The World Bank Samoa Health System Strengthening Program (P164382) Program Information Documents (PID) Appraisal Stage | Date Prepared/Updated: 26-Sep-2019 | Report No: PIDA166055 Page 1 of 9 The World Bank Samoa Health System Strengthening Program (P164382) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Program Data Country Project ID Program Name Parent Project ID (if any) Samoa P164382 Samoa Health System Strengthening Program Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) EAST ASIA AND PACIFIC 05-Aug-2019 05-Dec-2019 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Program-for-Results Financing Ministry of Finance Ministry of Health Proposed Program Development Objective(s) The Program Development Objective (PDO) is to improve the quality and efficiency of NCD prevention and control in Samoa. COST & FINANCING SUMMARY (USD Millions) Government program Cost 40.54 Total Operation Cost 40.54 Total Program Cost 40.54 Total Financing 40.54 Financing Gap 0.00 FINANCING (USD Millions) Total World Bank Group Financing 9.30 World Bank Lending 9.30 Total Government Contribution 31.24 Page 2 of 9 The World Bank Samoa Health System Strengthening Program (P164382) B. Introduction and Context Country Context 1. Samoa, an upper middle-income country with a gross national income (GNI) per capita of US$4,120 in 1 2018 , is a small Polynesian island state located in South Pacific. The population of Samoa was 196,000 people distributed among the two main (Upolu and Savaii) and two smaller islands (Apolima and Manono). The major drivers of the Samoan economy are tourism, agriculture and fishing, remittances and aid flows. The economy expanded by an annual average of 4.3 percent between 2002-07, before the global financial crisis, but over the last decade growth has slowed to an average of 1 percent per year, due in large part to a sequence of economic shocks and natural disasters that have hit the country over this period. Samoa’s economic development opportunities are constrained by remoteness from large markets and foreign suppliers, the small size of the domestic market, as well as the high frequency and intensity of natural disasters, the risk of which is expected to be exacerbated by climate change. These challenges have translated into comparatively low and volatile gross domestic product (GDP) growth rates, a structural gap between domestic revenues and expenditures, elevated public debt, high vulnerability to external shocks and subsequently a significant reliance on development aid. 2. The Strategy for the Development of Samoa (SDS) for 2016/17 - 2019/20 focuses on “Improved Quality of Life for All� and aims to achieve 14 key national outcomes within 4 broad sectors: economic, social, infrastructure and environment. Health is prioritized in the SDS as a critical component of well-being under the ‘Social Policies’ priority area, with the sixth key Outcome being ‘A Healthy Samoa and Well Being Promoted’. A key objective under the social priority is “an inclusive, people-centered health service with emphasis on health prevention, protection and compliance through; a national immunization program; a screening program for rheumatic fever; and non-communicable disease (NCD) control and management programs.�2 Sectoral and Institutional Context 3. Health outcome indicators have steadily improved over the past three decades in Samoa, with Samoa having achieved the highest life expectancy in the Pacific and among the lowest infant mortality rates (IMRs). Health financing in Samoa has seen an overall increase, driven by increases in public spending on health. The GoS spending on health care constitutes a large proportion of total health expenditure (THE), with public health spending per capita increasing by 30 percent between FY2006-08 and FY2014-16. Private and out of pocket expenditure in Samoa is low in absolute and relative terms. At the same time, Samoa substantially depends on external development partner financing, which represents around 20 percent of the total health expenditure (THE). The low growth rates and strained fiscal situation suggest a limited scope for additional health financing in the future, underlining the necessity to increase allocative and technical efficiency to meet the growing needs. The World Bank-supported Public Expenditure Reviews of 2014 and 2017 in the health sector of Samoa identified a significant scope for efficiency gains and better value for money. Namely, the following were highlighted: (a) substantial increase in non-direct service related spending since the creation of the National Health Service (NHS) and a considerable expansion of the Ministry of Health (MOH) governance and support functions; (b) substantial payroll expansions observed in both MOH and NHS, which implies the risk of crowding out other input factors, 1Source: World Development Indicators, 2018. 2 Strategyfor the Development of Samoa 2016/17-2019/20: Accelerating Sustainable Development and Broadening Opportunities for all, December 2016. Page 3 of 9 The World Bank Samoa Health System Strengthening Program (P164382) such as medicines; (c) heavy investments in curative services by Government of Samoa (GoS), leaving more cost- effective preventive and primary health services under-funded; and (d) overseas treatment accounted for 10-15 percent of THE in 2009/2010, while benefiting only 0.1 percent of the population. Also, the National NCDs Cost Analysis Study found that utilization of essential NCD medicines is very low in Samoa compared to other developing countries, and that NHS paid on average three to six times the WHO benchmark price for their NCD medicines. 4. Despite the positive health outcomes, rising NCDs have become the top cause of mortality in the country. NCDs account for 75 percent of the total disease burden in 2016, and more than half of all premature deaths in the country; NCDs are also the major driver of overseas medical treatment. The major NCDs affecting Samoa are diabetes, ischemic heart disease, cardiovascular disease, asthma, chronic obstructive pulmonary disease and cancers, with 28.9 percent of the population being hypertensive, and 24.8 percent having diabetes. The top risk factors (high body-mass index, high fasting plasma glucose, dietary risks, and high blood pressure) relate to unhealthy lifestyles and drive most of the death and disability related with NCDs, underscoring the importance of changing behaviors. Samoa is among the countries with the highest overweight rates in the Pacific, which have grown from 25.5 percent to 67.5 percent between 1978-2001, with higher obesity prevalence among women and an increasing trend of childhood obesity. Tobacco smoke as a risk factor also remains high, with smoking rates of 35.8 percent for men and 15.5 percent for women over the age of 153. Furthermore, like many Pacific Island Countries climate change related phenomena may be influencing other risk factors driving the burden of NCDs, such as physical inactivity, food insecurity, and poor nutrition. 5. The current health service delivery system, with quality and efficiency as main concerns, is not well poised to tackle the rising NCD challenges. The previous Fa’a Samoa (Samoan way) service delivery model had a strong focus on health prevention, primary health care (PCH), and community engagement. However, the split of MOH and NHS a decade ago has weakened the focus on public health and primary care. Largely publicly- owned, the current system is heavily hospital-centric, with patients bypassing PHC and overcrowding in the national referral hospital in Apia. The allocation of resources (personnel, equipment, supplies, infrastructure and vehicles) is skewed towards the Tupua Tamasese Meaole main national hospital. The 11 rural health facilities, comprising 6 rural district hospitals (3 on Upolu and 3 on Savaii) and 5 community health centers (3 on Upolu and 2 on Savaii), are largely under-resourced, under-staffed, and lacking the capacity to diagnose and manage chronic NCDs. Lack of an effective, systematic NCD disease management model is the significant system weakness, leading to the poor quality of NCD care provision. Gaps in the NCD control chain include low screening rates, weak follow-up and referral, and a lack of a patient tracking system. As a result, most of the patients in Samoa have not been detected, diagnosed and/or put under regular treatment. The country is also facing human resource constraints with shortage of physicians, continued emigration of medical professionals to neighboring countries, lacking long-term workforce planning and a career path for medical staff working at primary care settings. The MOH/NHS split has further exacerbated these constraints by separating medical treatment and public health service, resulting in the lack of care coordination across the health system. 6. Government of Samoa’s policy to address NCDs is founded on the priorities articulated in the SDS 2016/17-2019/20. The Government’s new Health Sector Plan (2019-2029) recognizes that NCDs continue to pose 3 Source: Samoa HIES 2013/14. Page 4 of 9 The World Bank Samoa Health System Strengthening Program (P164382) a strategic challenge to Samoa and prioritizes improved prevention, control and management of NCDs as one of its seven key strategic outcomes. Program for Results Scope 7. The recently completed National NCD Policy 2019-2023 is aligned to the strategic goals of the Health Sector Plan 2019-2029. The new NCD policy is operationalized by an Action Plan which details five key strategic areas: 1) Governance, Leadership, and Partnership. The specific activities are: establish multi-sectoral mechanisms to plan, guide, monitor and evaluate and enact NCD multi-sectoral plans, policies and legislations; strengthen partnerships with health service providers of NCD health screenings and counseling; strengthen partnership with sports agencies and other recreational programs to promote healthy lifestyles in communities; strengthen policies and legislations for NCDs; strengthen leadership; political commitment and coordination; and strengthen partnership with the education sector. 2) Health Promotion, Advocacy and Risk Reduction. The plan focuses on strengthening NCD awareness programs in communities to promote the importance of a healthy lifestyle; developing and implementing the school health program (including health promotion, nutrition, oral health education, rheumatic heart disease, and immunization); strengthening breastfeeding counseling and education to community nurses to convey the benefits of breast milk to women in the villages; strengthening access to mental health services; and improving health services targeted towards people with disabilities relating to NCDs. 3) Health System Strengthening to Address NCDs. This focuses on strengthening the health system through improvement of infrastructure; workforce development and capacity building for NCD management, prevention and control; integrating and scaling up NCD awareness and screening; strengthening referral systems for management of NCDs; improving overall systematic planning of procurement of essential drugs, diagnostic equipment and supplies; ensuring that patients who are referred are followed-up in terms of treatment, management, and outcome. 4) Surveillance, Monitoring and Evaluation (M&E). The activities under this key strategic area are strengthening national NCD registration systems, in particular registries for cancer, mental illness (suicide) injury and disability; strengthening the vital and civil registration systems to improve medical cause of death in reporting; strengthening the M&E system on NCDs; and enforcing policies and legislations to promote healthy lifestyles. 5) Disaster preparedness and NCDs. The two activities under this strategic area focus on strengthening the health and climate change action plan; and strengthening emergency responses to preparing for increased NCD risk associated with climate change. 8. The proposed Program for Results (PforR) will support a subset of the Government’s National NCD Policy and Action Plan 2019-2023 over a five-year period (March 2020 - December 2025) with the focus on scaling up the essential interventions of NCD control at the primary health care and community setting. The PforR, which is expected to become effective in March 2020, will support the scaling up of NCD interventions from June 2020 to June 2025, and will focus on knowledge generation, dissemination of lessons learned, and evaluation in the second half of 2025, with a closing date at December 31, 2025. The Program corresponds to all five key strategic areas of the government Action Plan. Page 5 of 9 The World Bank Samoa Health System Strengthening Program (P164382) 9. The PforR has four result areas and eight Disbursement Linked Indicators (DLIs), which focus on measurable and achievable improvements in the efficiency and quality of NCD control in Samoa: Result Area 1: Address behavioral risk factors through population-based health promotion Result Area 2: Increase screening, referral and diagnosis of NCD high-risk group and NCD patients Result Area 3: Strengthen primary care and quality of NCD management Result Area 4: Strengthen multisectoral NCD program stewardship and build institutional capacity 10. Program beneficiaries. The whole population of Samoa will benefit from the Program activities focusing on NCD prevention and management. As mentioned above, women are disproportionately at risk of NCD risk factors particularly obesity. The high prevalence of obesity among women is not only a risk factor for NCDs, but also has negative implications for women in child birth, neonatal mortality and malformations as well as breastfeeding. Therefore, women will benefit more from awareness and prevention programs for NCDs and related risk factors as well as from proper care and treatment of NCDs. The Program will also support capacity building of women village committees on NCD risk assessment, adoption of healthy lifestyles in relation to family food production, nutrition and physical activity through the PEN4 Fa’a Samoa. A focus on primary school children will ensure support actions facilitating long-term sustainable behavior change to prevent the development of risk factors and subsequent disease onset in later-life. The Program also aims to enhance institutional capacity for NCD control through supporting the National NCD Committee, a multi-sectoral NCD governance body, in its decision making and strategic guidance, and financing the capacity building of MOH in overall program implementation. The health workers in the primary health care facilities will also benefit from the training on standardized NCD management protocols. 11. The Program also aims to enhance institutional capacity for NCD control through supporting the National NCD Committee, a multi-sectoral NCD governance body, in its decision making and strategic guidance, and financing the capacity building of MoH in overall program implementation, with priority areas including monitoring and evaluation, information system, medical waste management, procurement, budget planning and reporting. The health workers in the primary health care facilities will also benefit from the training on standardized NCD management protocols. 12. Excluded activities. The PforR currently does not include any activities that are likely to have significant adverse impacts that are sensitive, diverse, or unprecedented on the environment and/or affected people. In terms of land access for construction of doctors’ accommodations and two regional district hospitals, for any proposed site where land lease is required which has not previously been in the control of MOH, screening for impacts would be undertaken, including brief assessment of physical and livelihood impacts. If significant impacts are identified or any primary residence must be relocated, the site shall be excluded from the PforR in accordance with the Bank's Policy and Directive on Program-for-Results Financing. The PforR also does not include any high- value contracts, which are normally not eligible for PforR Financing. 13. Role of development partners. External development assistance in the form of government bilateral aid, grants, credit and in-kind support constitutes an important part of total health sector spending in Samoa. Australia’s Department of Foreign Affairs and Trade (DFAT) and Ministry of Foreign Affairs and Trade of New 4 WHO Package of Essential Tools for Non-Communicable Disease Control (PEN). Page 6 of 9 The World Bank Samoa Health System Strengthening Program (P164382) Zealand (MFAT) are the two major, long-standing donors providing substantial development support to Samoa. Both DFAT and MFAT have indicated that addressing the NCD crisis and developing PHC are the priorities for their bilateral aid to Samoa. In recent years, China has become another significant partner through funding construction of the National Hospital and MOH Headquarters, providing medical equipment and devices as well as dispatching physicians to work in Samoa. The ADB is providing US$6 million to support an eHealth project. The World Health Organization provides technical assistance to GoS in supporting various programs, including PEN Fa’a Samoa. In addition, the United States Agency for International Development, and various United Nations agencies (UNFPA, UNICEF and UNAIDS) also support GoS in implementing various programs. Both DFAT and MFAT are currently in discussion with Samoa government to formulate the updated bilateral aid program in the health sector. The World Bank team is engaged closely with development partners to explore possible synergies with the proposed operation, including financing capacity building and international technical assistance when implementation begins. C. Proposed Program Development Objective(s) Program Development Objective(s) 14. The Program Development Objective (PDO) is to improve the quality and efficiency of the service delivery in Samoa for tackling the rising NCDs. 15. The following five PDO-level Program results indicators will be used to reflect and measure success in achieving the PDO: 1) Percentage of children ages 5-12 years, screened as overweight through school nurse program, who are referred and managed by a health promotion program, disaggregated by gender. 2) Number of districts with PEN Fa’a Samoa rolled out according to the updated protocol (with at least 70% of citizens ≥20 years old and at least 60% of Men≥20 years old in the districts screened). 3) Percentage of NCD high-risk people, identified through PEN Fa’a Samoa screening, who are diagnosed within 60 days at designated health facility. 4) Percentage of hypertensive patients, managed by rural health facilities, who have their condition under control following WHO definition. 5) Percentage of health sector budget allocated to primary health care and health promotion. D. Environmental and Social Effects 16. The Program has a strong positive social, environmental and health and safety net benefit. Overall, any adverse consequences of Program activities are expected to be limited. Environmental impacts may include a small increase in medical waste in villages and clinics where NCD screening will be increased. Some minor impacts of construction works may be experienced; however, these can be managed through the application of standard mitigation measures. Community health and safety in operation will be regulated through adherence to the Samoa Building Code. 17. The Environmental and Social Systems Assessment (ESSA) identified several gaps in the handling and management of health-care waste (HCW), with implications for environmental protection, and community and Page 7 of 9 The World Bank Samoa Health System Strengthening Program (P164382) worker safety. The key issues are associated with waste treatment and disposal: hazardous emissions from the incinerator at Tafaigata due to non-optimal burning temperature; and poor treatment and disposal of HCW on Savai’i. Aside from waste handling and disposal, there are many opportunities for improvement in the HCWM system including training for MoH waste management staff, awareness raising about HCWM amongst front-line MoH employees, and adoption and commitment to a HCWM policy by MoH management. 18. The Program could include the construction of housing for medical teams and two regional district hospitals. These will be small-scale structures, not much larger than typical Samoan dwellings. Potential environmental and social impacts associated with the construction and operation of these facilities include dust, noise, waste management, and wastewater during operation. These impacts are expected to be limited and can be readily mitigated by adopting recognized good practice. 19. The Program is expected to result in social benefits through improved health outcomes. The ESSA considered the issues associated with involuntary land acquisition and found that construction of doctors’ accommodation and construction/upgrading of rural district hospitals will take place on existing hospital sites, which are leased by the MoH. As such, no new land will be required for the implementation of the Program. The PforR approach however, means that this may evolve during implementation and additional needs may be identified. Based on this potential, the ESSA considered the legislative regime in Samoa and found a number of gaps between Bank processes and Samoan legislation. Program actions required to demonstrate these risks are adequately managed which include provision for enhanced consultation; brief assessment of impacts for sites proposed to be leased; and exclusion of sites where a primary residence is affected, or land acquisition would result in significant impacts. Buildings or civil works would also be limited to the construction of medical facilities involved in the diagnosis and treatment of NCDs. 20. The ESSA also considers any potential impacts on indigenous peoples. According to the Environmental and Social Safeguard Procedures and Instruments for Pacific Island Countries (PICs) developed by the World Bank’s East Asia and Pacific Regional Safeguard Secretariat (RSS), OP/BP 4.10 is not typically triggered in Samoa. Regardless of this, the implementation of the Program has been designed and developed with the needs of the Samoan people in mind and incorporates practices and processes which are closely aligned with the needs of all groups within the community. E. Financing Program Financing Sources Amount % of Total (USD Million) National Government 31.24 77.06 International Development Association (IDA) Grant 9.30 22.94 Total Program Financing 40.54 100.00 . Page 8 of 9 The World Bank Samoa Health System Strengthening Program (P164382) CONTACT POINT World Bank Name : Shuo Zhang Designation : Senior Health Specialist Role : Team Leader(ADM Responsible) Telephone No : 5220+34505 / Email : szhang2@worldbank.org Name : Carol Atieno Obure Designation : Economist (Health) Role : Team Leader Telephone No : 5766+1202215 Email : cobure@worldbank.org Borrower/Client/Recipient Borrower : Ministry of Finance Assistant CEO, Aid Coordination & Contact : Peresitene P. Kirifi Title : Debt Management Telephone No : 68534349 Email : Peresitene.Kirifi@mof.gov.ws Implementing Agencies Implementing Ministry of Health Agency : Director General of Health, Chief Contact : Leausa Toleafoa Dr. Take Naseri Title : Executive Officer Telephone No : 68568100 Email : ceo@health.gov.ws FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects Page 9 of 9