Document of The World Bank Report No: 59634-BB RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF BARBADOS SECOND HIV/AIDS PROJECT LOAN APPROVED BY THE BOARD ON AUGUST 7, 2008 TO THE MINISTRY OF FINANCE, INVESTMENT, TELECOMMUNICATIONS, AND ENERGY July 19, 2011 1 Restructuring Status: Draft Restructuring Type: Level two Last modified on date : 03/29/2011 1. Basic Information Project ID & Name P106623: BB Second HIV/AIDS Project Country Barbados Task Team Leader Shiyan Chao Sector Manager/Director Joana Godinho Country Director Francoise Clottes Original Board Approval Date 08/07/2008 Original Closing Date: 11/30/2013 Current Closing Date 11/30/2013 Proposed Closing Date [if applicable] EA Category C-Not Required Revised EA Category C-Not Required-Not Required EA Completion Date 02/25/2008 Revised EA Completion Date 2. Revised Financing Plan (US$m) Source Original Revised BORR 59.39 59.39 IBRD 35.00 35.00 Total 94.39 94.39 3. Borrower Organization Department Location Ministry of Finance, Investment, Barbados Telecommunications and Energy 4. Implementing Agency Organization Department Location National Commission on Barbados HIV/AIDS 2 5. Disbursement Estimates (US$m) Actual amount disbursed as of 03/29/2011 7.85 Fiscal Year Annual Cumulative 2010 0.00 7.85 2011 3.00 10.85 Total 10.85 6. Policy Exceptions and Safeguard Policies Does the restructured project require any exceptions to Bank policies? N Does the restructured projects trigger any new safeguard policies? If yes, please select N from the checklist below and update ISDS accordingly before submitting the package. 7a. Project Development Objectives/Outcomes Original/Current Project Development Objectives/Outcomes The project would support the implementation of the 2008-2013 Barbados National HIV/AIDS Strategic Plan, specifically to increase: - Adoption of safe behaviors, in particular amongst key populations at higher risk. - Access to prevention, treatment and social care, in particular for key populations at higher risk. - Capacity of organizational and institutional structures that govern the NAP. - Use of quality data for problem identification, strategy definition and measuring results. 7b. Revised Project Development Objectives/Outcomes [if applicable] Regional Vice President: Pamela Cox Country Director: Françoise Clottes Sector Director: Keith E. Hansen Sector Manager: Joana Godinho Task Team Leader: Shiyan Chao 3 BARBADOS SECOND HIV/AIDS PREVENTION AND CONTROL PROJECT P106623 LOAN 7585-BB Restructuring Paper 106623 TABLE OF CONTENTS A. SUMMARY................................................................................................................ 5 B. PROJECT STATUS AND REASONS FOR PROPOSED CHANGES ............... 5 C. PROPOSED CHANGES .......................................................................................... 6 ANNEX 1. PROPOSED REVISIONS TO PROJECT PERFORMANCE INDICATORS ................................................................................................................... 8 ANNEX 2. REVISED PROJECT RESULTS FRAMEWORK .................................. 11 ANNEX 3: PROPOSED CHANGES TO THE DISBURSEMENT TABLE ............. 13 4 RESTRUCTURING PAPER PROPOSAL TO RESTRUCTURE BARBADOS SECOND HIV/AIDS PROJECT SUMMARY 1. This Project Paper seeks the approval of the Country Director to introduce changes in the Project Documents for the Barbados Second HIV/AIDS Project (the Project) (Loan No. IBRD 7585-BB). The proposed changes are to (i) allow for Bank funding to support the development of a Health Management Information System (HMIS) under Component 2 of the Project to strengthen the country’s capacity for evidence-based planning, (ii) modify all nine Performance Indicators to separate out the target from the indicator itself in the phrasing of each indicator and refine the definitions and targets, and (iii) increase Bank financing of Component 2 expenditures for goods and consultants’ services from 79% to 100% due to the difficulty in providing counterpart funding by the Government of Barbados due to the impact of the global economic and financial crisis. PROJECT STATUS AND REASONS FOR PROPOSED CHANGES 2. The US$35 million Loan Agreement for the Barbados Second HIV/AIDS Project was signed on September 25, 2008 and became effective on January 6, 2009. The Project is a follow-on project to the Barbados HIV/AIDS Prevention and Control Project, which was successfully completed on December 31, 2007. The Government sought the Bank’s support to finance the implementation of the National HIV/AIDS Strategic Plan for the period of 2008-2013 and to increase access to prevention, treatment and social care by most at-risk population groups (MARPs). 3. The implementation of this Project has benefitted from the capacity built during the first HIV/AIDS Project and has been making steady progress. As of April 11, 2011, US$ 7.9 million (22.4 percent) of the Loan has been disbursed. 4. Advances have been made in the areas of prevention and treatment. Fifteen policies have been approved or are under consideration out of the 17 recommended by UNAIDS, seven line ministries continue to be involved in the national response and are revisiting work plans to strengthen efforts in reaching the MARPs. The 2008 surveillance report has been completed which provides the country with evidence to better understand the nature of the epidemic and target cost effective interventions to MARPs. An updated revision of the draft Barbados Prevention Plan (2008-2013) is a key step in further defining target populations, and specific to Prevention of Mother to Child Transmission (PMTCT), a thorough review of missed cases was undertaken by the Ministry of Health, which can be replicated for analyzing AIDS deaths and newly infected HIV cases in the country. Progress has also been made under Component 2 - 5 Institutional Strengthening - as reflected in the capacity building program for HIV/STI management and exchange programs with Howard University and Brazil’s National HIV and AIDS Program. 5. The global financial crisis had a negative impact on the budget of the Government of Barbados, in turn affecting the provision of counterpart funds for the project. The implementation of the project, particularly Component 2 has been delayed. Through a letter dated July 29, 2010, the Government of Barbados has requested to increase Bank financing of Component 2 expenditures for goods and consultants’ services from 79% to 100%. Due to the need to improve the capacity for evidence-based planning, the Government also requested to use the Bank funds to support the development of a Health Management Information System (HMIS) under Component 2 of the Project, which was discussed and agreed upon during the July 2010 supervision and documented in the respective Aide Memoire. The Government also wanted to use the opportunity of the project restructuring to modify the Performance Indicators to improve the definitions of the indicators and their targets. A thorough review of the indicators took place during the July 2010 supervision mission at which time the Bank and Government agreed to review and refine the project’s performance indicators. After consultations through various means such as video-conferences, email exchanges, and a mission visit in January 24-29, 2011, consensus by the Government and the Bank was reached on the proposed changes to the indicators. PROPOSED CHANGES 6. The restructuring will involve the following changes: (a) Part 2 of Schedule 1 to the Loan Agreement will be amended to allow the project fund to finance the development and implementation of a Health Management Information System (HMIS). Establishing a national health management information system is one of the priorities that have been identified by the Government of Barbados. To support this priority is in line with the project objectives to increase the capacity of organizational and institutional structures that govern the National AIDS Program; and strengthening the use of quality data for problem identification, strategy definition and measuring results. A HMIS will be a long-standing contribution to strengthening the country’s overall health system, not only for HIV/AIDS, but also for other health sector issues. (b) Section II of Schedule 2 to the Loan Agreement will be amended to introduce revised Performance Indicators. Annex 1 presents the proposed changes to the Performance Indicators and their targets. The changes consist of: (i) modifications to the wording of all nine indicators to separate out the target from the indicator itself; (ii) technically refining indicators to improve clarity of the definitions which are provided in the Operations Manual; and (iii) revising targets for which updated information is available. Annex 2 presents the revised project results framework with the targets agreed upon by the national project team and Bank team after an intensive consultation process. 6 (c) Section IV of Schedule 2 to the Loan Agreement will be amended to increase the Bank financing of Component 2 expenditures for goods and consultants’ services from 79% to 100%. Annex 3 presents the revised disbursement table. The global economic and financial crisis has affected revenue generation in Barbados and the project has experienced difficulties in getting counterpart funding to finance activities under Component 2. The Government has requested that the Bank increase the financing percentage for Component 2 in order to speed up the implementation of this component. The change in the increase in the percentage from 79 percent to 100 percent will not affect the allocation to each component instead the Government has agreed to shift some activities from Component 2 to Component 1. The Government’s procurement plan has reflected this change. As of April 11, 2011, Component 2 has disbursed US$119,373 (3.4 percent) of the total component allocation of US$3.5 million. The increase of the Bank financing percentage under Component 2 will reduce the government’s contribution to Component 2. This may affect the total project cost if Government cannot increase its financing in the end. This will be reviewed during the Mid-term Review in December 2011. 7. Since the performance indicators have been changed, we also updated the disbursement letter accordingly. 8. The proposed changes will not affect the original Project Development Objectives or the project design. The revised indicators will allow for more accurate measurement of the Project’s progress and impact. The proposed changes will also not affect the economic, financial, environmental, technical and social aspects of the Project as appraised. The institutional arrangements will all remain unchanged with the Ministry of Health as the main implementing agency. The proposed restructuring will not trigger any new safeguard policies nor affect the environmental safeguard rating of the Project. 7 Annex 1. Proposed Revisions to Project Performance Indicators All indicators have been revised to separate out the target from the indicator itself in the phrasing of each indicator. Original (i) Maintain the percentage of young people aged 15-24 years spontaneously Indicator1: indicating sexual relations as a way of transmitting HIV at a level of at least 90% during 2008 to 2013. Proposed (i) Percentage of young women and men aged 15-24 indicating sexual relations as a Indicator way of transmitting HIV (target: maintain a knowledge rate of at least 90% during 2008-2013). Change: The word “spontaneously” has been deleted since this question was always asked with options Original (ii) Increase the percentage of sex workers who report the use of a condom with Indicator: their most recent client from 80% in 2008 to 95% in 2013. Proposed (ii) Percentage of female sex workers reporting the use of a condom with their most Indicator recent client (target: increase from 80% in 2006 to 85% in 2012). Change: This indicator has been defined to female sex workers since male and female sex workers have different social networks. Therefore, they can’t be included in the same Respondent Driven Sampling (RDS). At this point the project does not have information on male sex workers and it will need a separate survey, which has not been planned. So far the campaigns and individual/group interventions to promote condom use in sex work under the project were mainly for female sex workers. The information is more accurate under the revised indicator. The target for the indicator has been changed to 85% as the survey will be conducted in 2012, leaving only one year for the project to achieve the target. Thus, 85% is more realistic. Original (iii) Increase the percentage of men who have sex with men reporting the use of a Indicator: condom the last time they had sex from 65% in 2008 to 75% in 2013. Proposed (iii) Percentage of men reporting the use of a condom the last time they had sex Indicator with a male partner (target: increase from 64% in 2007 to 70 % in 2011). Change: The target has been revised to 70% for 2011 as opposed to 75% in 2013. The reason is that data from the MSM survey will be available in 2011 and a realistic target for year-end 2011 is 70%. At end of 2011 and with the available data, the project can revisit the indicator to establish a realistic 2013 target. Original (iv) Increase the percentage of young people aged 15-24 years reporting the 1 The indicators in bold are disbursement related indicators. 8 Indicator: use of a condom the last time they had sex with a non-marital, non- cohabitating sexual partner from 21% in 2008 to 31% in 2013. Proposed (iv) Percentage of young men and women aged 15-24 years reporting the use of a Indicator condom the last time they had sex with non marital non cohabitating sexual partner (target: increase from 21% in 2005 to 65 % in 2013). Change: The target has been increased to 65% in 2013 from the original target of 31% in 2013. The reason for the change is mainly to set up a higher goal for the project as this is the second AIDS project for the country and significant efforts having been made to reach the 15-24 population group, it is realistic to push the project for stark progress in this area. This revised target was agreed to by the NHAC and the MOH. Original (v) Increase in the number of people from key populations at higher risk accessing Indicator: preventive services from 250 in 2009 to 500 in 2013. Proposed (v) Percentage of most at-risk populations (female sex workers and men who have Indicator sex with men) reached with HIV prevention services (target: for men who have sex with men increase to 75% by 2012 and for female sex workers increase to 70% by 2012). Change: The revised indicator defines the two high-risk population groups because these are the two most at risk groups which the project is targeting. The revised indicator uses percentage as opposed to absolute numbers because the data source for this indicator is from a study that will sample the populations studied, all the results will be in percentages, which will give us information on the coverage. Original (vi) Maintain the percentage of HIV-positive pregnant women receiving a Indicator: complete course of anti-retroviral prophylaxis to reduce the risk of mother-to- child transmission above 95% during 2008 to 2013. Proposed (vi) Percentage of identified HIV-positive pregnant women who gave birth in the Indicator last 12 months receiving a complete course of antiretroviral therapy to reduce the risk of mother to child transmission (target: maintain at a rate above 95% during 2008 to 2013). Change: The proposed change defines a time period for reporting to avoid double counting and allows for accurately measuring the outcomes. What is meant by complete course will be included in the definition; new indicators will reflect adherence to treatment and access to PMTCT services. The "last 12 months" means January 1 to December 31 of the year that is being reported. Original (vii) Maintain the percentage of people living with HIV on antiretroviral treatment Indicator: achieving virologic success in the last 12 months above 70% during 2008 to 2013. Proposed (vii) Percentage of people living with HIV on first line antiretroviral regimen Indicator achieving virologic success within the first 6 months of treatment (target: maintain a virologic success rate above 70%). Change: Indicator changed from last 12 to first 6 months which is technically appropriate to measure success of this line of treatment. 9 Original (viii) Increase in the funds disbursed to civil society organization under results- Indicator: based agreements with the NHAC to facilitate implementation of targeted program interventions for key populations at higher during 2008 to 2013. Proposed (viii) Amount of funds spent by civil society organizations under results-based Indicator agreements (target: reach the amount to US$150,000 by 2013). Change: The amount has been decreased to US$150,000 due to the limited number of CSOs operating in the country and the slow start to the CSO Grant System. Original (ix) Prepare a Strategic Plan 2013-2018 based on surveillance and monitoring and Indicator: evaluation data gathered during the Project. Proposed (ix) An evidence-based Strategic Plan for 2014-2018 prepared by June 2013. Indicator Change: The indicator has been reworded to emphasize the need for the Strategic Plan to be evidence-based and has set the target date as June 2013. 10 Annex 2. Revised Project Results Framework Measurement Insert the measured value, or a qualitative indicator, or a brief explanation of why indicators are not available, together with the date of the information Key Performance Indicators Baseline Value End-of-Project Target Value Number or text Date Number or text Date 1. Percentage of young women and Maintain a men aged 15-24 indicating sexual 94.3% 2005-2006 knowledge rate 2008-2013 relations as a way of transmitting of at least 90% HIV 2. Percentage of female sex workers reporting the use of a 80% 2006 85% 2012 condom with their most recent client 3. Percentage of men reporting the use of a condom the last time they 64% 2007 70% 2011 had sex with a male partner. 4. Percentage of young men and women aged 15-24 years reporting 21% the use of a condom the last time 2005-2006 65% 2013 they had sex with non marital non cohabitating sexual partner. 5. Percent of most at-risk populations (female sex workers MSM: 75% 2012 and men who have sex with men) NA 2008 reached with HIV prevention FSW: 70% 2012 services. 6. Percentage of identified HIV positive pregnant women who gave Maintain a birth in the last 12 months 96% 2006 PMTCT rate > 2008-2013 receiving a complete course of 95% ARV to reduce MTCT 7. Percentage of people living with Maintain a HIV on first line antiretroviral virologic regimen achieving virologic 60% 2008 success rate: success within the first 6 months of treatment. above70% 2012 8. Amount of funds spent by CSOs US$ 0 2007 2013 under results-based agreements. 150,000 9. Evidence-based Strategic Plan Strategic Plan 2014-2018 Plan 2008 June 2013 2014-2018. 2008-2013 developed Disbursement Indicator 11 12 Annex 3: Proposed Changes to the Disbursement Table Category Amount of the Loan Allocated Percentage of (expressed in USD) Expenditures to be financed (exclusive of Taxes) (1) Eligible Program 31,412,500 35% subject to Part B Expenditures (EPE) paragraphs 1 through 4 below (2) Goods and consultants’ 3,500,000 79% of expenditures until services under Part 2 of the it reaches USD 119,373.00 Project and 100% thereafter (3) Front-end Fee 87,500 Amount payable pursuant to Section 2.03 of this Agreement in accordance with Section 2.07 (b) of the General Conditions (4) Premia for Interest Rate 0 Amount payable pursuant Caps and Interest Rate to Section 2.07 (c) of this Collars Agreement TOTAL AMOUNT 35,000,000 13 14