Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB2236 Project Name SB Health Sector Support Program Region EAST ASIA AND PACIFIC Sector Health (100%) Project ID P097671 Borrower(s) SOLOMON ISLANDS Implementing Agency Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared March 9, 2006 Estimated Date of Appraisal Authorization December 20, 2006 Estimated Date of Board Approval April 30, 2007 1. Key development issues and rationale for Bank involvement Following three years of civil conflict and a three-year post-emergency period, the Solomon Islands (SI) is now shifting from emergency recovery to medium-term development planning. During the conflict, government control of the economy collapsed, lawlessness took off, and social services were seriously disrupted. The situation on the ground improved during the three years post-conflict with good progress in restoring government functioning and improving law and order. This was supported by the Australia-led Regional Assistance Mission to the Solomon Islands (RAMSI), which continues upon request from the GoSI. As the country phases out of the “post-conflict” period, attention is turning to medium-term strategy and planning at the national and sectoral levels. For instance, the next National Economic Recovery and Development Plan (NERDP) is currently under preparation and the Ministry of Health (MOH) has started preparing its strategy document for the years 2006-2010. Improving priority health outcomes in the Solomon Islands is an urgent need. Health status, which deteriorated significantly during the conflict, remains poor with indicators among the worst in the Pacific. Malaria incidence increased by 30% during the conflict and has remained high at 160-190 cases/1,000 in 2004-2005. Tuberculosis (TB) rates have also increased, reaching 93/100,000 in 2005, the highest since 1995. Acute respiratory infection rates are persistently high. Anecdotal evidence of increasing diabetes and high HIV risk factors in a recent survey—despite few identified HIV positive people to date—are emerging concerns. Maternal mortality (MMR) also appears to have increased in recent years, reaching 141.5/100,000 live births in 2004, from a low of 78.4 in 1997. Although no recent estimate for infant mortality (IMR) is available, the 1999 Census IMR of 66/1000 was among the highest in the region. Improving health outcomes requires addressing numerous challenges . Foremost among these are the allocation of government subsidy and related financing and expenditure issues; low technical quality of services; weak incentives to promote performance and to respond to demand- Page 2 side factors; unclear division of responsibilities between national and provincial health authorities; and an under-developed information system. Despite the significance of these issues, it is important to note that the process of addressing them has started. A health care network —of over 300 clinics, at least one hospital in each province, and a referral hospital in Honiara, the capital—is in place. Utilization, which fell during the conflict, has started to pick up. The MOH has also recently improved the availability of pharmaceuticals and medical supplies, begun some annual planning exercises, and initiated a review of health data. The role of partners and donors will continue to be central in supporting the sector. About 62% of total health expenditures is provided through external assistance. AusAID has been a key player to date, supporting the MOH’s operating and development budgets and providing a large team of technical advisers. The World Bank’s Health Sector Development Project has supported reproductive health, malaria, and rural infrastructure activities. Other donors, primarily Taiwan Republic of China and Japan, have focused on capital investment. These forms of assistance have contributed to the health sector’s partial recovery in the post-conflict period, but the GoSI has now expressed its interest in a more coordinated approach for the next round of donor support. Looking forward to this next phase, the key challenges include: · Health outcomes are poor, particularly for child and maternal health, with inequities between provinces and probably also between income groups. In addition to the poor outcomes noted above, there is considerable variation across province, with Malaita a consistent under-performer. · Although a systematic review of health sector financing is not yet complete, the hospital sector appears to take up a disproportionate amount of total expenditures. 1 Improving health outcomes will require better targeting of resources to key priority areas and outcomes, especially for poor and vulnerable populations. · Weak management capacity is compounded by gaps in information systems . Management skills in the centre and the periphery are limited. Linkages across various levels of the system are weak, as are linkages of resources to results. The information base to help improve these linkages is also limited. · The technical quality of health services is below par. Reasons for this include out-of- date clinical protocols, public health protocols which are incompletely utilized, weak accountability mechanisms with patchy performance monitoring of staff, and poor health infrastructure. · Little attention to demand-side factors has meant missed opportunities to increase service utilization and to ensure service responsiveness to patient demand. The 1 A public expenditure review (PER) for health, underway with AusAID coordination, is due for completion end April 2006 and will provide critical information needed for policy discussion around financing and expenditure allocation issues. Page 3 population exercises considerable choice in which services they access, as in Guadalcanal and Malaita provinces where 20% fewer women deliver in clinics than attend antenatal care. There is a need for better understanding of demand-side factors. · A fragmented approach to health sector assistance is straining government capacity. The involvement of numerous donors in the health sector has led to fragmented systems not anchored in a single sector strategy. Rationale for Bank involvement: There is a strong rationale for World Bank involvement. Further improvements in health outcomes, the goal of the proposed Health Sector Support Program (HSSP), is key for the future development agenda in the SI. Second, as a proposed sector-wide operation (see Annex), the HSSP provides an opportunity to try a new way of doing business in the health sector in the Pacific. It also leverages resources with the largest donor in the sector, AusAID, which provides about 40% of sector financing. This in turn supports the harmonization agenda and supports capacity building for the sector and for whole-of-government functions. Moreover, the design aims at setting a process in place whose benefits go beyond the program period and will help improve overall system performance for the medium to long term. The World Bank can also bring sectoral expertise and experience in SWAp operations to this process. The World Bank’s experience in health in the other Pacific countries, which face similar issues of small island states, will help policy dialogue as well as program design and implementation. Similarly, the Bank’s experience of SWAPs from EAP countries and from other regions will contribute to design and implementation. The proposed HSSP is consistent with the World Bank’s Regional Engagement Framework FY2006-2009 , which highlights the importance of improving the effectiveness of public expenditure in the social sectors through strategic partnerships with key donors. 2. Proposed objective(s) The HSSP’s development objectives will align with the MOH’s new National Health Strategy 2006-2010 (NHS), which will articulate a strategic vision for the health sector. It is the agreement within government to deliver health services focused on achieving a set of agreed target outcomes. Central to this is the recognition of the desirability for a whole-of-government approach in: · developing a national vision for the health sector and for the desired outcomes, consistent with the MDGs; · establishing enforceable policy oversight arrangements at the national and sub-national government levels to ensure MOH can implement the plan; · setting priorities for sectoral reforms based on a consensus between the national and provincial authorities and other stakeholders; · identifying both implementation and financing constraints at each level of government and ensuring that they are addressed in the priorities for sectoral reforms; and · developing implementation plans and arrangements for monitoring and evaluating progress over time by national and provincial authorities. Page 4 The NHS will be completed by mid-2006 to help guide the specific development objectives and performance indicators for the HSSP. In addition, the preparation process will help specify the objectives and targets more clearly. These will be consistent with the overarching goal of improving priority health outcomes with a focus on strengthening government systems, the oversight capacity of the MOH, and the implementation and monitoring capacities of provincial health authorities. 3. Preliminary description The HSSP will support the MOH in implementing its sector strategy through a framework which addresses roles, responsibilities, and performance at the central and provincial levels. The framework will follow the structure of the health system: Component 1- Central level support and capacity building . This component will provide support for key activities that fit the role of the central level. These can be organized as: · Stewardship role . This involves setting policies, standards, and other key strategic directions for the sector. The component will support the development of these products as well as build the capacity of MOH in these areas; · National level programs . These include activities which are national public goods, like health education, information and surveillance systems, and workforce development; · Technical support to provinces . This includes supporting the role of the center in providing technical support and guidance to the provinces through direct technical assistance, as well as the development of tools to assist the provinces in implementing their programs; and · Framework for non-government, church, and private sector participation in health services . These activities would support the role of the MOH in supporting engagement of stakeholders across the sector as a whole, in efforts to mee t the strategy’s targets and consumers’ demands. Component 2. Provincial levels support and capacity building . This component would support provinces in developing and implementing integrated five-year plans based on the national strategy and adapted to local conditions. These would address key priorities and lay out the activities to achieve the expected outcomes and outputs during the program. The activities would be province-specific and organized along both supply- and demand-side interventions. The proposed approach will encourage provinces to have clear outputs and results, build capacity to plan and implement programs, ensure integration of activities at the provincial level, and help establish linkages between the provincial and central levels. The program can then finance a slice of each agreed plan or specific activities. Component 3: Enhanced program management, monitoring and evaluation . This would support whole-of-government processes and management systems within MOH. It would also provide support for M&E of the program. Page 5 4. Safeguard policies that might apply An environmental assessment may be required, depending on the extent and nature of health facility construction to be financed under the HSSP and to address health care waste management issues. Safeguards requirements will be further assessed during preparation. 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 0 INTERNATIONAL DEVELOPMENT ASSOCIATION 5 Total 5 6. Contact point Contact: David Evans Title: Health Specialist Tel: + 1 202 458 1323 Fax: + 1 202 614 1242 Email: devans1@worldbank.org