Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB3406 Project Name JAMAICA SECOND HIV/AIDS PROJECT Region LATIN AMERICA AND CARIBBEAN Sector Health (80%);Other social services (20%) Project ID P106622 Borrower(s) GOVERNMENT OF JAMAICA Implementing Agency Ministry of Health Address: 2-4, King Street Oceana Building, Kingston, Jamaica, West Indies Environment Category [ ] A [X ] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared October 30, 2007 Estimated Date of Appraisal Authorization March 10, 2008 Estimated Date of Board Approval May 27, 2008 1. Key development issues and Rationale for Bank involvement. Jamaica is the third largest island in the Caribbean with a population of 2.6 million. In 2005, the Jamaican adult population – aged 15 to 49 years – was 1.4 million. It is estimated that 25,000 adults are infected with the HIV virus or a prevalence rate of 1.5%. The gender difference has been narrowing and there are now almost as many female AIDS cases as there are male. The majority (65%) of reported AIDS cases fall within the 20 to 44-year old age group. The prevalence varies across different population groups: HIV prevalence was found to be 9% among commercial sex workers in 2005, sentinel surveillance of public sexually transmitted infections clinics recorded an increase of HIV prevalence from 3% in 1990 to 4.6% in 2005. Heterosexual transmission is reported by 90% of persons with HIV, although the sexual practice of 40% of reported male AIDS cases in Jamaica is classified as unknown. The most recent population survey (KABP 2004) showed a persistence of risky behaviors such as multiple partners (50% of men), participation in transactional sex (20% of men and women), and failure to use condoms with non-regular partners (30% of men and 40% of women). Risky behavior is also evident among adolescents: drop in the median age of first sex for both male and females, multiple partners, and low reported use of condoms. 2. Government Strategy. Jamaica has confronted the HIV epidemic proactively for nearly two decades, steered by the Government-led National HIV/STI Program (NHP) from 1986 and the National AIDS Committee (NAC) established in 1988. The national response has also been guided by earlier medium-term strategic plans and the National HIV/AIDS Policy approved by Parliament in 2005. The NHP is implemented through the public health system, non-health line ministries reaching different populations groups, civil society organizations and the private sector. NHP has been financed through the Government’s own resources and external resources of which the largest three were the Global Fund, the World Bank and the US Government. Other external partners included UN agencies and bilateral donors. The Jamaica national response has Page 2 2 been closely coordinated with the Caribbean Regional Strategic Framework. The NHP works closely with regional institutions, among them the Pan Caribbean Partnership against HIV/AIDS (PANCAP), the University of the West Indies, the Caribbean Broadcasting Media Partnership on HIV/AIDS, the Caribbean Coalition of National Program Coordinators and the Caribbean Network of Persons Living with HIV/AIDS. 3. The national HIV/AIDS program has included: prevention, utilizing behavior change communication strategies; treatment, care and support. The national response has been the result of a multi-sectoral approach involving a wide range of stakeholders and partners. There have been some notable achievements by the national program. Campaigns beginning in the early 1980s raised the general awareness of HIV/AIDS. The national Knowledge Attitude and Behavior (KAPB) surveys conducted from 1988-1994 recorded an increase in knowledge up to 97%, however, behavior change towards less risk lagged behind knowledge, and strategies were adopted to address this challenge. Interventions targeted both specific population groups and the general population: mass media campaigns, targeted education interventions for youth through schools and interventions for youth out of school; peer education for commercial sex workers (CSW), men who have sex with men (MSM) and prison inmates; work place policies in key public institutions; campaigns targeted to prevention of mother-to-child transmission. Condom use increased - use by about 76% of men and 66% of women with a non-regular partner. 4. Despite the achievements to date, there are still major challenges ahead in the fight against HIV/AIDS in Jamaica. There are still inaccurate perceptions about HIV/AIDS and behavior change aimed at reducing risky behavior has not been fully realized. The KAPB survey in 2004 recorded a decline in the median age at first sex to 15.7 years in males and 17.2 years for girls (from 16.4 years for boys and 18.2 for girls in 1996). In 2006, only 2,500 (62%) of people who need antiretroviral treatment were accessing the treatment. Two-thirds of people needing treatment seek medical attention at a late stage of the disease, when the efficacy of treatment and the level of recovery attained may be limited. The capacity of the health system requires strengthening to handle the needs posed by the HIV/AIDS epidemic. 5. The National HIV/AIDS Strategic Plan (NSP), 2007-2012. The Government of Jamaica continues to sustain its commitment to confronting the HIV epidemic with the new multisectoral National Strategic Plan, 2007-2012. The plan outlines the vision, goal and guiding principles. It lays out the priorities and the cost. Current fiscal constraints do not permit the Government to absorb alone the cost of the national plan. It, therefore, is seeking financial support from the World Bank. It identifies the four priority areas of intervention: a) Prevention . Increasing efforts to engage different players in the public and private sector for a multi-sectoral response aimed at reaching key vulnerable groups and the general population to reduce risky behavior. b) Treatment Care & Support . Enhanced screening and diagnostic services; voluntary counseling and testing; PMTCT services; antiretroviral treatment and strengthening services for management of sexually transmitted infections, and, psychological and social support. c) Enabling Environment & Human Rights. Updating of legislation; further development and implementation of workplace and sector-specific policies and programs (to safeguard privacy Page 3 3 and confidentiality and address stigma and discrimination); improving access to condoms and contraceptives through affirmation of reproductive health rights. d) Empowerment & Governance. Operationalizing the “Three Ones” principals; improving the procurement management system; and foster greater harmonization and collaboration among public and private sector and NGOs and religious leaders to promote greater tolerance and acceptance of PLWHA and risk reduction. 6. Bank Assistance . The World Bank supported the Government’s response through The Jamaica HIV/AIDS Prevention and Control Project whose objectives were to assist the Government to: (a) curb the spread of the HIV/AIDS epidemic; (b) reduce the morbidity and mortality attributed to HIV/AIDS; (c) improve the quality of life of persons living with HIV/AIDS; and (d) develop a sustainable organizational and institutional framework for managing the HIV/AIDS epidemic over the long term. The project has made significant contributions including: management of STIs and opportunistic infections; antiretroviral treatment; prevention of mother-to-child transmission; blood safety; condoms promotion; and, behavior change communication. Capacity strengthening included: program management and monitoring, technical training, upgrading of laboratories and other health facilities including installation of a new health care waste management system that will process about 60% of the biomedical waste of all health care facilities in the country. Support has been provided to five non-health line ministries involved in advocacy, anti-stigma campaigns and workplace policies. A number of NGOs, FBOs, CBOs, and other private sector organizations have received grants mainly for prevention activities. 7. Rationale for Bank Involvement. Jamaica needs to sustain its response to the epidemic. The next 5-year program as outlined in the NSP will require a substantial amount of resources. The Government will be looking to the Bank and the Global Fund as the two main sources of external funds to help it address the funding gap. In addition, the project will also finance critical elements of the response such as strengthening the health delivery system and involvement of non-health line ministries (responsible for education, internal security dealing with inmates, labor, etc.) that reach specialized groups that are unlikely to be funded by other agencies. The Bank would also finance CSOs to reach high risk and/or vulnerable groups and emphasize the role of a strong institutional framework and capacity building with an emphasis on monitoring and evaluation, which is critical for strengthening the national program. The new project will help the Government manage a process of increasing transferring of costs of critical staff to its national budget. 8. Proposed objectives. The project will support Jamaica’s National HIV/AIDS program. Its Development Objectives are to support the Government’s efforts to: (i) enhance coverage and quality of appropriate HIV prevention interventions targeting those at high risk as well as the general population; (ii) provide early diagnosis and comprehensive treatment, care and support for persons infected with the virus; (iii) reduce the degree of stigma and discrimination associated with the disease; and (iv) strengthen the collection and the use of reliable data to guide and monitor program implementation and to evaluate the impact of the program. Page 4 4 9. Preliminary Project Description. The project will be financed by a loan of US$10 million and will be implemented over a period of five years. The loan would be a specific investment loan which is considered the most appropriate instrument since the project will support a number of interventions across a number of implementing agencies across the public service (health and other line ministries), civil society and the private sector. The project will use a two pronged strategy: targeting interventions at high risk groups and implementing non- targeted activities for the general population, especially in the area of stigma and discrimination. Key performance indicators will track the contribution of the project in achieving the desired program impact and outcomes by measuring: (i) changes in coverage and quality of appropriate HIV prevention interventions for those at high risk as well as the general population; (ii) share of infected persons with access to antiretroviral therapy and to treatment for opportunistic infections; (iii) number of affected households, orphans and vulnerable children that receive social and financial support; (iv) positive change in acceptance and discriminatory attitudes by health care workers, people in the workplace, and in the community toward persons living with HIV as measured by, inter alia, surveys, incident reporting or hotlines; and (v) ability of the M&E system to provide a valid, reliable, and continuous data flow to monitor performance and measure the achievements of the national response. Intermediate indicators will monitor the correct use of prevention strategies and treatment processes and the availability of timely inputs that may be causally related to project impact and outcomes. The project will have the following four components: a) Component 1: Expanding the Health Sector Response to HIV/AIDS. This component will finance technical guidance to strengthen the capacity of the Ministry of Health to implement the national response, to deliver HIV/AIDS related services for prevention, treatment and care, and to ensure synergy between the HIV/AIDS program and health system strengthening. The first Bank-financed project has already benefited the health sector by improving the diagnostic capability of the national laboratory and by installing an island-wide biomedical waste management disposal system that already processes 60% of the healthcare waste in the country. This project would build on this effort by strengthening the capacity of the Regional Health Authorities health systems. b) Component 2 . Scaling up the response by non-health Line Ministries . This component will scale up the response to HIV/AIDS by these implementing agencies reaching specific population groups by tackling basic cross-cutting HIV/AIDS activities that include: implementation of workplace HIV/AIDS policies; IEC/BCC for HIV/AIDS and STIs; condom distribution; and advocacy to reduce HIV/AIDS stigmatization and discrimination, particularly in the work place and in prisons. Additionally there are HIV/AIDS related interventions that are specific to a particular ministry. Five ministries are already participating in the national HIV/AIDS response: (a) Education, Youth and Culture; (b) Labor and Social Security; (c) Tourism; (d) Local Government, Community Development and Sports and (e)National Security. This component would finance interventions of selected non-health line ministries based on approved annual work programs aligned with the NSP as well as training of focal points and their respective ministerial HIV/AIDS Committees. c) Component 3: Scaling up the Business Community Response and the Civil Society Initiatives . Private sector groups such as the Jamaica Business Council, the Jamaica Employers Page 5 5 Federation and other umbrella organizations will continue to be supported under this component in a harmonized program with the Global Fund and the Government. These groups are critical to continue dealing with workplace programs in private companies and in promoting anti-stigma policies. Demand-driven subprojects accounted for a small share of total expenditures of the first project and this component intends to increase the participation of NGOs and FBOs in the national response. These organizations are effective in reaching HIV/AIDS vulnerable groups that are difficult to reach. Subprojects would be funded on the basis of proposals presented by CSOs. d) Component 4: Strengthening Institutional Capacity for Program Management, Monitoring and Evaluation, and Legal Technical Assistance. This component will support strengthening the institutional capacity for scaling up the national response through financing technical advisory services, training, staffing, equipment, goods and general operating costs for the following activities: (a) Upgrading institutional capacity of the MOH not only for coordinating and managing the Government’s National HIV/AIDS Program but also for supporting the capacity of the health sector to provide health services and thereby ensuring synergy between the HIV/AIDS program and the health system strengthening; (b) Strengthening the Surveillance, Monitoring and Evaluation Systems; KAPB studies and targeted research studies; and, (c) Assessing and recommending changes to the legal framework to protect the rights of those infected and affected including amending the Public Health Act to repeal outdated legislation and proposing a General Anti-Discrimination law. Safeguard policies that might apply 10. One safeguard policy, Environmental Assessment (OP/BP/GP 4.01) is expected to be triggered. The Government has a bio-medical waste management system in place. A number of investments in equipment and staff training have been financed under the ongoing Bank-financed project. It is expected that since this is a follow-on project, it will rely on the assessment under the ongoing project, highlighting as necessary any additional areas of strengthening that would be financed through the new project. Tentative financing Source : ($m.) Borrower 1 International Bank for Reconstruction and Development 10 Total 11 Contact point Contact: Mary T Mulusa Title: Senior Public Health Specialist Tel: (202) 473-1937 Fax: (202) 614-6054 Email: mmulusa@worldbank.org