IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-75560) ON A LOAN IN THE AMOUNT OF US$10 MILLION JAMAICA FOR A SECOND HIV/AIDS PROJECT

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized 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

2 CURRENCY EQUIVALENTS (Exchange Rate Effective: August 27, 2013) Currency Unit 1.00 JMD = US$0.01 US$ 1.00 = $ JMD FISCAL YEAR (April 1 March 31) ABBREVIATIONS AND ACRONYMS AIDS ANC ART ARV CAS CBO CSW DALYs FM GDP GFATM GOJ HIV IBRD ICR IOI KABP LIS M&E MARP MOH MSM MTR NHP NPC NPHL NPV NSP OIs PAD PCU PDO PLWHA P(MTCT) R/F RHA SIL Acquired Immunodeficiency Syndrome Antenatal Clinic Antiretroviral Therapy Antiretroviral Country Assistance Strategy Community Based Organizations Commercial Sex Workers Disability-Adjusted Life Years Financial Management Gross Domestic Product Global Fund for HIV/AIDS, TB and Malaria Government of Jamaica Human Immunodeficiency Virus International Bank for Reconstruction and Development Implementation Completion Report Intermediate Outcome Indicators Knowledge, Attitude, Practices and Behavior Laboratory Information System Monitoring and Evaluation Most at-risk Populations Ministry of Health Men-having Sex with Men Mid-term Review National HIV/AIDS Program National Planning Council National Public Health Laboratory Net Present Value National Strategic Plan Outcome Indicators Project Appraisal Document Project Coordination Unit Project Development Objectives Persons Living with HIV/AIDS Prevention of (Mother to-child Transmission) Results Framework Regional Health Authority Specific Investment Lending ii

3 STD STI SW SWAp TB TA UNAIDS UNGASS USAID Sexually Transmitted Disease Sexually Transmitted Infections Sex Workers Sector Wide Approach Tuberculosis Technical Assistance United Nations Program on HIV/AIDS United Nation General Assembly Special Session on HIV/AIDS 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

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5 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 Key Factors Affecting Implementation and Outcomes Assessment of Outcomes Assessment of Risk to Development Outcome Assessment of Bank and Borrower Performance Lessons Learned Comments on Issues Raised by Borrower/Implementing Agencies/Partners Annex 1. Project Costs and Financing Annex 2. Project Components and Outputs by Component Annex 3. Economic and Financial Analysis Annex 4. Bank Lending and Implementation Support/Supervision Processes Annex 5. Beneficiary Survey Results Annex 6. Stakeholder Workshop Report and Results Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Annex 9. List of Supporting Documents MAP JAM iv

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7 A. Basic Information DATA SHEET Country: Jamaica Project Name: Jamaica Second HIV/AIDS Project Project ID: P L/C/TF Number(s): IBRD ICR Date: 09/30/2013 ICR Type: Core ICR Lending Instrument: SIL Borrower: Original Total Commitment: GOVERNMENT OF JAMAICA USD 10.00M Disbursed Amount: USD 9.65M 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 Process Date Process Original Date Revised / Actual Date(s) Concept Review: 10/30/2007 Effectiveness: 09/23/ /23/2008 Appraisal: 03/17/2008 Restructuring(s): 05/22/2009 Approval: 05/13/2008 Mid-term Review: 10/25/ /30/2011 Closing: 11/30/ /31/2013 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Moderately Satisfactory Substantial Moderately Satisfactory Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Moderately Government: Satisfactory Satisfactory Quality of Supervision: Moderately Satisfactory Implementing Agency/Agencies: Moderately Satisfactory Overall Bank Performance: Moderately Satisfactory Overall Borrower Performance: Moderately Satisfactory vi

8 C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: No No Moderately Satisfactory Quality at Entry (QEA): None Quality of Supervision (QSA): None Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 5 10 Health Other social services Solid waste management Theme Code (as % of total Bank financing) HIV/AIDS Health system performance Participation and civic engagement Population and reproductive health Tuberculosis 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

9 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) Indicator Indicator 1 : Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years % of young people aged reporting the use of a condom the last time they had sex with a non-regular sexual partner. Value quantitative or Qualitative) Men: 76% Women 66% Men: 80.0% Women: 75.0% Men: 85.0% Women: 70.0% Men: 79.3% Women: 57.0% Date achieved 05/13/ /30/ /16/ /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 Qualitative) 10.0% <5.0% NA 1.4% Date achieved 12/30/ /30/ /30/2012 Comments (incl. % achievement) Achieved. Indicator 3: % of people expressing accepting attitudes towards persons living with HIV/AIDS (PLWHA), of all people surveyed aged 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/ /16/ /30/2012 Comments (incl. % achievement) Not achieved. viii

10 (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Component 1: Prevention Activities Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1: Value quantitative or Qualitative) % of young women and men aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission. Men: 37.4% Women: 42.3% Men: 70% Women: 80% Men: 45% Women: 50% Men: 35.6% Women: 51.3% Date achieved 05/13/ /30/ /16/ /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/ /30/ /16/ /30/2011 Comments (incl. % achievement) Achieved. Indicator 3: % of SW who received HIV testing in the last 12 months and who know the results. Value quantitative or 43.0% 50% 50% (SW) 59.2% Qualitative) Date achieved 12/30/ /30/ /30/2011 Comments (incl. % achievement) Achieved. Indicator 4: % of men who have sex with men (MSM) reporting the use of condom the last time they had anal sex with a male partner. Value quantitative or 74.0% 78.0% 80% 75.5% Qualitative) Date achieved 12/30/ /30/ /16/ /30/2011 Comments (incl. % achievement) Indicator 5: Value quantitative or Qualitative) Partially achieved. The % of MSM reporting the use of condom the last time they had anal sex with a male partner improved by 1.5 percentage point. Number of commercial sex workers (CSW) and MSM reached through prevention activities. CSW: 7790 MSM: 7832 NA CSW: 14,955 MSM: 14,059 CSW: 40,445 MSM: 22,145 Date achieved 12/30/ /16/ /30/2012 Comments (incl. % achievement) Achieved. ix

11 Indicator 6: % of inmates reached through prevention activities. Value quantitative or Qualitative) < 1% NA 15% 19% Date achieved 05/13/ /16/ /30/2013 Comments (incl. % achievement) Achieved. The target was surpassed by 4 percentage points. Component II: Treatment, Care and Support Indicator 7: % of adults & children with HIV still alive 12 months after initiation of antiretroviral therapy (ART). Value quantitative or 75.0% 90% 92.0% 75.6% Qualitative) Date achieved 12/30/ /30/ /16/ /30/2012 Comments (incl. % achievement) Indicator 8: Not achieved. Compliance to ART has been affected by a number of issues: transportation costs, food availability, stigma and discrimination, and challenges in tracking and identifying patients at risk. Number of men, women & children with advanced HIV receiving antiretroviral combination therapy according to national guidelines. Value quantitative or 3,000 9,000 NA 10,469 Qualitative) Date achieved 12/30/ /30/ /30/2012 Comments (incl. % achievement) Achieved. Indicator 9: % of HIV positive pregnant women receiving a complete course of antiretroviral (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/ /30/ /16/ /30/2012 Comments (incl. % achievement) Indicator 10: Achieved. % 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/ /30/ /16/ /30/2012 Comments (incl. % achievement) Achieved. x

12 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/ /30/ /30/2012 Comments (incl. % achievement) Achieved. Indicator 12: Percentage of institutions/organizations reached adopting HIV/AIDS policies. Value quantitative or 31% 93% NA 100% Qualitative) Date achieved 12/30/ /30/ /30/2012 Comments (incl. % achievement) Achieved. Indicator 13: Completion of computerization for Regional Labs. Value quantitative or Qualitative) 0 Systems completed for 3 regional labs NA 0 Date achieved 12/30/ /30/ /30/2012 Comments (incl. % achievement) Not achieved. Component IV: Health Sector Development Support Indicator 14: Value quantitative or Qualitative) Alternative treatment technology for biomedical waste management established in the Western Health Region. Date achieved 12/30/ /30/2012 Comments (incl. % achievement) Indicator 15: NA 1 NA 1 03/30/2013 Due to the financial crisis, the GOJ decided to expand and upgrade the existing plant rather than building a new one as originally planned. The expanded facility could handle 83% of medical waste from public health facilities in Jamaica. Environmental management and monitoring plans for each plant dealing with biomedical waste developed and being implemented. Value quantitative or 1 2 NA 1 Qualitative) Date achieved 12/30/ /30/ /30/2012 Comments (incl. % achievement) The facility is implementing a monitoring and management plan based on the National Guidelines. xi

13 Indicator 16: Assessment of Health sector obstacles to delivery of quality care. Value quantitative or Qualitative) NA An analytical report with recommendations for improvement NA Report available. Date achieved 12/30/ /30/ /30/2012 Comments (incl. % achievement) Achieved. G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 06/30/2008 Satisfactory Satisfactory /12/2008 Satisfactory Satisfactory /19/2009 Satisfactory Satisfactory /03/2009 Satisfactory Satisfactory /28/2010 Moderately Satisfactory Moderately Satisfactory /23/2011 Moderately Satisfactory Moderately Satisfactory /09/2011 Satisfactory Satisfactory /22/2012 Satisfactory Satisfactory /28/2012 Moderately Satisfactory Satisfactory 7.09 xii

14 H. Restructuring Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO Amount Disbursed at Restructuring in USD millions 05/22/2009 No S S /24/2012 No S S 7.09 IP Reason for Restructuring & Key Changes Made To revise Project indicators in order to better reflect the reality of the epidemic (including updated data) and 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 from the negative impact of the global economic downturn on the Government s budget. I. Disbursement Profile xiii

15 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 year age group. It was estimated that 25,000 (1.5 percent) adults aged years were infected with HIV, with the majority (65 percent) of reported AIDS cases falling within the 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, percent), commercial sex workers (CSW, 9 percent), STI clinic attendees (4.6 percent) in 2005; and prisoners (3.3 percent) in 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 HIV/AIDS National Strategic Plan (NSP), and the 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, 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 FY Country Assistance Strategy (CAS) (Report #31830-JM), which itself was aligned 1

16 with the Government s Medium-term Socio-economic Policy framework for , 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, 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 reporting the use of a condom the last time they had sex with a nonregular 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 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 userswho 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

17 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

18 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, 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 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 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

19 partnerships and reduced condom use by both men and women during the economic downturn from 2008 to 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 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 &

20 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 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 (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

21 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 subnational 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 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

22 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

23 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 , 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

24 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 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 (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 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, Figure 2: HIV Incidence, PLHIV New Infections 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,

25 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 ( ). As such, Jamaica appears to be well positioned to achieve the regional target of elimination of MTCT of HIV and congenital syphilis by 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

26 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

27 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 multisectoral 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 , up from 2.31% in and 7.89% 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 and

28 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 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 At the end of 2012, 9,275 adults and children were started on Highly Active Antiretroviral Therapy (HAART). Over a similar period ( ), 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

29 (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

30 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

31 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 costeffectiveness 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 NHPcoordinated 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

32 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

33 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

34 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Components Appraisal Estimate (USD millions) Actual/Latest Estimate (USD millions) Percentage of Appraisal Prevention Treatment, Care and Support Strengthening Institutional Capacity for Legislative Reform, Policy Formulation, Program Management, Monitoring and Evaluation Health Sector Development Support FX (Gain)/Loss.10 Total Baseline Cost Physical Contingencies 0.06 Price Contingencies Total Project Costs Front-end fee PPF Front-end fee IBRD 0.03 Total Financing Required (b) Financing Source of Funds Type of Cofinancing Appraisal Estimate (USD millions) Actual/Lates t Estimate Percentage (USD of Appraisal millions) Borrower International Bank for Reconstruction and Development

35 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

36 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) 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 Jamaica is on track to achieve the regional target of eliminating MTCT by Expanded prevention activities targeting key populations. Targets 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 Refurbished a major clinic facility for the incarcerated population, and also training and educational interventions. Strengthened capacity at the regional level for planning and implementing HIV/AIDS plans. Developed and implemented sectoral HIV/AIDS plans and policies. Three Workplace Program Officers hired and deployed within 6 ministries to develop and implement annual work plans, sensitization and training workshops. Nineteen agencies under the Office of the Prime Minister/Office of the Cabinet were sensitized and 10 senior staff members were trained to conduct these sessions contributing to sustainability of the program. Component 2: Treatment, Care and Support (US$1.81M) Activity Expansion of treatment of AIDS has significantly reduced AIDS related mortality. More than 10,000 AIDS patients were under ARV treatment. Capacity building, infrastructure, supplies (including for syphilis testing) and equipment for the National Public Health Lab. Infrastructure and equipment for the TB Laboratory. Mothers and children. Key populations. Incarcerated population. All Regional Health Authorities. Select Line Ministries and six Non-Line Ministries. More than 2,500 staff members sensitized. Staff at the Office of the Prime Minister/Office of the Cabinet, and associated agencies. Beneficiaries AIDS Patients and their families. Entire population TB patients 22

37 Supported 23 treatment sites to deliver integrated treatment to AIDS patients. Trained social workers and adherence counselors to provide counseling services. Procurement of HIV testing supplies, resulting in over 3,000,000 HIV tests conducted between 2008 and Procurement of alternative nutrition in support of the NHP Policy which discouraged breast-feeding amongst HIV-infected mothers. Entire population Entire population HIV-exposed infants for the first six months of life Annual Training/Capacity building for a wide cross-section of health care workers in PMTCT. Purchase of drugs for the treatment of Opportunistic Infections as well as Sexually Transmitted Infections. Contraceptive methodologies for PLWHA were also provided under the Loan. Nutritional supplements to promote ARV medication adherence. Essential staff members such as laboratory technical assistants, social workers, liaison officers and HIV Coordinators were hired. Renovation of a new treatment site in Portland which is close to completion. Updating of the HIV Management Manual. Health care workers General health sector PLWHA who were economically marginalized. Entire population Residents of Portland 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

38 More systematic and routine training was carried out to promote is community advocacy and increase HIV/AIDS awareness. Supported the implementation of the M&E Plan and the 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 survey. Results from these surveys and operational research provided valuable information for policy making. Entire population Entire population Entire population. 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 and monitoring plans, in line with national guidelines at one plant. Entire population 24

39 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 years in 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 AIDS cases and deaths are disaggregated by gender in Figure 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

40 Number of Cases Figure 3.1: Annual HIV, Advance HIV, AIDS Cases & AIDS Deaths ( ) 2500 HIV Adv HIV 2000 AIDS AIDS Death '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 Adv HIV AIDS AIDS Death Figure 3.2: Reported cases by Gender, Male Female Rate per 100,000 pop '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 Female

41 Table 3.1: HIV Prevalence among selected populations HIV Prevalence 2008/ /11 Adults years ( Spectrum estimate) ANC attendees (15 24 years) 1.6% 1.7% 17 in every % (2009) 0.90%(2011) 9 in a 1000 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 men 32% (2007) 32.9% (2011) 1 in 3;330 in a 1000 Inmates 3.3% (2003) 2.46% (2011) 25 in a 1000 Homeless persons/drug users 8.82% (2009) 8.17% (2011) 81 in a 1000 Source: Presentations at the National HIV/STI Programme 23 nd 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 multisectoral 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 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 costeffective 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

42 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 , up from 2.31% in and 7.89% Expenditure on CSW and youth showed a decline between , and , 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 Expenditure Categories (%) (%) (%) Communication for social and behavioral change (general population) Voluntary counseling and testing (VCT) Risk-reduction for vulnerable and accessible populations Prevention - Youth in school Prevention of HIV transmission aimed at people living with HIV Prevention programs for sex workers and their clients Programs for men who have sex with men 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

43 Cost per HIV Infection averted Cost per DALY Saved Table 3.3: Cost-Effectiveness of Different Types of Interventions (US$) Sex Worker interventions STI management VCT ARVs $8-12 $218 $ $0.35- $0.52 $9.45 $ $17.78 Antiretroviral in pregnancy IEC to change risky behavior $276 $1, $66.2 $720- $2, 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 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 ( ), 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, Source: National AIDS Program Deaths ADV HIV AIDS 29

44 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 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 costeffectiveness 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 Government s numerous priorities, as the Government relied primarily on fiscal contraction to address the level of aggregate expenditure, inflation and devaluation. Consequently, budget allocations for the National AIDS program were reduced by more than 60% in 2009 and 2010 (from US$4,979,500 to US$1,459,000). This resulted in the Program being able to pay staff salaries, but having no counterpart funding to contribute to Project activities. Figure 3.4: Jamaica's tight macroeconomic environment GDP GDP/D ebt Source: IMF, World Economic Outlook, April 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% % in Consequently, roughly 500,000 Jamaicans currently are living below the poverty line. 30

45 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 , 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 Figure 3.5: Jamaica is paying more of its HIV cost as Donors withdraw support 100% 80% 60% 40% 20% PEPFAR World Bank Global Fund GOJ 0% 2009/ / / / /14 Figure 3.6: What is Jamaica spending its money on? Management Social Mitigation ARV / /10 Treatment, Care Prevention 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,

46 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 HIV Prevalence (Line) 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Reported AIDS Deaths (Bar) 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, 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

47 Figure 3.8: HIV/AIDS KNOWLEDGE declining among Youth % of repondents Endorsement of Correct Preventive Practices 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 23 nd 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