purposes of Project appraisal, and along with this, specific areas for strengthening biomedical waste were also identified. These included: training of health care workers on the handling of medical waste; support for drafting a new National Medical Waste Management Regulation; and upgrading regional medical waste collection systems and treatment facilities. Compliance to safeguards was consistently rated Satisfactory in Project Implementation Status Reports (ISRs). Despite some delay in the expansion of the Biomedical Waste Management Facility, all planned activities were successfully completed. 25. Fiduciary Compliance. Financial Management (FM) was rated Moderately Satisfactory at Project closing - and frequently during Project implementation - due to delays in both documenting incurred Project expenditures and submitting withdrawal applications, and in submitting Interim Financial Reports (IFRs) and audit reports. Audit reports, however, were unqualified, and auditors found no material weaknesses in the internal control arrangements of the Project, reflecting a favorable internal control system in place for administration of Project funds. FM challenges faced by the client, however, included: (a) a cumbersome payment process resulting from the ‘Structure of Government Contribution’ across components (for example, prevention 3 percent, treatment 5 percent) which required two checks for each purchase; and (b) the ceiling of US$850,000 for ‘Outstanding Advance’ under the Designated Account (DA), which proved somewhat restrictive during the economic recession, and contributed to delays in Project implementation. Although the Project provided for 7 the participation of the RHAs, for example, the funds from the DA could not be used to provide advances to these implementing agencies. This caused delays in the implementation of activities by the RHAs, and resulted in the GOJ providing cash flows by way of warrants. 26. Procurement. The handling of procurement was largely appropriate throughout the implementation period, with proper application of all procurement procedures. An independent review carried out in June 2013 found no major deviations, or indications of fraud and corruption. Procurement plans, however, were not updated on a regular basis, and unlike the careful handling of consultant and larger International Competitive Bidding and National Competitive Bidding packages, filing for small procurement was found to be non-existent in the procurement unit. In addition, delays in planning made it impossible to finalize some critical procurement and hence commit the full loan amount. On this basis, the independent review conducted at the end of the project rated Project procurement processing as Moderately Satisfactory. 27. The client raised a number of procurement issues throughout implementation: (a) the difficulties in obtaining three quotations under the shopping method; (b) the low thresholds for prior review for direct contracting and sole sourcing; and (c) concern that the Bank did not have the in-house technical expertise to clear the technical specifications for planned procurement on biomedical waste management, resulting in delays. 2.5 Post-completion Operation/Next Phase 28. In an environment with limited fiscal space, the Government has focused on improving the overall efficiency of the program, and the cost-effectiveness of interventions. In this regard, one major change has been the integration (approved in March 2013) of the NHP into the National Family Planning Board (NFPB) to form one statutory body. The overall goal of this integration is to strengthen the link between family planning, HIV/STI and sexual and reproductive health, and to maximize coverage and health outcomes for the population, while optimizing the use of scarce resources. In addition, the expectation is that this new structure should improve the capacity of the NHP to attract grant funding and international development assistance, as it provides a more optimal governance framework within which Projects can be financed and monitored. There is no follow-on World Bank health operation, although a Development Policy Lending Program is under preparation, which includes a health sector policy trigger on improving health financing, which could positively affect HIV/AIDS financing in the future. The GFATM is continuing to finance the Jamaica’s HIV/STI program during the transitional period from mainly donor financing to domestic financing. 8 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 29. The PDOs were and remain highly relevant and consistent with Jamaica’s priority to fight the spread of HIV/AIDS. The Project was and remains consistent with the global commitment to fight the spread of the HIV/AIDS epidemic; the Bank, country and sectoral assistance strategies; and the NSP. As previously noted, the Project design was guided by strategic and cost-effective priorities identified in the NSP. These priorities remain relevant today. On this basis, the relevance of objectives is rated High. 30. Project components, organization and the M&E design were reflected in the PDO. The design of this Project built on support provided under the previous Bank-funded Project, and contributed to the GOJ’s NHP by supporting: prevention programs targeting key populations at higher risk for HIV and the general population; and strengthening treatment, care and support and the country's multi-sectoral capacity to respond to the epidemic. Notably, the Project design included interventions not covered by GFATM funding, and complemented initiatives supported by other bilateral donors and UN agencies. In this regard, Bank funding - and the Project design - was harmonized with other ongoing efforts, and prioritized an overall coordinated response to the epidemic. 31. Project implementation was relevant, and in line with the PDO. As previously noted, the Project moved towards a SWAp. The informal SWAp arrangement assisted the GOJ in coping with budgetary constraints and allowed the Government to meet the GFATM counterpart funding requirement to obtain a US$48 million grant to implement the NHP. The implementation of the NHP has been successful and many of its programmatic indicators were achieved. The GFATM has rated the Jamaica NHP very highly. On this basis, Project design and implementation is rated as Substantial. Consequently, given high relevance of objectives, overall relevance is rated as Substantial. 3.2 Achievement of Project Development Objectives 32. The Jamaica HIV/AIDS response has resulted in a number of significant achievements. It is clear that this Project contributed to these achievements, particularly given the above mentioned SWAp approach. 4 An assessment of Project efficacy will review achievements under each of the individual PDOs in turn. A list of outputs by component is provided in Annex 2. 4 In monetary terms, the GFATM supplied the greatest financial assistance for Jamaica’s HIV/AIDS program over the period 2008 - 2013, contributing US$34.28m of the US$47.59m or approximately 72% of the expenditure. The World Bank was the second highest contributor, followed by USAID. 9 PDO #1: Deepening of prevention interventions targeted at high risk groups and for the general population 33. An estimated 27.5 percent of the loan amount was used to support prevention interventions, which represented an estimated 14% of funds going towards prevention activities in the NHP, with two of the Project’s three OIs linked to prevention activities. Both OIs were not achieved, and some results were below the baselines: the percentage of young people aged 15-24 reporting the use of a condom the last time they had sex with a non-regular sexual partner (OI#1), and the percentage of people expressing accepting attitudes towards PLWHA, of all people surveyed aged 15-49 (OI#3). 34. As discussed earlier the reduction in using condoms and an increase in transactional sex among young women are closely related to the difficult economic environment in Jamaica, over which the project had no control. The indicator related to attitudes towards PLWHA was a composite indictor with many dimensions. Progress was made in the areas of willingness of caring for PLWHA and allowing them to work, but not in the area of accepting PLWHA to handle food. 35. There was progress made towards achieving PDO#1 under the NHP, which the Project supported. The adult HIV prevalence rate has been maintained at less than 2 percent since the mid-1990s. Reductions in prevalence have also been accompanied by a reported decline in the number of new infections by 25 percent (Figures 1 and 2). HIV prevalence among female sex workers was reduced from 9% in 2005 to 4.1% in 2011. These were considered important accomplishments in the context of a severe financial crisis. 36. Improvements in HIV prevalence and incidence have been influenced by a number of key activities supported under the NHP. Specifically, HIV testing has been significantly scaled-up, and there has been significant outreach to key populations at higher risk for HIV and the general population. Significant efforts were taken to develop a multi-sectoral response through the formation of partnerships with select line and non-line Ministries. Figure 1: HIV prevalence, 1990 – 2010 Figure 2: HIV Incidence, 1990 - 2011 3 40000 2.5 30000 2 PLHIV 1.5 20000 1 New 10000 Infections 0.5 0 0 1990 1995 2000 2005 2010 1990 1995 2000 2005 2011 Source of Figures: UNAIDS (2013). “Investing to End HIV/AIDS. What should Jamaica do?” Presentation at Caribbean Regional Meeting on Strategic HIV Investment and Sustainable Financing, Jamaica, May 27 - June 1, 2013. 10 37. Achievement of this PDO was also measured through 6 IOIs: 4 were achieved and surpassed their targets and 2 were partially achieved. Based on this, and the foregoing discussion, achievement of this PDO is rated Modest. PDO #2: Increasing of access to treatment, care and support services for infected and affected individuals 38. An estimated 15.6 percent of the loan amount was used to support treatment, care and support services, 5 with one of the Project’s three OIs - which was achieved/ surpassed - linked to this PDO: the percentage of infants born to HIV infected mothers, who are HIV infected (OI#2). This indicator was reduced by 86 percent, and represents a significant achievement under the NHP and Project. Vertical transmission of HIV has been less than 5 percent for the past five years, down from a high of over 10 percent a decade ago. Specifically, the Project contributed to the success of the PMTCT Programme by training a wide cross-section of health care workers in PMTCT, and making alternative nutrition available for HIV-exposed infants for the first six months of life. Notably, Jamaica has also achieved the elimination of vertical transmission of syphilis as defined by having three consecutive years of less than 0.5 cases per 1000 live births (2008 – 2010). As such, Jamaica appears to be well positioned to achieve the regional target of elimination of MTCT of HIV and congenital syphilis by 2015. Considering these significant achievements, as well as full attainment of targets for 3 of the 4 IOIs as discussed below, achievement of this PDO is rated Substantial. 39. Two treatment indicators: number of men, women & children with advanced HIV receiving ACT according to national guidelines (IOI#8) surpassed the target by 1,469; and the % of HIV positive pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of MTCT (IOI#9) achieved its target. 6 The one care and support indicator: the % of ANC clients that are counseled and tested for HIV (IOI#10) was also achieved, and was estimated to be over 95 percent at Project closing. This is another significant achievement under the NHP and this Project. The indicator percentage of adults & children with HIV still alive 12 months after initiation of ART (IOI#7) improved by only 0.6 percent. PDO #3: Strengthening of program management and analysis to identify priorities for strengthening the health sector capacity to respond to the HIV/AIDS epidemic and other priority health problems 5 This represented an estimated 8% of funds going towards treatment, care and support activities in the NHP. 6 Achievement of these indicators benefitted from close harmonization and coordination between GFATM and WB funds For example, while access to ARVs was made possible through the financial support of the GFATM, this project facilitated, inter alia, the purchase of drugs for the treatment of Opportunistic Infections and STIs, as well as nutritional supplements to promote ARV medication adherence, and assist PLWHA who were economically marginalized. 11 40. This PDO spanned Components 3 and 4 of the Project - “Strengthening Institutional Capacity for Legislative Reform, Policy Formulation, Program Management, Monitoring and Evaluation” and “Health Sector Development Support”. An estimated 53.1 percent of the loan amount was used to support achievement of this PDO. Considering significant institutional strengthening under this PDO, both for the NHP and the health system as a whole, achievement is rated as Substantial. Specifically, institutional strengthening occurred in the following key areas: (a) Policy Formulation. There were notable achievements towards developing an enabling environment through the formulation, reform and introduction of a number of policies, position papers, and technical reports. These included: (i) preparation of a draft cabinet submission for the amendment of the Public Health Order (Notifiable Diseases) supported by a technical report on the proposed amendments; (ii) Adoption of the National HIV Workplace Policy as a Green Paper by Parliament in February 2010; (iii) Revision of the National Workplace Policy on HIV and AIDS in May 2012; (iv) presentation of a position paper with recommendations, outlining the proposed amendment to the Nurses and Midwives Act, to the Nursing Council of Jamaica on behalf the NHP; and (v) revamping the national HIV-related discrimination reporting and redress system. (b) National Public Health Laboratory and TB Laboratory. Capacity building (for example, hiring of essential staff members such as laboratory technical assistants), infrastructure, supplies and equipment were all provided to the NPHL and the TB Laboratory. (c) Waste management. While the original plan was to build a second Biomedical Waste Management facility, a decision was made in 2011, in response to the financial crisis, to expand the existing plant - with upgraded treatment, storage and transportation capacity - rather than build a new one (IOI#14). This upgraded facility can handle approximately 83 percent of the infectious waste generated by public health care facilities across the island, and is currently implementing environmental management and monitoring plans, in line with national guidelines (IOI#15). (d) HIV Program Management. As discussed in Section 2.3, significant support has been provided for HIV/AIDS M&E. This has been critical in both developing a strong evidence-based approach that complies with local, regional and international guidelines to inform the local response; and in paving the way for an efficient and sustainable response to HIV. 41. In addition to the two IOIs noted above, this PDO was also measured by an additional four IOIs. Three of these were fully achieved. One (additional) significant achievement under the Project has been an increase to 100 percent of the cases that are reviewed and referred to the relevant redress bodies with detailed recommendations for redress (IOI#11). This surpassed the target of 70 percent. In 12 addition, the percentage of institutions/organizations reached adopting HIV/AIDS policies (IOI#12) improved well-beyond its target of 93 percent, to 105 percent due to an additional 11 institutions/organizations being identified and targeted. A third IOI (#16) - Assessment of Health sector obstacles to [the] delivery of quality care - was completed, although through non-Project. The Bank did take a lead in supporting analytical work on the sustainability of Jamaica’s HIV/AIDS response. The one IOI which was not achieved is the Completion of computerization for Regional Labs (IOI#13). While the target was 3, no labs were computerized because of a delay in permission from the GOJ to use funds for this activity - given concerns regarding the tight macroeconomic environment - and at a much later stage, challenges with procurement. 42. Given “Modest” rating for PDO#1 and Substantial achievement on other two PDOs, overall Project efficacy is rated as Substantial. 3.3 Efficiency 43. By Project closing, approximately 96.5 percent of the loan had been disbursed. 44. The Project (and in effect the NHP) adopted a comprehensive approach involving funding for prevention interventions targeting both the key and the general populations, in addition to scaling up of treatment, care and support services. This approach maximized the number of infections averted and the number of Disability Adjusted Life Years (DALYs) saved. Specifically, Project interventions focused on selected internationally recognized cost-effective interventions for implementing the NSP, which were based on the drivers of the epidemic: STI management, interventions for key populations at higher risk for HIV, VCT, PMTCT, and ARV treatment. Although it is not possible to assess allocative efficiency of the NHP, and the Project, due to a lack of information on the financing, costing and outputs of the NHP, it is clear that Project interventions were technically sound, and made a significant contribution to the fight against HIV/AIDS. For example, there was a significant emphasis on prevention activities (Figures 1 and 2), which result in quantifiable benefits of averted productivity losses and savings on in-patient care and on treatment of opportunistic illnesses. 45. In addition to this, significant attention was placed on strengthening the multi- sectoral approach through partnerships with a cross-cutting range of stakeholders, as well as decreasing stigma and discrimination through interventions such as the development of an enabling environment, and outreach to both key populations at higher risk for HIV and the general population. Notably, the efficiency of this outreach was improved by promoting, inter alia, community interventions, workplace interventions, and VCT which target the general population while simultaneously allowing for the multiplier effect of prevention among key populations at higher risk for HIV. Approximately 18.9% of total expenditures on the prevention component were spent on MSM in 2011-12, up from 2.31% in 2009-10 and 7.89% 2010-2011. Meanwhile, expenditure on CSW and youth showed a decline of 61% (from 3.50% to 1.38%) and 8.4% (from 10.65% to 9.76%) respectively between 2011-12 and 2010- 13 11. This decline can be regarded as an efficient use of resources since given challenges in reaching MSM, but successes among CSW, a deliberate decision was made to increase resources focused on MSM, at the expense of CSW. Expenditures across categories for the Prevention Unit are shown in Table 3.2, Annex 3. 46. The efficiency of the treatment component of the Project can be quantified in terms of cost effectiveness, based on a death averted due to treatment and care. At a programmatic level, treatment has expanded from approximately 3,000 adults and children on treatment in 2007 to 10,469 by Dec 2012. At the end of 2012, 9,275 adults and children were started on Highly Active Antiretroviral Therapy (HAART). Over a similar period (2008 – 2011), the number of deaths reported has been held relatively constant (Figure 3.3, Annex 3). This is a significant achievement for the program as these figures represent the lowest level of reported deaths since 1998, and occur in the context of increased surveillance and greater case identification. Notably, the expanded program covering ART was made possible through careful harmonization and coordination between the Bank and GFATM. This donor coordination optimized the planning cycle and reduced duplication in both planning and implementation, and was a critical efficiency gain for the MOH, as it reduced the transaction costs associated with managing different donor funded activities. 47. Finally, one additional efficiency gain to the sector has been the integration of the NHP into the NFPB to form one statutory body. This integration should help to maximize coverage and health outcomes for the population, while optimizing the use of scarce resources, and improving efficiency in the overall response to reproductive health. In light of this discussion, overall Project efficiency is rated Substantial. 3.4 Justification of Overall Outcome Rating Rating: Moderately Satisfactory 48. On the basis of the Substantial relevance, Substantial efficacy and Substantial efficiency, the overall Project outcome is rated as Moderately Satisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 49. There is consensus that HIV/AIDS contributes to the persistence of poverty as it affects not only the stock, but also the accumulation of human capital. Also, HIV/AIDS affects economic activity in a number of ways. Consequently, through scaling up of prevention which averts infection, and treatment which averts death, the Project has had a positive impact on poverty. In terms of gender issues, the development of an enabling environment for women to make an informed choice, and economic empowerment of women are critical issues in reducing the vulnerability of women to HIV/AIDS. A significant reduction of HIV prevalence rate among female sex workers from 9% in 2005 to 4.1% in 2011 indicated the impact of the NHP. 14 (b) Institutional Change/Strengthening 50. The Project supported activities which aimed to strengthen institutional capacity in the areas of policy formulation, program management, and M&E. In addition, the Project also: (a) expanded the capacity of line ministries, RHAs (for example, in the areas of financial management and procurement), and non-state actors; and (b) supported the development of broad ownership and strong institutional coordination mechanisms for an expanded response, which included the involvement of all relevant key stakeholders. (c) Other Unintended Outcomes and Impacts (positive or negative) 51. This Project played a key role in helping the GOJ leverage additional donor funds. This included US$44.2M from the GFATM, and US$26M from USAID/PEPFAR. Based on the sustainability study conducted by the Bank in collaboration with the GOJ and UNAIDS, GFATM has provided an additional grant of approximately US$2M to Jamaica to assist with the transitional period from external to domestic financing. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops N/A 4. Assessment of Risk to Development Outcome Rating: Significant 52. Particularly in the last year of Project implementation, there was a concerted attempt to address sustainability issues, in an effort to reduce the risk to development outcome. The following factors should contribute to the sustainability of achievements: (a) continuing high level of Government commitment to the fight against HIV/AIDS; (b) development of an enabling policy and legal environment, with strong political support and leadership for dealing with HIV/AIDS; (c) development of broad ownership and strong institutional coordination mechanisms for an expanded response; and (d) conversion of a number of NHP positions into permanent established posts to create an institutionalized and sustainable core group of professionals to implement the NHP. 53. In spite of these measures, however, the risk to development outcome remains substantial. First, despite significant achievements, AIDS remains as a major threat to overall economic development in Jamaica. Secondly, this environment has been further challenged by the increasing cost of treatment, coupled with reductions in external financing. However, despite a severely constrained fiscal space, Jamaica is paying more of its HIV cost as donors withdraw support (Annex 3). Given limited budget allocations, there is both an operational risk that the country will not be able to sustain the momentum built by the Program; and a technical risk that the country will not be able to further develop and maintain an institutionalized and sustainable core 15 group of professionals to implement the NHP. Finally, stigma and discrimination remains high, and continues to affect both adherence to care, and risk taking behavior. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory 54. As a follow-on health operation, this Project was prepared in a short time period; built upon the successes and lessons learned from the previous health project; was strongly grounded in the NSP; and in line with the Bank’s accumulated technical expertise in the implementation of HIV/AIDS projects both in the Caribbean, and across the world. To ensure that there were no gaps in financing, the Project retroactively financed eligible expenditures up to an aggregate amount of US$1.3M. Important risks were identified and the risk mitigation measures were generally adequate. However, two challenges which had a significant impact on the pace of implementation, and which were not identified as risks in the PAD, were: insufficient counterpart funding; and the socio-cultural environment which posed a persistent challenge in reaching key populations at higher risk for HIV. (b) Quality of Supervision Rating: Moderately Satisfactory 55. Supervision missions were regular, and sought to proactively identify implementation challenges and issues requiring follow-up. In addition, the ISRs were clear, action-oriented, and candid, and sought advice and support, when necessary, to assist the client with Project implementation. The proactivity of the Bank team is clearly evident in a decision- shortly following Project effectiveness - to restructure the Project. Also, as previously discussed, the team should be commended for their efforts to support and encourage donor coordination, in the interest of an overall harmonized HIV/AIDS response. Finally, as discussed in Section 2.4, FM and procurement oversight and support by the Bank was considered to be generally adequate. However, there was consensus from the client on the need for more support in overcoming procurement-related difficulties, with an independent procurement review noting that the Bank could have increased flexibility and the quality of the procurement supervision. In addition to this, the Bank could have considered further revising the prevention outcome indicators (as discussed in Section 2.3) to make these more realistic particularly given the severity of the financial crisis to Jamaica. (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory 56. Based on the above discussion, which show moderate shortcomings in Bank performance in ensuring quality at entry and during supervision, overall Bank performance is rated Moderately Satisfactory. 16 5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory 57. The GOJ remains highly committed and supportive of the NHP and was very supportive of the Project. Specifically, the Government has made significant strides in the development of an enabling environment, and in particular, in trying to redress the high levels of stigma and discrimination through a number of policy reforms and consultations with key cross-cutting stakeholders. Although counterpart funding was a problem for a significant period of time due to a reduction in the Project's budget allocation by more than 60 percent (as a result of the economic crisis), it is important to consider that by the Project closing, counterpart funding was approximately 145 percent of the appraised amount, and the Government kept the project even when it was under pressure to reduce debt and provided additional funding for project activities when its budget situation improved. In addition, at least 20 consultants were integrated into the Government to create an institutionalized and sustainable core group of professionals to implement the NHP. In parallel, and given reductions in donor funding, the GOJ has been working to rapidly improve the efficiency and cost- effectiveness of the response. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 58. This Project was implemented by the MOH through its departments and the four decentralized RHAs; four key non-health line ministries and CSOs; and the Jamaica Business Council. The MOH - and in particular, the PCU under the NHP- coordinated activities, and provided technical and fiduciary support to implementing entities, which were responsible for execution of Project activities. The PCU included an experienced team of professionals that coordinated the technical and fiduciary activities of the first HIV/AIDS project. They had been trained in World Bank procedures and performed well under this Project. Notwithstanding good performance, and overall achievements of the NHP, the performance of the Implementing Agency (IA) is rated Moderately Satisfactory due to late planning on procurement-related issues (due in part to the absence of an integrated information system and heavy workloads of fiduciary staff); delays in the submission of IFRs and audit reports; and some delays in submitting work plans and in updating procurement plans. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory 59. Given Moderately Satisfactory rating of Government Performance in Ensuring Quality at Entry, and Moderately Satisfactory performance by the implementing agency, overall Borrower performance is rated Moderately Satisfactory. 17 6. Lessons Learned 60. The following key lessons have been derived from the implementation of this project. These are organized by thematic areas. 61. Prevention. Behavior change takes time, particularly in countries like Jamaica with complex socio-cultural environments. Consequently, it is important that the anticipated outcomes recognize and take into account: (a) the time lag between activities and results; (b) the potential challenges in setting and achieving Project targets; (c) the inputs and strategies needed to effect change; and (d) importantly, emerging options such as the use of treatment as prevention. 62. National HIV/AIDS Program. A strong HIV/AIDS response involves a number of critical inputs. Firstly, strong leadership at the highest governmental level generates the most effective national responses to HIV, but must be accompanied by a national strategic plan, which is technically sound, underpinned by epidemiological and behavioral data, and adequately funded. Secondly, there is a need to ensure that the response is inclusive and involves meaningful partnerships with all relevant actors at the national and local levels. Finally, strong leadership at the national level is critical in ensuring that donor funds are complimentary to, and harmonized with other ongoing efforts, and prioritize an overall coordinated response to the epidemic. 63. Operational. During Project preparation, the overall environment for procurement should be assessed, and the design of procurement arrangements should balance transparency and accountability with effective implementation. For instance, higher thresholds for requiring competitive bidding should be considered, along with some relaxation or flexibility of the need to obtain three quotations under the shopping method should be considered. This is particularly critical in small island states like Jamaica with limited numbers of local vendors, and small quantities, which make bidding unattractive to external vendors. In addition, the weak capacity, particularly in procurement could have been addressed through more hand holding and training to prevent some delays. 64. Sustainability. Given fierce competition for limited resources, it is critical that a sustainability plan is developed early on during Project implementation, with adequate stakeholder involvement to ensure ownership and “buy-in”. This plan should be underpinned by: (a) an understanding of the epidemic and past HIV programs; (b) an assessment of both allocative and technical efficiency; and (c) a consideration of the merits of a vertical HIV/AIDS program vis-à-visa more integrated and broader health systems approach. 7 7 The Bank with support from GOJ and UNAIDS carried out a study on the financial sustainability of the national HIV/AIDS response, which helped the government to develop a sustainability strategy plan for the National HIV/AIDS response. 18 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies – Annex 7 (b) Cofinanciers - NA (c) Other partners and stakeholders - NA 19 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Actual/Latest Components Estimate (USD Estimate (USD Percentage of Appraisal millions) millions) Prevention 3.34 2.98 89.22 Treatment, Care and Support 1.81 1.69 93.37 Strengthening Institutional Capacity for Legislative Reform, Policy 4.26 6.21 146.95 Formulation, Program Management, Monitoring and Evaluation Health Sector Development 2.10 .82 39.05 Support FX (Gain)/Loss .10 Total Baseline Cost 11.54 11.80 Physical Contingencies 0.06 Price Contingencies Total Project Costs 11.54 Front-end fee PPF Front-end fee IBRD 0.03 Total Financing Required 11.54 11.89 103.47 (b) Financing Appraisal Actual/Lates Type of Co- Estimate t Estimate Percentage Source of Funds financing (USD (USD of Appraisal millions) millions) Borrower 1.54 2.24 145.46 International Bank for 10.00 9.65 96.5 Reconstruction and Development 20 Annex 2. Project Components and Outputs by Component Description of Project Components 1. Component 1: Prevention (appraisal estimate: US$3.34M). This component aimed to scale-up prevention activities in support of efforts to halt and reverse the spread of the epidemic. Various implementing entities were expected to intensify their prevention activities: the Ministry of Health (MOH) and the Regional Health Authorities (RHAs), four non-health line ministries, Civil Society Organizations (CSOs) and the Jamaica Business Council. This component was comprised of three sub-components: (a) Prevention Activities by the MOH and RHAs to provide technical guidance for the national response to HIV/AIDS, and to deliver HIV/AIDS related prevention services; (b) Prevention Activities by the non-health line ministries to improve the multi-sectorality of the response; and (c) Prevention Activities by CSOs and the Private Sector. 2. Component 2: Treatment, Care and Support (appraisal estimate: US$1.81M). This component provided financing to support: (a) efforts to enhance laboratory diagnostic services; (b) training of staff in the use of new equipment; (c) refurbishing of selected treatment sites as well as the procurement of drugs and essential supplies (for example, nutritional supplements, and testing supplies); (d) refurbishing regional laboratories to facilitate decentralization of laboratory services; (e) training of staff, and health care workers in comprehensive management of HIV/STI/TB, prevention of mother to-child transmission (PMTCT), counseling and testing, public health management and behavior change communication; and (f) curriculum development to support training activities. 3. Component 3: Strengthening Institutional Capacity for Legislative Reform, Policy Formulation, Program Management, Monitoring and Evaluation (M&E) (appraisal estimate: US$4.26M). This component aimed to strengthen the institutional capacity for legislative reform, policy formulation, project management and monitoring and evaluation through three sub-components: (a) technical assistance (TA) to support Policy Formulation for an Enabling Legal and Regulatory Environment and Human Rights; (b) Program Management to support the coordination and management of the Government's NHP; and (c) support to the implementation of a comprehensive M&E system to provide continuous feedback to monitor trends in the epidemic and enhance the delivery of HIV services. 4. Component 4: Health Sector Development Support (appraisal estimate: US$2.10M). This component aimed to support the development of the health sector though: (a) upgrading and improving the management of the Biomedical Waste Management system; and (b) a comprehensive diagnostic assessment of the obstacles that limit the capacity of the health sector to deliver quality health care efficiently (including HIV/AIDS related services) to those needing it most, along with the investment and operational costs of the actions identified in the assessment. 21 Outputs by Component Component 1: Prevention (US$3.34M) - Subcomponent 1(a): Prevention Activities by the Ministry of Health (MOH) and the Regional Health Authorities(US$2.99M) - Subcomponent 1(b): Prevention Activities by the Non-Health Line Ministries (US$0.30M) - Subcomponent 1(c): Prevention Activities by Civil Society Organizations and the Private Sector (US$0.050M) Activity Beneficiaries Supported condom distribution and carried out three media Sexually active populations. campaigns to encourage condom use. The percentage of SW using condom has maintained above 90%. On-site rapid testing was increasingly provided to population, particularly key populations with higher risk of HIV infection. Expanded the Prevention of Mother-to-child Transmission (MTCT) Mothers and children. and more than 95% of pregnant women attended antenatal clinics and tested for HIV. The MTCT Transmission rate has been reduced from over 10% in 2006 to 2.4% in 2011. Jamaica is on track to achieve the regional target of eliminating MTCT by 2015. Expanded prevention activities targeting key populations. Targets Key populations. for reaching MSM and SW through prevention activities were surpassed and inmates reached by prevention activities was increased from less than 1% to 19%, during 2008-2012. Refurbished a major clinic facility for the incarcerated population, Incarcerated population. and also training and educational interventions. Strengthened capacity at the regional level for planning and All Regional Health implementing HIV/AIDS plans. Authorities. Developed and implemented sectoral HIV/AIDS plans and policies. Select Line Ministries and six Non-Line Ministries. Three Workplace Program Officers hired and deployed within 6 More than 2,500 staff ministries to develop and implement annual work plans, members sensitized. sensitization and training workshops. Nineteen agencies under the Office of the Prime Minister/Office of Staff at the Office of the the Cabinet were sensitized and 10 senior staff members were Prime Minister/Office of the trained to conduct these sessions contributing to sustainability of Cabinet, and associated the program. agencies. Component 2: Treatment, Care and Support (US$1.81M) Activity Beneficiaries Expansion of treatment of AIDS has significantly reduced AIDS AIDS Patients and their related mortality. More than 10,000 AIDS patients were under families. ARV treatment. Capacity building, infrastructure, supplies (including for syphilis testing) and equipment for the National Public Health Lab. Entire population Infrastructure and equipment for the TB Laboratory. TB patients 22 Supported 23 treatment sites to deliver integrated treatment to Entire population AIDS patients. Trained social workers and adherence counselors to provide counseling services. Procurement of HIV testing supplies, resulting in over 3,000,000 Entire population HIV tests conducted between 2008 and 2012. Procurement of alternative nutrition in support of the NHP Policy HIV-exposed infants for the which discouraged breast-feeding amongst HIV-infected mothers. first six months of life Annual Training/Capacity building for a wide cross-section of Health care workers health care workers in PMTCT. Purchase of drugs for the treatment of Opportunistic Infections as well as Sexually Transmitted Infections. Contraceptive General health sector methodologies for PLWHA were also provided under the Loan. PLWHA who were Nutritional supplements to promote ARV medication adherence. economically marginalized. Essential staff members such as laboratory technical assistants, Entire population social workers, liaison officers and HIV Coordinators were hired. Renovation of a new treatment site in Portland which is close to Residents of Portland completion. Updating of the HIV Management Manual. Entire population Component 3: Strengthening Institutional Capacity for Legislative Reform, Policy Formulation, Program Management, Monitoring and Evaluation (US$4.26M) - Subcomponent 3(a): Policy Formulation for an Enabling Legal and Regulatory Environment and Human Rights (US$0.412M) - Subcomponent 3(b): Program Management (US$3.308M) - Subcomponent 3(c): Monitoring and Evaluation (US$0.545M) Activity Beneficiaries Introduction of the Charter of Fundamental Rights and Freedoms, the amendment of the Sexual Offences Act and the commencement Entire population of work on revising the Public Health Order. There were notable achievements towards developing an enabling environment for HIV/AIDS. This included: (a) preparation of a draft cabinet submission for the amendment of the Public Health (Notifiable Diseases) Order supported by a technical report on the proposed amendments; (b) Adoption of the National HIV Workplace Policy as a Green Paper by the Parliament in February Entire population 2010; (c) Revision of the National Workplace Policy on HIV and AIDS in May 2012; (d) presentation of a position paper with recommendations, outlining the proposed amendment to the Nurses and Midwives Act, to the Nursing Council of Jamaica on behalf the National HIV/STI Programme; and (e) revamping the national HIV-related discrimination reporting and redress system. Appointment of three Workplace Programme Officers who were Line Ministries deployed within the ministries to mobilize and implement the annual work plans, and sectoral workplace policies. 23 More systematic and routine training was carried out to promote is Entire population community advocacy and increase HIV/AIDS awareness. Supported the implementation of the 2007-2012 M&E Plan and the Entire population development of one integrated database to support the NHP. Strengthened research capacity to carry out operational researches not only related to HIV/AIDS. The project supported the SW & MSM Second Generation Surveillance surveys and the KABP 2012 Entire population. survey. Results from these surveys and operational research provided valuable information for policy making. Component 4: Health Sector Development Support (US$ 2.10M) - Subcomponent 4(a): Biomedical Waste Management (US$2.0M) - Subcomponent 4(b): Diagnostic Capacity Assessment of the Health Sector (US$0.1M) Upgrading of the Biomedical Waste management plant in the Western Region, which is a state of the-art facility and has capacity to treat 83 percent of annual medical waste from public health Entire population facilities. To improve sustainability, services are provided under a Service Level Agreement. Development and implementation of environmental management Entire population and monitoring plans, in line with national guidelines at one plant. 24 Annex 3. Economic and Financial Analysis 1. A formal economic and financial analysis for the purpose of this ICR was not carried out. The information below is taken largely from the PAD, a study led by the World Bank on the Financial Sustainability of Jamaica’s HIV program, presentations from the 2012 Annual Review meetings, a presentation by UNAIDS on “Investing to End HIV/AIDS. What should Jamaica do?”, and a number of external data sources on the cost effectiveness of HIV interventions. All sources of data are listed in Annex 9. HIV/AIDS- Status and Trends 2. It is estimated that HIV prevalence is 1.7 percent among the adult population (15 to 49 years) but the prevalence rate is much higher among key populations at higher risk for HIV-MSM (32 percent) and CSW (5 percent). UNAIDS estimates that there were 32,000 PLWHA in 2009 (i.e. 1.1 percent of the total population of 2.8 million). This represented a small increase from previous years and was only slightly lower than at its peak when there were 33,000 PLWHA in the mid-1990s. The population has grown over this period, and thus the number of PLWHA has remained nearly constant. Consequently, seen in proportion to the population as a whole, the number of PLWHA implies a decline in HIV prevalence from 2.2 percent (1995) to 1.7 percent (2009) among those aged 15–49 years in 1995. 3. Among young adults, HIV/AIDS accounts for one-quarter of deaths between those aged 15 to 59 years, and is the leading cause of death among males between the ages of 30 and 44 years. The impact of HIV/AIDS has resulted in a substantial reversal of health gains achieved in other areas. For example, life expectancy in the country grew at an average rate of 0.2 years annually between 1955/60 and 2005/10 but as a result of HIV/AIDS life expectancy at birth was reduced in by 1.6 years in 2005/10. Such aggregate estimates, however, mask the role of HIV/AIDS among young adults. Figure 3.1 shows the HIV, Advance HIV, AIDS Cases and AIDS Deaths over the period 1982 – 2011. AIDS cases and deaths are disaggregated by gender in Figure 3.2. 4. Factors driving the epidemic continue to be: multiple sexual partners; insufficient condom use; High HIV rate among MSM; High HIV rate among CSW; Transactional Sex; PLWHA who are unaware of their status; early initiation of sexual activity; and High STI rate. The HIV prevalence rates among selected populations are outlined in Table 3.1 below. There is consensus that HIV/AIDS contributes to the persistence of poverty as it affects not only the stock, but also the accumulation of human capital. HIV/AIDS affects economic activity in several ways. It leads to decreases in productivity, increased absenteeism of the economic work force and increased turn-over. Moreover, HIV/AIDS depletes the stock of human capital as skilled workers die prematurely. At the same time that the epidemic causes an increase in the demand for government services (particularly in health), it can also lead to reductions in public revenues. As such, HIV/AIDS puts considerable strain on public finances, with a potentially substantial negative long-run impact of HIV/AIDS on economic development. 25 Figure 3.1: Annual HIV, Advance HIV, AIDS Cases & AIDS Deaths (1982 – 2011) 2500 HIV Adv HIV 2000 AIDS Number of Cases AIDS Death 1500 1000 500 0 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 HIV 1 1 0 9 41 100 77 137 185 332 480 530 597 838 971 112210641436153016671433168518631937212119471868173815621631 Adv HIV 1 1 0 3 8 34 36 65 70 143 135 219 335 511 491 609 643 892 903 939 989 107011121344118610981197148915031246 AIDS 1 1 0 3 8 34 36 65 70 143 135 219 335 511 491 609 643 892 903 939 989 1070111213441186 781 925 909 935 973 AIDS Death 0 1 1 0 9 18 21 40 37 105 108 146 200 269 243 393 375 549 617 588 692 650 665 514 432 320 401 378 333 392 Figure 3.2: Reported cases by Gender, 1982 - 2011 60.00 Male Female 50.00 40.00 Rate per 100,000 pop. 30.00 20.00 10.00 0.00 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 Male 0.090.090.000.260.601.692.203.853.806.397.7011.016.125.624.229.031.841.641.739.544.546.946.353.250.033.639.537.237.340.6 Female 0.000.000.000.000.001.280.851.601.995.353.266.6210.915.114.618.618.227.431.632.931.334.237.948.238.825.029.230.231.931.5 26 Table 3.1: HIV Prevalence among selected populations HIV Prevalence 2008/2009 2010/11 Adults 15-49 years 1.6% 1.7% 17 in every 1000 ( Spectrum estimate) ANC attendees (15 – 24 1.1% (2009) 0.90%(2011) 9 in a 1000 years) Female sex workers 4.9% (2008) 4.1% (2011) 41 in a 1000 STI clinic attendees 2.4% (2009) 2.8% (2010) 28 in a 1000 Men who have sex with 32% (2007) 32.9% (2011) 1 in 3;330 in a 1000 men Inmates 3.3% (2003) 2.46% (2011) 25 in a 1000 Homeless persons/Drug 8.82% (2009) 8.17% (2011) 81 in a 1000 users Source: Presentations at the National HIV/STI Programme 23nd Annual Retreat and Planning Review Workshop. Technical Justification for Project Interventions 5. Consequently, the most cost-effective interventions were selected to address the four priority areas of the NSP: (a) decrease stigma and discrimination, resulting in increased acceptability of services and increased uptake; (b) strengthen the multi- sectoral approach through partnerships which include improved capacity of all stakeholders, resulting in increased quantity, quality, availability and access to services; (c) develop a strong evidence-based approach that complies with local, regional and international guidelines to inform the local response; and (d) strengthen the M&E system to pave way for an efficient and sustainable response to HIV. Other guiding principles of the national response in the NSP included equity; participation of PLWHA; promotion and protection of human rights; transparency and accountability; and application of the International Labor Organization principles on HIV/AIDS and the world of work. The National HIV/AIDS Policy and the Draft NSP 2007-2012 put significant emphasis on the provision of a supportive legal and regulatory environment. 6. Prevention. During appraisal, the World Bank applied the Allocation by Cost-effectiveness (ABC) model. The model focuses on prevention programs only, and does not impose trade-offs between funding prevention against treatment and care. It analyzes alternative resource allocations differentiated by strategy and target population group. Findings from the application of this model indicated that a substantial impact can be obtained even with limited resources. The most cost- effective interventions were: condom distribution targeted to high-risk groups; information, education and communication for key populations at higher risk for HIV (including CSW, MSM, and prisoners and VCT). Although it is difficult to disaggregate funds spent purely on the key populations at higher risk for HIV from 27 the total prevention interventions, since community interventions, workplace interventions, and VCT can also reach key populations at higher risk for HIV —it is estimated that roughly 18.9% of total expenditures on the prevention component were spent on MSM in 2011-12, up from 2.31% in 2009-10 and 7.89% 2010-2011. Expenditure on CSW and youth showed a decline between 2011-12, and 2010-11, moving from 3.50% to 1.38%, and 10.65% to 9.76% respectively. Expenditures across categories for the Prevention Unit are shown in Table 3.2 below. Table 3.2: Prevention Unit- Expenditure Categories 2009 – 2010 2010 – 2011 2011 – 2012 Expenditure Categories (%) (%) (%) Communication for social and behavioral 73.80 39.13 33.32 change (general population) Voluntary counseling and testing (VCT) 4.74 10.68 1.97 Risk-reduction for vulnerable and accessible 2.95 14.10 21.14 populations Prevention - Youth in school 4.95 10.65 9.76 Prevention of HIV transmission aimed at 0.39 1.83 2.33 people living with HIV Prevention programs for sex workers and 1.71 3.50 1.38 their clients Programs for men who have sex with men 2.31 7.89 18.93 Total ( US$) 6, 491,207 5, 706, 085 3, 607, 702 Source: NASA Report based on all funding sources 7. The analysis further estimated that with an optimal allocation for these interventions of US$1.0 million would prevent between 5,100 and 12,000 infections, corresponding to between 11% and 19% of primary and secondary infections. Inclusion of secondary infections allows for the multiplier effects of prevention in some subgroups. The cost per infection averted was in the range of US$84 and US$196. Another finding was that at a budget of US$10 million, only about 25% of all primary and secondary infections can be prevented because it becomes increasingly difficult to reach certain population groups that are at highest risk. This implied that after a certain threshold, there is a need to go beyond these interventions to fund strategies that lead to expanded coverage, including reduction of stigma, decriminalization of certain behaviors, increased service coverage etc. 8. In spite of this, however, and as noted in the PAD, Governments do not allocate resources solely on the basis of cost-effectiveness. For ethical and human rights reasons other interventions at a given budget constraint level, would be less cost-effective. These include safe blood and PMTCT which may be selected by a Government for inclusion in the basic package of services. These recent findings are in line with earlier findings on cost-effective interventions outlined in Table 3.3 below. This table, adapted from Jha et al. (2001) summarizes the range of values from the literature relating to the cost-effectiveness of some of the most frequent interventions in HIV/AIDS prevention and treatment. 28 Table 3.3: Cost-Effectiveness of Different Types of Interventions (US$) Sex Worker STI VCT Anti- IEC to ARVs interventions management retroviral change in risky pregnancy behavior Cost per $8-12 $218 $249- $276 $1,324 HIV 346 Infection averted Cost per $0.35- $0.52 $9.45 $12.77- 10.51 $66.2 $720- DALY $17.78 $2,355 Saved 9. Individual country programs, therefore, will maximize the number of infections averted and the number of Disability Adjusted Life Years (DALYs) saved, in an effort to ensure that the most cost-effective interventions obtain sufficient attention and financing, and are not crowded out. Consistent with this thinking, Jamaica selected a comprehensive approach which has funding for preventive interventions both for targeting key populations at higher risk for HIV as well as for reaching the general population in addition to the proposed scaling up of treatment and care. 10. The efficiency of the treatment component of the Project can be quantified in terms of cost effectiveness for a death averted due to treatment and care. Treatment has expanded from approximately 3000 adults and children on treatment in 2007 to 9,680 by Dec 2012. At the end of 2012, 9275 adults and children were started on HAART. This represents a steady increase from 2004 when 400 patients were placed on treatment. Over a similar period (2008 – 2011), the number of deaths reported has been held relatively constant (see Figure 3.3 below). This is a significant achievement for the program as these figures represent the lowest level of reported deaths since 1998, and occur in the context of increased surveillance and greater case identification. Figure 3.3: Reported cases by Gender, 1982 - 2011 1600 1400 1200 1000 Deaths 800 ADV HIV 600 AIDS 400 200 0 2008 2009 2010 2011 Source: National AIDS Program 29 11. The cumulative deaths averted between 2008 and 2012 due to treatment are currently being estimated, although given that interventions have already been provided, the actual number of deaths averted is likely to be higher than that estimated. 8 12. The cost-effectiveness of antiretroviral therapy in the Caribbean was studied using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) international model, an adaptation of the CEPAC US model, a state-transition simulation model of HIV disease in resource-limited settings. Projections were made for survival, cost, and cost-effectiveness of treating and HIV-infected cohort in the Organization of Eastern Caribbean States (OECS). The data used was from the Jamaica HIV/AIDS Tracking System, a national surveillance database and projections. The results indicated that without treatment, mean survival was 2.3 years. One ART regimen added an additional 5.86 years of survival benefit compared with no treatment. The incremental cost-effectiveness ratio was US$ 690 per year of life saved. A second regimen added 1.04 years of survival benefit. The incremental cost- effectiveness ratio was US$10,960 per year of live saved. Results depended on the cost of ART second-line drugs and the per person lifetime costs decreased from US $17,020 to $ 9,290 if the costs of second-line drugs decreased to those available internationally. Financing for HIV and AIDS 13. Jamaica faces macroeconomic challenges including a high debt stock. Jamaica’s tight macroeconomic environment is diagrammatically shown in Figure 3.4 during Project implementation, the fiscal space restriction by the GOJ was a concern particularly during the last two years of the global recession. This resulted in the Project having to compete with the Figure 3.4: Jamaica's tight macroeconomic Government’s numerous priorities, as the environment 150 Government relied primarily on fiscal 2 140 contraction to address the level of aggregate expenditure, inflation and devaluation. 130 Consequently, budget allocations for the 0 National AIDS program were reduced by 2000 2002 2004 2006 2008 2010 2012 2014 120 more than 60% in 2009 and 2010 (from 110 US$4,979,500 to US$1,459,000). This -2 GDP resulted in the Program being able to pay GDP/D 100 staff salaries, but having no counterpart ebt -4 90 funding to contribute to Project activities. Source: IMF, World Economic Outlook, April 2013 8 Through scaling up of prevention, which averts infection, and treatment- which averts death, it can be argued that the project has- at least theoretically- had a positive impact on poverty. Notwithstanding this theoretical linkage, the PIOJ estimates that poverty levels have increased from 12.3% in 2008, to 16.5% in 2009, and to 18.5% - 20.3% in 2010. Consequently, roughly 500,000 Jamaicans currently are living below the poverty line. 30 14. Even in the post-recession period, budget allocations remain limited. As such, there is an operational risk that the country will not be able to sustain the momentum built by the Program. The sustainability of the ARVs, for example, is a major concern. Also, while most patients cannot afford to access HIV tests in the private sector, the public sector is under severe stress. On an individual level, the continued contraction of the Jamaican economy has negatively impacted the most vulnerable of the population. While the demand for social welfare benefits has increased, the pool of resources has not expanded to meet this need. As such, nutritional concerns including food availability and access to services (due to financial challenges) have been documented as major impediments to adherence. 15. In an environment with limited resources, and with decreases in external donor funding, Jamaica is increasingly covering most of the costs of the NHP (see Figure 3.5 below). Notably, while the GOJ financed less than 5% of direct costs over the period 2007 - 2011, they financed the majority of indirect costs. As such, there is a need to ensure that resources are focused on the most cost-effective interventions. Figure 3.6 shows how funding was spent across different priority areas between 2009 and 2011. Figure 3.5: Jamaica is paying more of its HIV cost as Donors withdraw support 100% 80% PEPFAR 60% World Bank 40% Global Fund GOJ 20% 0% 2009/10 2010/11 2011/12 2012/13 2013/14 Figure 3.6: What is Jamaica spending its money on? Management 2010/11 Social Mitigation 2009/10 ARV 19.3 15.3 Treatment, Care Prevention 0 5 10 15 20 25 30 35 40 45 Source of Figures: UNAIDS (2013). “Investing to End HIV/AIDS. What should Jamaica do?” Presentation at Caribbean Regional Meeting on Strategic HIV Investment and Sustainable Financing, Jamaica, May 27 - June 1, 2013. 31 Performance of the national response 16. The HIV/AIDS program has shown a number of significant achievements: (a) while over 30,000 Jamaicans still live with HIV prevalence has declined (see Figure 1); (b) incidence has declined from a peak of 5,495 (1993/4) to 2,022 (2011) (see Figure 2), and treatment is saving lives (see Figure 3.7). In 2010, 8,047 Jamaicans were on treatment, but 44% of those who needed it were not. That said, there is consensus that more effective strategies need to be found to reduce the high prevalence of HIV among MSM, with a specific emphasis on measures to increase their risk perception, reduce their social vulnerability, combat stigma and discrimination and empower MSM to practice safe sex. Figure 3.7: Treatment is saving lives; universal access to ARTs introduced in 2004 3.0% 800 Reported AIDS Deaths (Bar) 700 HIV Prevalence (Line) 2.5% 600 2.0% 500 1.5% 400 300 1.0% 200 0.5% 100 0.0% 0 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source of Figures: UNAIDS (2013). “Investing to End HIV/AIDS. What should Jamaica do?” Presentation at Caribbean Regional Meeting on Strategic HIV Investment and Sustainable Financing, Jamaica, May 27 - June 1, 2013. 17. According to the 2012 KAPB survey, however, HIV/AIDS knowledge is declining among youth- both males and females, and reflected in risky behaviour choices (see Figure 3.8). 9 This shows a worsening trend from the 2008 KABP which showed high awareness and knowledge of HIV- although these did not translate into behaviour change. 9 Correct preventive practices measures the proportion of the population able to endorse correct HIV/AIDS preventive practices. The younger age cohort (15-24 year olds) must endorse 3 preventive practices: condom use always, one faithful partner, abstinence while the older age cohort (25-49 year olds) must endorse 2 preventive practices: condom use always, one faithful partner. 32 Figure 3.8: HIV/AIDS KNOWLEDGE declining among Youth Endorsement of Correct Preventive Practices 100 75.2 78.6 79.5 78.3 78.3 79.9 74.3 72.8 80 65.3 % of repondents 63.3 56 55.3 60 40 20 0 Males 15-24yrs *** Females 15-24yrs ** Males 25-49yrs Females 25-49yrs. Year 2004 (baseline) Year 2008 Year 2012 Source: “Highlights of the 2012 national KABP survey”. Presentation at the National HIV/STI Programme 23nd Annual Retreat and Planning Review Workshop. Conclusion 18. In summary, Jamaica’s NHP aims to maximize the number of infections averted and the number of Disability Adjusted Life Years (DALYs) saved, in an effort to ensure that the most cost-effective interventions obtain sufficient attention and financing, and are not crowded out. Consistent with this thinking, the program has adopted a comprehensive approach which includes funding for both prevention interventions which are targeted to key populations at higher risk for HIV and the general population, as well as scaling up of treatment, care and support services. Project interventions are technically sound, and have made a significant contribution to the fight against HIV/AIDS, as evidenced by, for example, reductions in prevalence and incidence, and a significant scaling-up of treatment. Given a lack of information on overall financing for the NHP (including on both program expenditures and outputs), however, it is not possible to assess allocative efficiency of the NHP. 19. In spite of successes and in-roads in challenging areas such as influencing behavior change among key populations at higher risk for HIV, a key challenge in both sustaining and further scaling up the response will be financing. Jamaica continues to face macroeconomic challenges including a high debt to GDP ratio, coupled with reductions in external financing to the NHP. In this environment, further emphasis will be placed on maximizing efficiencies and cost-effectiveness of interventions. 33 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Keith E. Hansen Director LCSHD Sector Manager Mary T. Mulusa Sr. Operations Officer CFPIR Task Team Leader Patricia E. Macgowan Procurement Specialist LCSPT Procurement Specialist Emmanuel N. Njomo Consultant LCSFM Consultant Sr. Environmental Gunars H. Platais Sr. Environmental Economist LCSEN Economist Rolande Simone Pryce Sr. Operations Officer AFTG2 Sr. Operations Officer Financial Management Fily Sissoko Financial Management Manager SARFM Manager Aracelly Woodall Sr. Program Assistant LCSTR Sr. Program Assistant Yao Wottor Procurement Specialist LCSPT Procurement Specialist Willy L. De Geyndt Consultant LCSHH Consultant Supervision/ICR Joana Godinho Sector Manager LCSHH Sector Manager Shiyan Chao Sr. Economist LCSHH Task Team Leader Rianna Mohammed-Roberts Sr. Health Specialist AFTHW ICR Task Team Leader Carmen Carpio Sr. Operations Officer LCSHH Sr. Operations Officer Mary T. Mulusa Sr. Operations Officer CFPIR Task Team Leader Elizabeth Mziray Operations Officer HDNHE Peer Reviewer Robert Oelrichs Sr. Health Specialist HDNHE Peer Reviewer Maria E. Gracheva Sr. Operations Officer SASHN Peer Reviewer Norma M. Rodriguez Procurement Analyst LCSPT Procurement Analyst Sr. Financial Management Sr. Financial M. MozammalHoque LCSFM Specialist Management Specialist Sr. Procurement Yingwei Wu Sr. Procurement Specialist LCSPT Specialist Judith Morroy Procurement Specialist LCSPT Procurement Specialist Yao Wottor Procurement Specialist LCSPT Procurement Specialist Maria Elena Paz Gutzalenko Program Assistant LCSHE Program Assistant Viviana Gonzalez Program Assistant LCSHH Program Assistant Emmanuel N. Njomo Consultant LCSFM Consultant ZukhraShaabdullaeva Consultant HDNHE Consultant Judith Marcano Williams Consultant LCSHH Consultant Yuyan Shi Consultant LCSHH Consultant Harry ToewsWiebe Consultant LCSHH Consultant Gurdev Singh Consultant LCSDU Consultant Michael J. Darr Consultant LCSEN Consultant Willy L. De Geyndt Consultant LCSHH Consultant 34 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY08 19.53 213.95 Total: 19.53 213.95 Supervision/ICR FY09 10.68 63.30 FY10 17.34 66.39 FY11 14.88 105.54 FY12 24.15 146.54 FY13 27.69 136.80 Total: 94.74 518.57 35 Annex 5. Beneficiary Survey Results N/A 36 Annex 6. Stakeholder Workshop Report and Results N/A 37 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR 1. Jamaica’s response to HIV has been guided by a national plan since as early as 1988. Oversight of the response was provided by a well-established National HIV/STI Programme (NHP) and National AIDS Committee. Multi-sectoral involvement was a feature of the response from the very early stages. The NHP engaged other government ministries and agencies, non-governmental organizations (NGOs), community based organizations (CBOs), faith-based organizations (FBOs), the private sector, people living with HIV (PLHIV) as well as vulnerable populations. 2. Funding for the current Five Year Program (2008 – 2013) was provided from three main sources. The Global Fund provided grant funds of US$39.90 Million (67%) of the US$60.00 million of budgeted expenditure for the period. The IBRD provided loan financing of US$10 million or 17% of the total. USAID and direct funding from the Government of Jamaica accounted for the balance. 3. The World Bank loan was structured as an investment based loan with financing of detailed activities, with co-financing from the GOJ. This project benefitted from an accelerated preparation phase and was built on the previous World Bank loan which ended in March 2008 and achieved loan effectiveness in November 2008. 4. The loan however carried a retroactive financing clause which allowed for financing of activities from April 2008, the ending of the first loan, and November 2008 the formal commencement of the second loan. This allowed for a seamless transition from one project to the next and maintenance of the capacities, people and activities that were established through the first loan. The loan was structured with the following main components: Component 1: Prevention -The prevention component of the NHP was mandated to prevent new HIV infections. This included identifying new HIV infections and channeling these persons into existing treatment and care services. The IBRD loan accounted for US$2.80 Million or approximately 15% of expenditures in this component. Component 2: Treatment, Care and Support -The primary objective of this component was to increase the capacity to provide basic treatment, care and support to PLHIV. The IBRD Loan contributed US$1.56 Million or 7% of expenditure in this component. Component 3: Institutional Capacity for Policy Formulation, Programme Management and Monitoring & Evaluation -This component had the widest range of programme area and supported changes to the legislative and policy framework, coordination and management of the NHP and strengthening the M&E system. Of the total expenditure of US$57.01 million, it accounted for US$4.49 million or approximately 8%. The IBRD provided 72% of actual expenditure under this component over the period. 38 Component 4: Health Sector Development- This component was primarily concerned with infectious waste management and the assessment of the obstacles that limit the capacity of the health sector to deliver quality health care. All indicators for this component were IBRD indicators and the IBRD provided 100% financing or US$0.82 Million for this component. Table 7.1: Budget VERSUS EXPENDITURE by Components Component IBRD Budget ($M) Expenditure ($M) DRAFT Prevention 2.71 2.80 Treatment 1.65 1.56 Strengthening Capacity 4.56 4.49 Health Sector Development 1.05 0.82 Front-end Fee 0.03 0.03 10.00 9.70 5. There were no significant restructuring of the loan over the period though reallocations were made to the cost categories as per below table. One extension for three months was requested and granted resulting in the closing of the loan at the end of March 2013, rather than November 2012. Table 7.2: Revised Cost categories Cost Category Initial Budget ($M) Revised Budget ($M) 1 3.25 2.71 2 1.74 1.65 3 3.05 4.56 1.95 1.05 5 0.03 0.03 10.00 10.00 6. The project was geared towards achieving the below agreed targets which were restructured mid project as per below table. Table 7.3: Revised Indicators and Targets Key Indicators Original Target Revised Target % of young women and men aged 15 – 24 Men 70% Men 45% who both correctly identify ways of Women 80% Women 50% preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission % of young people aged 15 – 24 yrs. Men 85% (No change in target) reporting the use of a condom the last time Women 70% Men 85% they had sex with a non-regular sexual Women 70% partner % of SW reporting condom use with their >92% Maintain >90% most recent client 39 Key Indicators Original Target Revised Target % of SW reporting condom use with regular Maintain >90% paying client % of SW that received HIV testing in the 50% last 12 months and who know their results % of men reporting the use of a condom the 80% last time they had anal sex with a male partner Number of CSW and MSM reached through CSW: 30,000 prevention activities MSM: 19,000 Number of inmates reached through 15% prevention activities % of adults and children with HIV still alive 92% 90% 12 months after initiation of ART Numbers of men, women & children with 9,000 advanced HIV receiving antiretroviral combination therapy according to national guidelines % of HIV-positive pregnant women 100% Maintain at 80% receiving a complete course of ARV prophylaxis to reduce the risk of MTCT % of ANC clients that are counseled and 100% Maintain >90% tested for HIV % of infants born to HIV-infected mothers, <5% (No change in target) who are HIV-infected <5% % of reported cases of HIV-related 70% discrimination receiving redress % of people expressing accepting attitudes Men 46% towards PLWA, of all people surveyed aged Women 40% 15 – 49 yrs. Completion of computerization for regional Systems completed Systems completed labs and populating data for 3 regional labs Alternative treatment technology for 1 biomedical waste management established in the Western region Environmental management and monitoring 1 plans for each plant dealing with Biomedical Waste developed and being implemented 40 Main Achievements 7. The project realized many achievements over the period including maintenance of the adult HIV prevalence at less than 2% since the mid-1990s. HIV prevalence among public antenatal and STI clinic attendees also declined. While the HIV prevalence among antenatal women increased from 0.14% to 1.96% between 1989 and 1996, it declined over the last 15 years. The rates for 2010 and 2011 were at 1% and below. This overall decline was attributed to successful behavior change strategies among the general population. Also notable was that in 2010, UNAIDS reported that the number of new HIV infections in Jamaica had declined by 25% over the previous 10 years. Table 7.4: HIV Prevalence among key populations in Jamaica HIV Prevalence 2008/2009 2010/11 Adults 15-49 years 1.6% 1.7% ANC attendees 1.3% (2007) 0.93% (2010) 1.1% (2009) 0.90%(2011) Female sex workers 9.0% (2005) 4.1% (2011) 4.9% (2008) STI clinic attendees 2.4% (2009) 2.8% (2010) Men who have sex with men 32% (2007) 32% (2011) Inmates 3.3% (2003) 2.2% (2010) 3.3% (2006) 2.5% (2011) Homeless persons/Drug users 8.8% (2009) 12% (2010) 8.2% (2011) 8. In support of this success were the mass media campaigns developed by the NHP to address priority issues. These included: • Adherence to medication and promotion/normalization of voluntary HIV testing. • Sigma reduction. The “Yes I Can” campaign featured a second pair of persons living with HIV (PLHIV) publicly disclosing their status and encouraging support for PLHIV. This campaign was extremely important in facilitating the creation of an enabling environment. • Parenting and discussions about sexuality. Parents were encouraged to speak openly and honestly with their children about sex and sexuality through the “Time to Talk” campaign. • Multiple partnerships. “Stick to One Partner” was designed in response to Jamaica’s ongoing problem. • Condom use. Three media campaigns were developed to further encourage condom use: “Pinch, Leave an Inch and Roll” targeted building condom use efficacy among adolescents and young people, “Big Man Use Condom” featured a popular dance hall artiste and targeted young males while “Smart Sexy Wise” targeted females. 41 9. Prevention site-based interventions were implemented among SWs and MSM. Condoms and lubricant were distributed and risk reduction conversations and condom efficacy skills-building activities were conducted. The IBRD targets for number of SW (30,000) and MSM (19,000) reached through prevention activities were surpassed as interactions were had with over 40,000 SW and over 22,000 MSM. 10. Vertical transmission of HIV has been less than 5% for the past five years coming from a high of over 10% a decade ago. Additionally, Jamaica appeared to be well positioned to achieve the regional target of elimination of mother-to-child transmission of HIV and congenital syphilis by 2015. The national Prevention of Mother-to-Child Transmission (PMTCT) programme which was implement in 2004 included routine opt-out testing of antenatal clinic attendees, provision of antiretrovirals (ARVs) and access to alternate feeding for HIV-infected women. A national survey revealed that 95% of pregnant women attending public clinics in 2010 and 2011 were tested for HIV and treatment or prophylaxis was provided for more than 85% of HIV infected mothers and more than 98% of their infants received ARVs for PMTCT. Based on programme monitoring data this trend continued through 2012. 42 Table 7.5: PMTCT in Jamaica, 2006 – 2012 (Public Sector) 2006 2007 2008 2009 2010 2011 2012 No. of ANC 28,446 22,478 29,119 30,076 26,697 28,946 23,535 Attendees (95%) (95%) (>95%) Tested No. of HIV 442 358 616 440 432 317 344 positive women delivered % of women 85% 85% 84% 83% 86.3% 86.8% 85.8% getting ARVs No. of HIV – 433 362 612 439 419 313 340 exposed infants No. of Infants 403 350 605 430 408 311 (99%) 338 getting (93%) (97%) (98%) (98%) (97%) (99%) PMTCT (MTCT) <10% <5% <5% 4.3% 4.6% 2.4% To be Transmission determined Rate 11. HIV testing was significantly scaled-up over the years. The number of HIV tests done was less than 100,000 annually prior to 2004 but over three million tests have been done and results returned, cumulatively between 2008 and 2012 and by the end of September 2012, 9,680 adults and 453 children with advanced HIV were started on antiretroviral (ARV) treatment. 12. A state-of-the-art Waste Management Facility was upgraded at a cost of US$0.9M, expanding the treatment capacity to 1,000 Tonnes per year, which represents approximately 60% of the island’s annual medical waste generation of 1,600 tonnes, was also established to support public healthcare facilities. Other key achievements included: • In 2009, for the first time the GOJ provided funding to support 20 posts. Another major achievement during the period was the integration of the NHP into the National Family Planning Board (NFPB) in 2013 to form one statutory body with responsibility for sexual and reproductive health. • During the 2008 to 2011 period Jamaica had Prime Ministers from each of the major political parties. They committed to be high-level leadership advocates and to join the multi-sectoral partnership on HIV/AIDS. • In 2011, the People’s National Party again reaffirmed their commitment and The Honourable Bruce Golding, when he was Prime Minister signed his commitment to eliminate stigma, discrimination and gender inequalities affecting Jamaica’s HIV/AIDS Response. • Revision of the National Workplace Policy on HIV and AIDS in May 2012. It was revised based on ILO Recommendation 200 and recommendations from the Attorney General. It was resubmitted to the Human Resources 43 Committee of the Cabinet and approved as a White Paper in July 2012. The policy will be tabled in the parliament for approval. • Increased operational research occurred, including implementation of a national HIV research agenda through the Monitoring and Evaluation Reference Group (MERG) to answer key questions for programme management. • The HIV M&E Plan, 2012-2017: The M&E Plan was developed through an extensive participatory process of assessing the existing M&E system. • Completion of a comprehensive Health Sector Assessment Study supported by the IADB. This study provides a comprehensive assessment of the country’s burden of illness, the key programmes required to mitigate this to an acceptable level and proposes alternative financing mechanisms to fund the response. 13. The following Table indicates the project performance against revised targets. Table 7.6: Project performance against revised targets Indicator Revised Achievement Level of Completion Target % of young women and men Men 45% Men: 35. 6% Target partially aged 15 – 24 who both correctly Women 50% Women: 51.3% achieved. identify ways of preventing the (2012) sexual transmission of HIV and who reject major misconceptions about HIV transmission % of young people aged 15 – 24 Men 85% Men 79.25% Target not achieved. yrs. reporting the use of a Women 70% Women 57% condom the last time they had Among 15-19 year sex with a non-regular sexual olds, 82.9% of males partner and 75.3% of females reported condom use with non-regular partner. However, there was a sharp decline among the 20 – 24 year olds. % of SW reporting condom use Maintain 91% (2011) Target achieved. with their most recent client >90% % of SW that received HIV 50% 59.2% (2011) Target achieved. testing in the last 12 months and who know their results % of men reporting the use of a 80% 75.5% (2011) Target not achieved. condom the last time they had anal sex with a male partner Number of CSWs and MSM CSW: 30,000 CSW:40,445 Target achieved. reached through prevention MSM: MSM: 22,145 activities 19,000 % of inmates reached through 15% 19% Target achieved. prevention activities 44 Indicator Revised Achievement Level of Completion Target % of adults and children with 90% 75.6% (2012) Target partially HIV still alive 12 months after achieved. initiation of ART Number of men, women and 9,000 10,469 (2012) Target achieved. children with advanced HIV receiving antiretroviral combination therapy according to national guidelines % of HIV-positive pregnant Maintain at 85.8%(2012) Target achieved. women receiving a complete 80% course of ARV prophylaxis to reduce the risk of MTCT % of ANC clients that are Maintain >95% (2012) Target achieved. counseled and tested for HIV >90% % of infants born to HIV- <5% 1.4% Target achieved. infected mothers, who are HIV- infected % of reported cases of HIV- 70% 100% Target achieved. related discrimination receiving redress % of people expressing Men 46% Men 36.5% Target partially accepting attitudes towards Women 40% Women 33.8% achieved. PLWA, of all people surveyed Willingness to care aged 15 – 49 yrs. for a family member who was sick with HIV(81.8%), and agreement that a teacher who was HIV+ (but not sick) should continue teaching (76.3%) received broad endorsement but willingness to buy vegetables from an HIV+ person (28.9%) and keeping the HIV+ status of a family member secret (31.3%) did not. Completion of computerization Systems In progress. for regional labs completed for 3 regional labs Alternative treatment technology 1 1 Target achieved. for biomedical waste management established in the Western region 45 Indicator Revised Achievement Level of Completion Target Environmental management and 1 1 Target achieved. monitoring plans for each plant dealing with Biomedical Waste developed and being implemented Project Expenditure 14. The project realized expenditures of US$ 9.7 Million or 97% of the loan amount with vast majority of the under expenditure related to the non-procurement of two specialized medical waste collection vehicles and equipment for the decentralization of the Laboratory information system. Expenditures per Component and cost category is outlined below. Table 7.7: Expenditures per Component and cost category Component Category Revised Budget/ Final Expenditures at closing US$ (Un-audited)/US$M Prevention 1 2,714,000 2.80 Treatment & Care 2 1,647,000 1.56 & Support Strengthening 3 4,562,000 4.49 Capacity Health Sector 4 1,052,000 0.82 Development Front End Fee Front End Fee 25,000 0.03 Total 10,000,000 9.70 Main Challenges 15. While the achievements were many, there were some challenges. Despite a documented reduction in new HIV infections and the HIV prevalence among sex workers, prevalence rates remained high among MSM (32%). Behavioural surveillance revealed that the main factors driving the epidemic, namely multiple partnerships, early sexual debut, high levels of transactional sex and inadequate condom use, have remained high over the last 30 years. On the background of the country’s contracting economy, the global financial crisis and potential reduction in external funding, another major concern is the potential loss of gains due to challenges in the wider health system which limits the full integration and expansion of HIV services necessary to achieve and maintain sustainability. 16. Stigma associated with HIV also remained a concern throughout implementation. The socially marginalized groups, especially MSM, were still stigmatized and discriminatory acts were far too common. Stigma and discrimination also slowed the progress of development of social policy and legislation. Policy makers were reluctant to take bold steps to promote an enabling environment that 46 would reduce the vulnerability of those most at risk and better facilitate the provision of services and practice of safer sex. 17. Fighting the epidemic within the MSM population remained a significant gap in the programme. The HIV prevalence among MSM remained unacceptably high at 32% and there has been no improvement in the proportion of MSMs reporting the use of a condom the last time they had anal sex, from 74% that it was in 2008. 18. The practice of multiple partnerships which is a primary driver of HIV infections in Jamaica persist within our culture. The 2012 KAPB Survey reported a 2% increase between 2008 and 2012, with a significant increase noted among the 15 – 24 year-old age group. The target for the IBRD PDO indicator regarding the percentage of young people aged 15-24 reporting the use of a condom the last time they had sex with a non-regular sexual partner was partially achieved. 19. The percentage of young women and men aged 15 - 24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission has declined for males between 2008 and 2012. 20. Many implementing stakeholders lacked the capacity to conduct appropriate surveillance or evaluations and to use available data for decision-making. Very few stakeholders had a committed M&E position, and even fewer had developed M&E plans for their programmes. Other key challenges experienced during implementation included: • The ‘Structure of Government Contribution’ across components (e,g. Prevention 3%, Treatment 5%) led to additional administrative monitoring which resulted in additional accounting and audit costs. This was attributed directly to the fact that two (2) cheques had to be prepared (one from the Designated Account and the other from the GOJ) to suppliers in respect of each transaction. • Fiscal Space Restriction by the Government of Jamaica was a concern particularly during the last two years of the global recession. This resulted in the project having to compete with the Government’s numerous priorities, as the Government relied primarily on fiscal contraction to address the level of aggregate expenditure, inflation and devaluation. • The ceiling of US$850,000 for ‘Outstanding Advance’ under the Designated Account proved somewhat restrictive during the period of the recession. The GOJ was occasionally required to provide cash flow to meet urgent project expenses, with the World Bank subsequently reimbursing the GOJ Consolidated Fund. This contributed to delays in project implementation. 47 • In Procurement/Service Contracting the project was required to satisfy the procurement guidelines of the World Bank as stipulated in the Loan Agreement along with the contract procedures to be observed by government entities outlined in the local Contractor General’s ‘handbook’. From time to time this resulted in more than one tier of approval which led to programme delays. • Worsening poverty in view of the link between risky sexual behaviour and social inequities has implications for the spread of HIV. The Planning Institute of Jamaica (PIOJ) projected that poverty levels in Jamaica increased from 16.5% in 2009, and 12.3% in 2008to 18.5%- 20.3% in 2010. Consequently, roughly 500,000 Jamaicans currently are living below the poverty line. Lessons Learned • Strong leadership at the highest governmental level generates the most effective national responses to HIV. Along with this, a national strategic plan for HIV is essential to guide the response if human and financial resources are to be optimally utilized. Epidemiological and behavioural data must inform the development and monitoring of the national strategic plan. • Meaningful partnerships are critical to strong national and local responses. The partners include governments, health professionals, people living with HIV, vulnerable groups, local CBOS and NGOs. • Laws and policies that counter stigma and discrimination against people living with HIV and vulnerable populations reduce the negative impact of the disease and enhance prevention, health-promotion, treatment and care efforts. However, despite the non-existence of this enabling legal framework, significant work can still be done among those most vulnerable and marginalised groups. • Investment in prevention, treatment care and support at the present time significantly reduces future human and financial costs. Similarly, rational and effective use of antiretroviral and other HIV-related treatments improves the outcome by reduction in HIV and AIDS-related mortality and morbidity. • Wide-ranging public-information campaigns help counter denial, normalize HIV, reduce stigma and discrimination and lead to reduced levels of HIV infection. However, the main challenge to continued stigma is the reluctance of persons living with HIV to disclose to their family and friends. • Integration of the HIV response into sexual reproductive health programmes within the ambit of the primary health care response can lead to broader reach and deeper sustained impact. • Programme or Policy based loans with 100% financing may lead to greater efficiency in implementation. 48 Sustainability 21. The World Bank Project facilitated significant investments in the general health system as well supported the implementation of the national HIV response. Early after the introduction of the National HIV/STI Programme, the treatment and care component was integrated into the general health care system. Field health care workers (clinicians, pharmacists, nurses, social workers, contact investigators, etc.) received extensive and on-going training/updates over the period of the loan thereby ensuring institutionalization/sustainability of the treatment and care response. Capacity building sessions will continue post-loan and will be integrated into in- service education sessions. 22. The integration of the National HIV/STI Programme (NHP) into the National Family Planning Board (NFPB) to form one executive agency with responsibility for sexual and reproductive health will support the sustainability of the HIV Prevention Component and the Enabling Environment and Human Rights component has set up a steering committee consisting of legal officers from Ministries of Labour and Social Security, Health, National Security and Justice as well as civil society representatives to ensure continuity of its work. 23. The Government has also committed (by way of budgetary allocations) to continue to provide HIV testing and monitoring laboratory supplies, infant supplementary feeds as well as antiretroviral drugs. Conclusion 24. The World Bank Project facilitated significant investments in the general health system as well as supported the implementation of the national HIV response. The infrastructure investments including the expansion of the Portland Health department, Expansion of the capacity at the South East Medical Waste Management Plant and the expansion of the sample collection area of the National Public Health Laboratory will continue to serve the health sector for years to come. The investment in staff training and development will also be sustained as the Government has created posts for the key staff at the PCU and have taken over the payment of staff at the field level. The project also leveraged other resources as it formed the counterpart funding for the USAID and Global Fund projects and hence contributed to the overall success of Jamaica’s National Response. The integration of the HIV response into the National Family Planning Board to create a “One Authority” will also help to ensure sustainability of the gains achieved by the project. 25. The World Bank Project facilitated significant investments in the general health system as well supported the implementation of the national HIV response. The infrastructure investments including the expansion of the Portland Health department, Expansion of the capacity at the South East Medical Waste Management Plant and the expansion of the sample collection area of the National Public Health Laboratory will continue to serve the health sector for years to come. The investment in staff training and development will also be sustained as the Government has 49 created posts for the key staff at the PCU and have taken over the payment of staff at the field level. 26. The integration of the HIV response into the National Family Planning Board to create a “One Authority” will also help to ensure sustainability. 27. The current socio economic climate within the country however will continue to erode the gains and unless investments in HIV is continued at least at the same level the gains could be reversed in the medium term. 50 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A 51 Annex 9. List of Supporting Documents (a) Client Interviews Dr. Nicola Skyers, Director, National HIV/STI Programme Patricia Russell, Regional Behaviour Change and Communication Coordinator/ North East RHA. Karlene Temple-Anderson, Director, Enabling Environment and Human Rights/ National HIV/STI Programme. Dr. Sharlene Jarrett, Senior Director, Monitoring and Evaluation/ National HIV/STI Programme. Sannia Sutherland, Director, Prevention/ National HIV/STI Programme. Edgar Watson, Director, Finance/ National HIV/STI Programme. Dr. Geoffrey Barrow, Director, Treatment, Care & Support/ National HIV/STI Programme. Mrs. Saskia Frater Smith, External Cooperation Management Division. Nadia Adams, Procurement Manager/ National HI/STI Programme. Dr. Marcia Graham, Regional HIV/STI Coordinator/ Western Regional Health Authority. Dr. Sharon Lewis, Medical Officer (Health)/ Portland Health Department. Dr. Lundie Richards, Director/ National Public Health Lab. Dr. Kevin Harvey, Director/ Health Promotion and Protection Branch. Mr. Benjamin Waysome, Director, Strategic Human Resource Management/ MOH. Navarene Hylton, Director, Waste Management Unit. (b) Internal Bank Documents World Bank Aide-memoires (2008-2012). Mid-term review report, May 2011. Implementation Status Reports (2008-2012). Knowledge Attitudes and Behavior Surveys 2008, 2012. 52 Project Appraisal Document, April 9, 2008. Project Loan Agreement, dated June 10, 2008. National HIV Strategic Plan 2007-2012. ICR- HIV/AIDS Prevention and Control Project (Second Phase of the Multi country HIV/AIDS Prevention and Control APL for the Caribbean). (c) Presentations Harvey, Kevin (2012). “Sexual & Reproductive Health and HIV/AIDS: Integration for improve coordination and service delivery”. Presentation at the National HIV/STI Programme 23nd Annual Retreat and Planning Review Workshop. Skyers, Nicola. “The Epidemiology of HIV in Jamaica (Programmatic implications for the high risk approach).” Presentation at the National HIV/STI Programme 23ndAnnual Retreat and Planning Review Workshop. Sutterland, Sannia. “Highlights of the 2012 national KABP survey”. Presentation at the National HIV/STI Programme 23nd Annual Retreat and Planning Review Workshop. UNAIDS (2013). “Investing to End HIV/AIDS. What should Jamaica do?” Presentation at Caribbean Regional Meeting on Strategic HIV Investment and Sustainable Financing, Jamaica, May 27 - June 1, 2013. (d) External Documents Dinkelman, T., Lam, D., & Leibbrandt, M. (2007). Household and community income, economic shocks and risky sexual behavior of young adults: evidence from the Cape Area Panel Study 2002 and 2005. AIDS, 21(Suppl 7), S49. Dinkelman, T., Lam, D., & Leibbrandt, M. (2008). Linking poverty and income shocks to risky sexual behaviour: evidence from a panel study of young adults in Cape Town.South African Journal of Economics, 76, S52-S74. Haacker M (2004a). HIV/AIDS: The impact on the Social Fabric and the Economy. InHaacker M (ed.) The Macroeconomics of HIV/AIDS. International Monetary Fund,Washington: DC. Haacker M (2004b). The impact of HIV/AIDS on Government Finances and Public Services. In Haacker M (ed.) The Macroeconomics of HIV/AIDS. International Monetary Fund,Washington: DC. 53 Jha, P., et al. (2001) "The evidence base for interventions to prevent HIV infection in low and middle incomecountries". Background paper of the Commission on Macroeconomics and Health, the World Health Organization. Mziray, Elizabeth; Haacker, Markus; Shiyan Chao. 2012. Assessing the financial sustainability of Jamaica's HIV Program. Washington DC: World Bank.http://documents.worldbank.org/curated/en/2012/12/17120450/assessing- financial-sustainability-jamaicas-hiv-program. Robinson, J., &Yeh, E. (2011).Transactional sex as a response to risk in Western Kenya.American Economic Journal: Applied Economics, 3(1), 35-64. Robinson, J., &Yeh, E. (2012).Risk-Coping through Sexual Networks Evidence from Client Transfers in Kenya. Journal of Human Resources, 47(1), 107-145. 54 19°N 19°N 78°W 77°W JAMAICA Caribbean Sea Montego Montego Bay Falmouth Bay Runaway Bay Lucea St. Anns Bay HANOVER SAINT G rea Dry H Ocho Rios Oracabessa t Dolphin Head Montpelier arb Port Maria (545 m) our M JAMES T R E L AW AW N Y ts. SAINT SAINT Negril A N N Moneague MARY Annotto Bay WESTMORELAND Port Antonio Savanna SAINT Christiana La Mar Frankfield B Bluefield Linstead lu Bay ELIZABETH e PORTLAND Chapelton Walk Bog Walk SAINT M ck SAINT ou ANDREW nt Bla Mandeville C AT H E R I N E Halfway Tree Tree ai 18°N Black River CLARENDON Town Spanish Town Blue Mt. Peak ns 18°N (2256 m) Ped KINGSTON ro MANCHESTER May Pen SAINT Pla KINGSTON ins THOMAS Old Harbour Minh o 78°W Port Port Morant J AM AI CA Lionel Town Por tland Bight SELECTED CITIES AND TOWNS PARISH CAPITALS NATIONAL CAPITAL Caribbean Sea RIVERS MAIN ROADS 0 5 10 15 20 25 Kilometers RAILROADS SEPTEMBER 2004 This map was produced by the Map Design Unit of The World Bank. 0 5 10 15 20 Miles IBRD 33423 The boundaries, colors, denominations and any other information PARISH BOUNDARIES 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 INTERNATIONAL BOUNDARIES endorsement or acceptance of such boundaries. 77°W