The World Bank Health System Strengthening Project (P175170) Project Information Document (PID) Concept Stage | Date Prepared/Updated: 31-Aug-2021 | Report No: PIDC32469 Aug 12, 2021 Page 1 of 18 The World Bank Health System Strengthening Project (P175170) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name Tuvalu P175170 Health System Strengthening Project (P175170) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) EAST ASIA AND PACIFIC Jan 24, 2022 Mar 29, 2022 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Ministry of Finance and Ministry of Health, Social Economic Development Welfare and Gender Affairs Proposed Development Objective(s) The Project Development Objectives (PDOs) are to increase the utilization of and strengthen the management of quality essential health services provided across Tuvalu, and to provide immediate and effective response in case of an eligible crisis or emergency. PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 15.00 Total Financing 15.00 of which IBRD/IDA 15.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Development Association (IDA) 15.00 IDA Grant 15.00 Environmental and Social Risk Classification Concept Review Decision Aug 12, 2021 Page 2 of 18 The World Bank Health System Strengthening Project (P175170) Moderate Track II-The review did authorize the preparation to continue Other Decision (as needed) B. Introduction and Context Country Context 1. Tuvalu, classified as an upper-middle income country (UMIC) with a gross national income per capita of US$ 4,059 in 20191, is one of the smallest, most remote, and climate change-vulnerable countries in the world, and is categorized as a fragile state. The Human Capital Index2 (HCI) estimates that a child born in Tuvalu today will be 44 percent as productive when she grows up as she could be if she enjoyed completed education and full health. This is a lower HCI than the average for East Asia and Pacific region (59 percent) and for UMICs (56 percent). The country’s population of 11,000 is spread across nine inhabited small islands, with a total land area of only 26 square kilometers, scattered over 0.5 million square kilometers of the western Pacific Ocean. This makes Tuvalu one of the most densely populated countries in the world. Similar to the urbanization trend seen in many other countries, 64 percent of Tuvalu’s population lives on the capital island of Funafuti, an increase from 54 percent in 20103. The age distribution of the population is slightly different between Funafuti and the Outer Islands, with Funafuti attracting more of the working-age population, and outer islands having a larger share of the population over 60 years of age. Six of the islands (Nukulaelae, Funafuti, Nukufetau, Vaitupu, Nui, and Nanumea) are low- lying atolls made up of islets (motus) with infertile, sandy or gravel coralline soils. The other three islands (Nanumaga, Niutao and Niulakita) are raised limestone reef islands with poor soil quality and limited flora. The average elevation in Tuvalu is one meter above sea level, while the highest point in the country is 4.6 meters above water. Most of Tuvalu’s population live on land less than one meter above sea level. The atolls also have extremely narrow land masses; for example, Funafuti is less than 100 meters wide on average. 2. The very small size of the domestic economy and Tuvalu’s extreme remoteness from major markets, near total dependence on imports, particularly of food and fuel, and vulnerability to external shocks, climate change and rising sea levels pose significant challenges to macroeconomic performance. The public sector dominates economic activity. Tuvalu has few natural resources, except for its fisheries and earning from fish exports and fish licenses for Tuvalu’s territorial waters are a significant source of government revenue. International aid, including support from the World Bank, and the Tuvalu Trust Fund (TTF), an international trust fund established in 1987 by development partners, are an important cushion for meeting shortfalls in the government’s budget. Private sector development opportunities are highly constrained by the lack of economies of scale in such a small and 1 Source: World Bank World Development Indicators (WB WDI, accessed June 2021. 2019 latest data available). 2 Source: https://www.worldbank.org/en/publication/human-capital and https://openknowledge.worldbank.org/handle/10986/34432 3 Source: WB WDI Aug 12, 2021 Page 3 of 18 The World Bank Health System Strengthening Project (P175170) fragmented domestic market and by severe infrastructure deficits in utilities, transport, and communications. Limited economic opportunities are reflected in the fact that 26 percent of the population living below the national poverty line. Tuvalu’s narrow based economy and vulnerability to external shocks exposes it to volatility in macro- economic performance and this is exacerbated by the financial impact of climate change and the cost of climate- related adaptation projects. In common with other Pacific Island countries Tuvalu also confronts economic and escalating fiscal costs associated with meeting the health care needs of an aging population and epidemic of non- communicable diseases (NCDs). 3. Tuvalu remains one of the less than 20 countries without a confirmed COVID-19 infection and avoided a recession thanks to the Government’s substantial COVID-19 fiscal package, which was financed by buoyant fishing license revenues and increased donor grants. The Government of Tuvalu (GoTv) closed its borders in early 2020 when the first COVID-19 cases were confirmed in Fiji, ensuring that the country remained COVID-free. Due to the border closures and domestic containment measures, economic growth was 1 percent in 2020. The Government implemented a COVID response package of around 30 percent of GDP to enhance social protection and support economic growth, in turn pushing up expenditures. At the same time, fishing licenses revenues rose to 56 percent of GDP, almost 30 percent higher than budget. Donors provided an additional 8.6 percent of GDP of COVID-related grant support. As a result, Tuvalu registered a fiscal surplus of 5 percent of GDP in 2020. 4. The economy is expected to rebound in 2021 with growth projected at 2.5 percent, supported by increased recurrent government spending, a gradual resumption of infrastructure projects and the adult population vaccinated against COVID-19. Growth is projected to peak at 4 percent in 2024, factoring in full resumption of international travel, continued high public spending, and full implementation of planned infrastructure projects, including those financed by the Green Climate Fund. The Government is projected to register a GDP fiscal deficit of 7 percent in 2021, reflecting declining revenue and continuing spending pressures. Tuvalu is expected to have a fully vaccinated adult population shortly, through the receipt of vaccines from the international COVAX initiative and direct donations from Australia. The opening up of travel is still restricted with COVID-19 outbreaks uncontrolled in transit country of Fiji and in the Pacific region. Thus, economic recovery is still dependent on control of the COVID-19 pandemic in the greater subregion. Sectoral and Institutional Context 5. Health expenditure in Tuvalu almost doubled in real terms between 2008 and 20184; it remains largely publicly financed resulting in high financial protection, but also vulnerability to fiscal shocks. In the last decade to 2018, health expenditure as a share of GDP increased from 11% to 19%, with per capita health expenditure increasing from US$ 350 to US$ 693 in constant 2018 US$. In that same period, domestic health expenditure out of total GoTv expenditure increased from 11% to 14%, with a high of 17% in 2011 and 2012. All health services are free in Tuvalu, and the majority of the health system is funded by government and delivered by the Ministry of Health (MoH)5; current health expenditure is largely public (93% of current health expenditure in 2018), with a relatively high reliance on volatile external financing (average of 19% in the last 5 years to 2018). Out-of-pocket expenditure is consistently less than 1% of current health expenditure. Because health services depend heavily on government 4 Source: Global Health Expenditure Database (accessed June 2021. 2018 latest data available). 5 Health is a department under the Ministry of Health, Social Welfare and Gender Affairs Aug 12, 2021 Page 4 of 18 The World Bank Health System Strengthening Project (P175170) financing, tightening fiscal space and declining tax revenues (resulting from the COVID-19 pandemic) put the delivery of health services at risk. Government expenditures on health is expected to have fallen in 2020-2021 because of the inability to refer patients to overseas medical providers – one of the main service delivery mechanisms – due to the COVID-19 related cessation of inter-country travel. This will be temporary as there is likely to be pent up demand when travel resumes. Priorities in Population Health 6. While health outcomes have improved over the decade to 2019, Tuvalu continues to grapple with a growing burden of non-communicable diseases (NCDs), while still facing challenges with some communicable diseases and broader maternal, child and newborn health concerns. Tuvalu is not included in the Universal Health Coverage (UHC) monitoring reports or in the UHC Index of Services Coverage indicator6 so it is difficult to assess what progress the country has made towards UHC.7 Average life expectancy was 70 years for females and 66 years for males in Tuvalu in 20198, up from respectively ~68 and 65 in 2009. 7. In 2019, NCDs accounted for 72% of the burden of diseases, up from 64% in 1999. NCDs account for a higher burden of disease in females than in males. Tuvalu had the world’s fourth highest age-adjusted comparative diabetes prevalence in adults in 2019 (22.1%) and is projected to move to third place through to 2030 and 20459. The major NCDs causing the most death and disability combined in Tuvalu are Ischemic heart diseases, diabetes, and stroke. Malnutrition for children aged 2 years and under is a significant problem in Tuvalu, with 46.5% of them classified as obese, and 17% having some level of malnutrition10. 8. Lifestyle-related risk factors drive most of the death and disability related to NCDs, underscoring the importance of behaviors and the environment. Overall, the top risk factors associated with the highest disease burden in Tuvalu in 2019 were closely linked to NCDs and included high fasting plasma glucose, high body-mass index, high blood pressure, and behavioral risks such as tobacco use and dietary choices. Since 2009, the top three risk factors, high cholesterol, and kidney disfunction have all seen double digit increases ranging from 13 to 22%. In addition, tobacco smoking and dietary risks continue to increase. In 2016, Tuvalu had the 5th highest obesity rate in the world (51.6%). Obesity rates in the country have been steadily increasing and are higher for women than for men. Climate change is also likely to exacerbate malnutrition risks and the metabolic and lifestyle risk factors for diet related NCDs. It is expected to reduce short- and long-term food and nutrition security both directly, through its 6 Source: World Health Organization (WHO). “Primary Health Care on the Road to Universal Health Coverage. 2019 Monitoring Report. https://www.who.int/healthinfo/universal_health_coverage/report/uhc_report_2019.pdf . According to IHME’s UHC Effective Coverage Index, Tuvalu scores 39.6% on how well it’s providing effective, essential health services (only 0.2% change from 20 19). http://www.healthdata.org/tuvalu 7 Unless otherwise specified, this concept note largely reports international databases health outcome data; we note that there are significant differences between global health outcomes data and the data reflected in the MoH annual reports (latest available is 2019). 8 Source: Institute for Health Metrics Evaluation (IHME). According to the Tuvalu 2019 annual report, life expectancy in Tuvalu was much lower, at 52 years in 20198 9 Source: International Diabetes Federation (IDF). “IDF Diabetes Atlas. Ninth Edition 2019�. https://www.diabetesatlas.org/upload/resources/material/20200302_133351_IDFATLAS9e-final-web.pdf 10 Source: Annual Report 2019. Tuvalu Ministry of Health. Latest international data we could find was from 2007. Aug 12, 2021 Page 5 of 18 The World Bank Health System Strengthening Project (P175170) effects on agriculture and fisheries, and indirectly, by contributing to underlying risk factors such as water insecurity, dependency on imported foods, urbanization and migration and health service disruption11. 9. While the NCD burden of disease is escalating, Tuvalu reports some good progress with core maternal and child health indicators, as well as with various communicable diseases. Tuvalu has reached the Sustainable Development Goal (SDG) target of less than 25 deaths per live births for child mortality, with the under-five mortality rate declining from 32.8 per 1,000 live birth in 2009 to 23.9 per 1,000 in 2019. In that same period, the decline was from 29 to 21.5 per 1,000 for females, and from 35.7 to 26.1 for males 12. Similarly, infant mortality rates declined from 27 to 20 deaths per 1,000 live births in that same period (24.1 to 17.9 for females, and 30.2 to 22.5 for males), while neonatal mortality rates declined from 21.6 to 16; however, more significant efforts will be needed to reach the SDG goal of less than 12 deaths per 1,000 live births. Immunization rates vary but remain above 85% since 2009. Immunization rates for DPT3, HepB and measles were respectively 92%, 92% and 96% in 201913. Exacerbated by the high levels of smoking, crowded living conditions, poor nutrition and comorbidity with diabetes, tuberculosis is the fifth cause of death in Tuvalu14. In 2019 Tuvalu has the fourth largest incidence of tuberculosis15 amongst Pacific Island countries (296 per 100,000 people per year). In that same period, tuberculosis (TB) treatment success rates (as a percentage of new cases) increased from 83% to 93%.16 10. There is little recent data on gender equality issues in Tuvalu and on gender differences in health more generally. Labor participation rates were much higher for men (58.5%) than women (39.7%) in 201717. There is some slight difference in primary or secondary school attendance between males and females; the gender parity index (ratio of women to men enrolled) was 0.92 for primary school enrollment in 2019, and 1.22 for secondary school enrollment18. Health information, including Government strategies, have little information for addressing health differences between gender or other groups that may be of concern. The pending release of 2020 Multi- Indicator Cluster Survey results will provide an opportunity for redressing this gap. According to United Nations (UN) Women19, gender-based violence (GBV) remains a significant issue in Tuvalu. Over a third of Tuvalu women reported having experienced physical violence during their lifetime, with 8% reporting experiencing physical violence during pregnancy. Most of the women reporting physical violence said that a current husband or intimate partner had been violent towards them (90%), with a small number reporting violence by a sibling (8%). Close to one in five women (21%) have experienced sexual violence with 13% of women saying their first sexual intercourse was involuntary. Almost half of Tuvaluan women have experienced either physical or sexual violence, with 12% of women experiencing both forms. There are efforts of addressing GBV and the Government’s health, social and legal services available, yet gaps remain such as in skills of health workers and health facilities able to offer space for private counseling. 11 Source: Tuvalu Health and Climate Change Country Profile 2019. 12 Source: WHO Global Health Observatory. Note: The 2019 MoH annual report tells a very different story. Indeed, it reports that the infant mortality rate increased from 17.7 in 2017 to 56.7 in 2018, and the under-five mortality rate which has increased from 17.6 to 58.6. It is unclear why the national and global data differs so much. 13 Source: WHO vaccine-preventable diseases: monitoring system. 2020 global summary 14 Source: IHME http://www.healthdata.org/tuvalu 15 After the Republic of Marshall Islands, Kiribati and Papua New Guinea. Source: WHO GHO. 16 Source: WB WDI, accessed June 2021. 17 Source: 2017 Population & Housing Mini-Census Preliminary Report. 18 Source: WB WDI. 19 Source: https://asiapacific.unwomen.org/en/countries/fiji/co/tuvalu#Anc_here Date not specified. Aug 12, 2021 Page 6 of 18 The World Bank Health System Strengthening Project (P175170) 11. Disasters and climate change continue to pose a threat to Tuvalu. When Cyclone Pam hit Tuvalu in 2019, almost half of the Tuvalu population was affected by the Category 5 cyclone, which caused massive destruction. The Cyclone caused an estimated US$ 10 million in damages across the country, ~30% of the country’s GDP. The key health vulnerabilities sensitive to the effects of climate change in Tuvalu include diarrheal disease (due to contaminated food and/or water), respiratory disease (infective and obstructive), compromised food security (with impacts on nutrition and NCDs), vector-borne diseases, mental health/psychological problems, injuries and deaths from extreme weather events, fish poisoning (ciguatera) and skin infections/infestations. Heat stress is increasingly being recognized as a key health threat due to climate change in Tuvalu20. Of course, significant weather and climatic events such as Cyclone Pam can cause severe service disruption of health services (affecting individual facilities, travel between islands and facilities, and personally affect the health workers). Challenges in Service Delivery to Address the Population’s Health Needs 12. Tuvalu has a network of public health facilities covering both Funafuti island and the outer island clinics but has limits in covering the health needs of the population. The publicly financed and delivered health system places a central service role on the one hospital in the country, the Princess Margaret Hospital (PMH), located on the main island of Funafuti. PMH provides primary and secondary care for patients in Funafuti and those who are referred from outer islands. The hospital has 50 beds with separate wards for men, women and infants. It offers basic routine medical, surgical, obstetric, and gynecologic services. There is a basic Intensive Care Unit (ICU), a surgery room and nurses' station. PMH also provides accident and emergency services. The hospital has established a specialist department to study and manage climate change-related illnesses, such as dengue and food-born illnesses. Two health clinics, one south and the other north of Funafuti, provide primary clinical services. However, the population on Funafuti mostly self-refers to PMH for even basic primary health care services. Eight health centers covering outer islands are staffed by nurses who provide primary health care and public health services as well as emergency deliveries. Many of these centers are not that old but are exhibiting wear and tear due to limited maintenance and need adaptation based on the challenging climatic environment. Patients needing more relatively basic hospital-level diagnostic and clinical care, that is beyond the scope of services offered at PMH, are referred to overseas hospitals through the Tuvalu Medical Treatment Scheme. At present, all doctors in Tuvalu are based at PMH, but also provide community outreach services to the nine outer island medical centers. The outer island health centers are expected to be staffed by a midwife, a registered nurse, a nurse aide, and an environmental health officer but this varies between islands due to staff capacity and shortages. Staff shortages, both nursing (in 2018, 15 of the 72 MoH nursing positions were vacant21) and medical (of the 11 approved doctor position in 2018, 8 were training overseas) present a challenge in ensuring quality and equitable care is available to residents throughout Tuvalu. The majority of the medical officers are general practitioners and eight of the current established number of doctors are currently training overseas in the specialty fields of anesthetics, surgery, pediatrics, emergency medicine and obstetrics and gynecology. Since 2017, Tuvaluan doctors who have been educated in Cuba and Fiji have undertaken a structured 18 months’ internship training program in Kiribati to strengthen their skills. Ten of them have already returned to Tuvalu and a further 4 were in the processing of completing their internship when COVID-19 hit. Post graduate training of medical staff is ongoing for doctors, 20 Source: WHO, 2019. Health & Climate Change. Country Profile 2019. 21 Source: Tuvalu NHSP 2020-24. Aug 12, 2021 Page 7 of 18 The World Bank Health System Strengthening Project (P175170) nurses, and allied health staff. Tuvalu has also contracted with overseas medical workers and receives visiting medical teams to address shortages in health workers. 13. The Tuvalu Medical Treatment Scheme (TMTS) is an essential mechanism for providing a wider range of both diagnostic and therapeutic health services, but careful management is needed of this high cost public expenditure. Prior to the COVID-19 travel restrictions, expenditures on the TMTS continued to increase annually and are projected to increase in the medium term due to an aging population and the rising prevalence of NCDs. Expenditures of the TMTS increased by 43 % between 2016 (AU$ 4.6 million) and 2018. In 2018, Tuvalu spent AU$ 6.6 million on TMTS for 215 patients (about 2% of the total population), accounting for 59% of MoH’s expenditure. In 2019, TMTS spent US$ 4.7 million for 188 patients (53 females and 47 male) – 38% of MoH’s expenditure. The main reasons for overseas referral were cancer diagnosis and management, gynecological conditions, kidney and heart diseases. Of the balance of 2018 expenditure, 38% was spent on curative care, 10% on administration and headquarters, and 5% on primary and preventative healthcare services. Patients were largely sent to Fiji and India, including 13 who were sent to live permanently in Fiji for long term kidney dialysis treatment, all expenses paid. Between 2016 and 2019, spending on TMTS as a percentage of GDP fluctuated, with a high of 12% in 2017 and a low of 6.5% in both 2016 and 2018. It was 9% in 2019. 14. While the country is facing significant challenges of rising NCDs, the current health service delivery system is not well set up to tackle the challenges. NCD clinics are currently offered twice a week at PMH in a single overcrowded room, with severe limitation on treatment and rehabilitation services for NCD and diabetes. At the same time, the general outpatient department of PMH is the main provider of chronic NCD services because it is accessible to most of the population in Funafuti. Management of NCDs on outer islands is conducted by trained health clinic nurses, but not well linked with diagnostic and management tools, nor easy access to advice from a physician. Public health screening programs for NCDs, as well as for TB, Leprosy, sexually transmitted infections (STIs), cervical cancers, and other early diagnostic assessments are expensive and currently only offered in Funafuti. To effectively manage NCDs requires timely and effective coordination between population-based health promotion, disease detection, early on-set management, and referrals in case of elevated risks and complications. The information on chronic disease patients is duplicated/fragmented at different points in the system and even between departments of PMH, there is disjointed information. 15. PMH does not have sufficient capacity to deliver necessary and quality services for the central referral hospital of the country, but the conditions for them to improve are growing. While a COVID-19 outbreak would place considerable constraints on an already challenged health system, current international travel restrictions have limited the capacity of Tuvaluans to access some specialized services usually delivered through the TMTS and visiting medical teams. Emergency-related diagnostic and treatment facilities is of particular need, including expansion of laboratory and radiology, proper operating theater, post-operative recovery, and improved intensive care. PMH facilities are too confined and not of sufficient quality to be able to accommodate these services which could be delivered by Tuvalu’s returning educated and trained doctors and nurses as well as complemented by contracted and visiting medical teams (once borders re-open). Although Tuvalu relies extensively on external referral and visiting medical teams, it has not yet expanded its capacity to deliver services through regularly established teleconsultation channels with international health providers. PMH itself has initiated teleconsultation with outer island clinics, but the bandwidth is limited putting constraints on the type of teleconsultation available (i.e. not allowing for sharing of video or pictures) though Tuvalu is investing in its Aug 12, 2021 Page 8 of 18 The World Bank Health System Strengthening Project (P175170) broadband capability which should allow to expand teleconsultation in the next few years. As seen globally during the COVID-19 pandemic, there is a surge in the use of teleconsultation to redress staff capacity, distance, and travel barriers. While the capacity to deliver services in terms of physical facility, equipment and availability of trained staff are a significant constraint, there are also challenges in terms of the clinical management to ensure that the services are safe and of sufficient quality. As yet, the hospital does not have routine clinical governance arrangements such as regular mortality audits, drug and therapeutic committees, asset management and routine maintenance plans22, and infection prevention and control and committees. Patient records are partly paper based, partly electronic through a hospital information system. Though PMH houses the central medical store, information on the availability of medicines is not transparent to clinicians and can only be accessed through the pharmacist. Some progress has been made with infection prevention and control (IPC) at the hospital. Recent efforts to improve cleanliness in departments have resulted in improved infection control and a better experience for patients and staff. However, IPC continues to be a significant challenge, including in the operating theater and most PMH departments, as well as in outer islands clinics that lack adequate water, sanitation, and hygiene facilities. A new incinerator intended to be used for all combustible waste from the health facilities is being installed in Funafuti. However, there is not a safe way to transport medical waste between the PMH, other facilities (from port for outer-island clinics) and the incinerator itself. Limited Capacity of Underlying Systems for Managing Health Systems 16. Maintaining adequate pharmaceutical stock is a challenge with regular stock-outs for drugs and consumables recorded in 2018 and 2019. Tuvalu uses an open source information system for stock management called “mSupply� in the central pharmacy, but challenges remain in keeping stock levels accurate. Several factors contribute to the shortage of supplies including: (i) lack of efficient procurement practices with each department at PMH responsible for its own planning of purchases and centralized Government procurement through the government’s Ministry of Finance; (ii) inadequate knowledge of the data management of the mSupply inventory software to track the ordering, prescribing and dispensing of medicines resulting in incorrect estimates and forecasting; (ii) limitations in the mSupply roll-out as it is currently limited to central medical store and not visible to other PMH clinical departments or at the health clinics; (iii) unresponsiveness of suppliers to quotation requests due to the relatively low number of items being ordered; (iv) length of time to receive supplies due to problems with transportation and timely payment of accounts; (v) limited storage space in the Pharmacy department, which has been exacerbated by the recent increase in supplies related to COVID-19; and (vi) staff shortages. 17. The lack of adequate data and analysis limits the efforts to improve service delivery in Tuvalu. Decision makers need access to timely and quality data on the health system’s inputs, outputs and outcomes, disaggregated by age, sex and location where relevant. This is currently not available in Tuvalu. The latest health sector Annual Report publicly available is from 2019, and as previously mentioned, health outcomes data significantly differs from the outcome data available in international databases. The main source of health service delivery data comes from PMH which has a hospital information system considered not fit-for-purpose as it was donated and partially adapted from a large tertiary hospital outside of Tuvalu and is still partially in a foreign language. Therefore, it is largely not used by managers and clinicians. Health records are therefore partly paper-based and partly electronic, 22The maintenance department of PMH is responsible for the upkeep of hospital buildings so that the facility is safe for patients and staff. In 2019 a Maintenance Plan was drafted, however progress against planned implementation was less than expected. Aug 12, 2021 Page 9 of 18 The World Bank Health System Strengthening Project (P175170) fragmented, and largely inadequate. Other challenges include ongoing software licensing issues and lack of skilled information technology staff. The limitations in the availability and quality of data means decision makers have little evidence to inform better use of resources as part of annual planning and budgeting, nor do they have regular monitoring and evaluation processes in place to review performance. Information from the outer island clinics is entirely paper-based reports with limitations and delays in the receipt of the information. The outer islands satellite internet project that started in 2019 represents a good opportunity for the improvement of the connectivity and information sharing with the outer-island clinics. Government of Tuvalu’s Response to Health Sector Challenges 18. As a first priority, the GoTv is managing the current COVID-19 health response by ensuring that Tuvalu remains vigilant against entry of the disease to Tuvalu and protects its population through vaccination. As described earlier, the GoTv has managed to keep COVID-19 outside its borders through travel restrictions. At the onset of the pandemic, there was need to build capacity for testing of repatriated population and this was done at the public health laboratory through international support, such as the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and others. The GoTv also triggered the activation of the Contingency Emergency Response Component (CERC) of the World Bank supported Maritime Investment in Climate Resilient Operations Project (MICRO) Project which has provided operational financing for the Government’s repatriation effort. The CERC is also in the process of providing some support for equipment and consumables to maintain essential health services being provided in Tuvalu. Tuvalu is committed towards vaccinating its population with the earliest available supply. Starting in April 2021, Tuvalu received vaccines through the international COVAX initiative for a two-dose course covering 20% of its adult population and more recently have received vaccine donations from Australia to cover the remaining adult population. Logistical support to carry out these efforts has been provided by WHO and UNICEF. The Asian Development Bank has also made support for COVID-19 and other vaccines in Tuvalu and other Pacific Island countries through its regional effort to support the effective coverage of introducing new vaccines. 19. The GoTv has established a TMTS Review Taskforce, led by the Ministry of Health, Social Welfare and Gender Affairs (MoH for short), and directed it to develop a draft policy to reduce overseas medical treatment costs. Fully implemented, TMTS reforms could result in potential cost savings as well as improve its governance through a more clearly structured process for decision making, rational through defined criteria and also, hopefully, more efficient in deliberating on access to health services for the population. In the longer term, substantial savings would provide fiscal space to allow for investments in the primary and preventative programs would benefit the broader population and improve healthcare outcomes (including NCDs), reducing the need for specialized late stage care. The World Bank is engaged with the GoTv on its TMTS reform through policy dialogue in conjunction with a development policy operation. 20. The MoH has prepared a National Health Strategic Plan (NHSP) 2020-2024 to address the strategic priorities of the Government and the health actions and interventions are reflected under seven Key Result Areas (KRA) with their own specific objectives. The KRA focus of the strategic plan are: (i) leadership and governance; (ii) non- communicable and communicable disease; (iii) health security and climate change; (iv) reproductive, maternal, neonatal, child and adolescent health services; (v) primary health care; (vi) clinical and allied health services and (vii) stakeholder partnerships. The NHSP 2020-2024 operationalizes the need for further reform of health services, in line with the Governments National Strategy for Sustainable Development 2016 to 2020, as the way forward Aug 12, 2021 Page 10 of 18 The World Bank Health System Strengthening Project (P175170) for the provision of effective and quality clinical and preventative health care service as the foundation for improved personal health outcomes for all. The MoH developed the National Strategic Plan for NCD 2017-2021 that focuses on four main areas: tobacco use, harmful use of alcohol, physical inactivity, and nutrition. The plan provides a roadmap for the Department of Public Health to combat NCDs in the future. The MoH receives significant support from technical partners and regional partnerships for various part of this agenda. The nature of the support is largely small in value, technical in nature and with a significant focus on population-based public health issues such as nutrition, disease surveillance, disaster planning or direct aid in case of emergencies. 21. The GoTv has requested technical and financial assistance from the World Bank for health system strengthening in light of the need to increase service delivery capacity. While the priority to increase service delivery capacity has been part of the GoTv and MoH health sector development plans, the COVID-19 pandemic has made this more acute. International examples of health systems easily over-run, unable to care for its population even at the onset of the disease outbreak have been clear; and, in Tuvalu, travel for health care has been impossible placing a real urgency to invest in in-country service delivery capacity to the extent possible. Relationship to CPF 22. The World Bank’s Pacific Regional Partnership Framework (RPF) 2017-202123 and as extended to 202323, covering 9 of the Pacific Island Countries (PIC9) including Tuvalu, has the objective of strengthening health systems and addressing NCDs under the Third Focus Area of Protecting Incomes and Livelihoods. The RPF recognizes the development challenge of rapidly increasing non-communicable diseases (NCDs), and their related impact on acquired disability and reduced productivity, and the related fiscal pressures that the response to NCDs placed on the countries. Inequities are also evident between underserved rural populations and those living near urban centers. The third focus area also highlighted that the protecting lives and livelihoods required strengthening resilience to natural disasters and climate change including the resilience of health systems to address these challenges. The proposed project directly addresses these by developing the capacity for NCD prevention, detection, and management in Funafuti but also the outer islands. The project also has a longer-term objective of affecting the fiscal pressure to refer abroad through building more capacity to essential hospital services in country, while also strengthening the capacity of the health system to be more resilient to significant weather and climatic events. 23. The project results will contribute to the achievement of Sustainable Development Goal (SDG) 3 -- ensure healthy lives and promote wellbeing for all at all ages -- and the Priority Directions for the Health, Nutrition and Population (HNP) World Bank Practice Group. One of the targets for 2030 under SDG 3 is to ‘reduce by one-third premature mortality from NCDs through prevention and treatment’. Investment in early detection and management of NCDs, the primary focus of this project, is crucial to the achievement of this SDG target. The project also contributes to SDG 3 target for universal health coverage – ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services -- by increasing the utilization and quality of necessary essential primary and secondary health services. 23 The Pacific RPF includes Tuvalu along with 8 other small island Pacific countries can be found at the following link: http://Regional Partnership Framework (P156647) FY17-FY21. (Reports 120479 and 145750-EAP) Aug 12, 2021 Page 11 of 18 The World Bank Health System Strengthening Project (P175170) C. Proposed Development Objective(s) 24. The Project Development Objectives (PDOs) are to increase the utilization of and strengthen the management of quality essential health services provided across Tuvalu, and to provide immediate and effective response in case of an eligible crisis or emergency. Key Results (From PCN) 25. Achievement of the PDOs will be measured by the indicators listed in Table 1. The list of indicators will be agreed during preparation and appraisal, particularly focused on having clear definitions and measurement of the indicators. Table 1. Proposed PDO Indicators by Element of the PDO PDO Elements PDO Indicators Increase 1. Increase in the adult population screened and stratified for risks for NCDs utilization of 2. Increase in the adult population registered and treated for hypertension and diabetes quality essential at enhanced24 primary health care clinics and specialized NCD outpatient clinic at the health services PMH provided across 3. Increase in the number of patients treated at an enhanced1 PMH for tracer secondary Tuvalu care and diagnostic services Strengthen the 4. Increase in the use of patient-centered medical records at the clinics and PMH management of particularly for monitoring of chronic NCD patients quality essential 5. National health assemblies conducted including with performance of the health sector, health services including with sex-disaggregated data, and citizen feedback on service availability and provided across quality. [or similar citizen-engagement related indicator] Tuvalu Provide Will be added to the Project Results only if activated immediate and effective response in case of an eligible crisis or emergency D. Concept Description 26. The draft Tuvalu National Health Strategic Plan for 2020-2024 (NHSP) provides a point of departure to identify priority interventions, new development activities, and programs for the proposed Tuvalu Health System Strengthening Project (HSSP). The NHSP has grouped broad goals and specific activities under seven Key Priority Areas, shaping the discussions, content, and components of the proposed World Bank project. Development of the project and its implementation will be aligned, coordinated, and planned in conjunction with engaged bilateral partners such as Foreign Affairs and Trade Ministries of New Zealand (MFAT) and Australia (DFAT), regional 24 Enhanced to define elements of quality such as facility infrastructure meeting essential functional standards, staff trained to meet agreed competency standards, telemedicine consultation, availability of essential medicine, etc. Aug 12, 2021 Page 12 of 18 The World Bank Health System Strengthening Project (P175170) entities such as The Pacific Community (SPC), the Asian Development Bank (ADB), and key technical partners, including WHO and UNICEF. 27. The proposed project will support the Tuvalu MoH to implement elements of its NHSP. It would do this through two technical components: (i) Improved availability and quality of health services across Tuvalu; and (ii) Strengthen systems for better health service management. These two technical components will be supported by a third component on project management, monitoring and evaluation support. In case of a future emergency, the project would include a fourth component allowing for reallocation of Project resources based on the defined need of that emergency. Project financing for all goods, works, services and project-related operating costs will take into consideration existing, current, and planned investments by other external partners. The proposed health infrastructure development will be carried out considering both environmental and social risks assessments, as well as opportunities for developing more energy efficient and climate resilient health facilities. Component 1: Improved availability and quality of health services across Tuvalu (approximately U$ 12.75 million) 28. Subcomponent 1a: Improve the availability and quality of services provided at PMH. As part of its national health reform priorities, the MoH plans to substantially expand and improve the quality of services provided at PMH particularly for: diagnostic services (notably radiology and laboratory), emergency and other urgent care (including for domestic violence), national medical store/warehouse, surgical operations and post-operative recovery, intensive care and rehabilitation. A major emphasis will be placed on improving the patient experience and health outcomes through a dedicated outpatient center for integrated health promotion, detection, and management of NCDs. The urgency to be able to provide quality essential medical and surgical services locally is based on the extreme vulnerability of Tuvaluans to major service disruptions and foregone care as demonstrated by the recent COVID-19 pandemic experience. The exact health services that the expanded PMH will be able to provide will depend on three key linchpins including: (i) availability of human resources including through existing and training of national staff, contracted staff, regularly scheduled visiting teams and establishment of routine teleconsultation with international health provider; (ii) the financial trade-offs of building and operating services in Tuvalu as opposed to the cost of providing the service abroad; and (iii) the ability to ensure adequate quality with the patient volume that would be specifically available in the overall small population of Tuvalu. The Project activities would include: (i) conducting a more detailed assessment to define the service priorities and options taking into consideration the concerns mentioned25; (ii) detailing the functional and physical description of the facility, including all necessary requirements for ensuring that the facility adapts to the local hazards, changing climatic conditions and energy efficiency; (iii) site specific plans for mitigation against environmental and social impact as specified in the requirements for environment and social standards; (iv) detailed architectural design; (v) demolition and construction of a new hospital wing on the territory of the PMH complex, including the design characteristics for energy efficiency and resilience to significant weather and climate change events; (vi) purchase of related medical equipment and supplies; (vii) design and implementation of plans to supplement in-country human resources through established teleconsultation systems with an international provider, contracting of international medical providers, upgrade of Tuvalu general practitioners with specialists skills, and planning for routine visits of international medical teams for services in Tuvalu when possible again; and (viii) training and support for clinical governance arrangements such as mortality audits and IPC committee as well as defined standard operating procedures to improve the quality of certain priority service areas (i.e. operating theater, admittance and discharge procedures, diagnosis, treatment and referral for gender-based violence). Investments 25 To be initiated during project preparation. Aug 12, 2021 Page 13 of 18 The World Bank Health System Strengthening Project (P175170) would include works, medical equipment (including radiological equipment) and supplies, technical assistance, and training. This may include training abroad for the attainment of specialist qualifications by Tuvalu medical staff. The scope may also include providing some recurrent costs associated with supporting international teleconsultation systems and visiting medical teams. 29. Subcomponent 1b: Strengthen the capacity of core public health programs. This subcomponent would generally build the capacity of the public health system for public health screening of the population and its environment for interventions that can be managed in Tuvalu. Activities would include: (i) design and establishment of a larger public health lab (in the new PMH Wing included under subcomponent 1a), building on the capacity that was established under the partner support for COVID-19 related screening, including field vehicles for specimen collections and outreach services; (ii) assessment of the needs and implementation of a plan for defining standard operating procedures and training of the public health lab staff; (iii) design and undertake an external peer review of the public health lab from a more established regional public health lab to provide support in establishing good quality control; (iv) design and implementation of an integrated screening program of the adult population, including for diagnosis and risk stratification for NCDs, particularly hypertension and diabetes; and (v) capacity building for the design and implementation of strategic public health communications, in coordination with other development partners such as ADB, WHO and UNICEF, but with specific analysis and planning due to gender, location, and other key differences in risk patterns and health seeking behavior. The Project would also support health communication strategies to embed cross-cutting issues like gender-based violence. Investments would include equipment, laboratory reagents, vehicles, technical assistance, and training. It will be important to work with technical partners such as WHO and SPC in the design and quality assurance mechanisms for the expanded laboratory and population screening plans. 30. Subcomponent 1c: Improved management of NCDs in the community and outer island clinics . Given the high burden of NCDs in the population and the financial strain of treating severe complications through the overseas medical treatment scheme, it is important to significantly improve the early management of the disease for those who are at high risk and for those who can be treated effectively on an outpatient basis through the system of clinics and through a specialized NCD clinic which will be established under PMH. Activities would include: (i) ensuring standard treatment protocols for the management and referral of hypertensive and diabetic patients at primary health care level are available and staff are trained in their use; (ii) defining standards and ensuring readiness of facilities to detect and manage cases of hypertension and diabetes26, including through point of care diagnostic equipment where feasible, training, and availability of essential medicines; (iii) enhancing the teleconsultation capacity between outer island clinics and PMH; and (iv) promoting and building capacity for self- help patient groups for peer-to-peer support. Where possible, training on NCDs would be integrated with other primary health care training needs including those that are related to emergency response and injury in case of hazardous or other trauma event; prevention and awareness raising for heat-related illnesses; and detection and referral in case of gender-based violence. Investments could include technical assistance and training; point of care diagnostic technologies; and information, communication, and technology (ICT) related equipment. At the moment, it is considered that the Project would piggy-back on the improved internet connectivity initiatives already underway and, therefore, not have to directly invest in satellite or broadband connections themselves though it will be further investigated during preparation to the extent that those initiatives will directly benefit and link with the health facilities. The Project will coordinate with WHO which is working with the MoH on strengthening NCD prevention and control, including introducing the Package of Essential NCD Interventions 26 Not including cases of high risk for a catastrophic event or complications which would be referred to PMH. Aug 12, 2021 Page 14 of 18 The World Bank Health System Strengthening Project (P175170) (PEN). The Project will provide the resources to expand upon and roll out the support initiated by WHO and other partners. 31. Subcomponent 1d: Strengthen Infection Prevention and Control and Medical Waste Management. As a foundation to the improved quality of essential health services, this subcomponent would aim to improve the infection prevention control and medical waste management systems in practice at PMH and across the island clinics. Activities would include: (i) assessment of current system, standard operating procedures, capacities of human resources and gaps for proper hygiene and infection control management and waste management; (ii) development of procedures and training of staff based on the gaps defined; (iii) upgrade of the water, sanitation and hand-hygiene facilities in the outer island health clinics, i.e. through improving and expanding the rain water collection and storage facilities, functioning hand-washing stations with appropriate soaps, and functioning and environmentally appropriate latrines for men, women and disabled access; and (iv) investment in a vehicle to be used on Funafuti island (including from ports for waste of outer island health clinics) for the transport of waste (medical and otherwise) to designated points of disposal and incineration. Investments would include small infrastructure, technical assistance, training, and vehicle. This subcomponent will need to be carefully coordinated with the support from (i) Taiwan for an incinerator to be used for medical waste, (ii) the ADB through UNICEF on IPC and medical waste in conjunction with the COVID-19 vaccine deployment, and (iii) SPC and WHO on IPC policy and guidelines. Component 2: Strengthen systems for better health service management (approximately US$ 1.5 million) 32. Subcomponent 2.1: Strengthen information management for better service delivery. One of the big constraints for better patient management is the lack of patient-centered information that can used to manage to track patients over time and through the referral system and generally the fragmentation and ill-use of existing health information related systems. The Project would support the adaptation and roll-out of a simplified digital patient record that can be used from the point of screening, stratification and management of NCDs which could be used across the system from community, health care clinics, and for the management of chronic disease patients at PMH. The simplified system would have the capability to be integrated with any larger scale management information system at the PMH and export summary information for general public health reporting, and, therefore, would not be the development of another parallel system. At the same time, the Project would support an assessment of the PMH hospital management information system in order to lay out a step-wise plan for the upgrade or replacement of the current system to make it functional across the different components (patient records, lab, radiology, pharmacy, administration, etc.). The replacement of the system would be outside the Project, but any minor investments in hardware, local area network connections or similar that may improve the use of the existing system may be supported. The Project would also support the collection and routine update of health facility readiness information both to ensure the ability to provide quality essential health services, but also ensure a minimum readiness in case of hazardous event. Investments would include: (i) technical assistance and training; (ii) software application adaptation and training; and (iii) ICT equipment and related small in-hospital works to establish network. The Project will coordinate with MFAT and DFAT development support that has been focused on the roll-out of the mSupply logistics management information system to promote the use of mSupply for the purposes of regular monitoring of pharmaceuticals and other essential health commodities availability, but also to determine if the support could be expanded to include related elements such as the patient monitoring system and facility readiness surveys. 33. Subcomponent 2.2: Strengthen the health planning, budgeting, and implementation. Given the Project investments in expanding service delivery and quality, this has significant implications to ensure that the recurrent Aug 12, 2021 Page 15 of 18 The World Bank Health System Strengthening Project (P175170) costs for operations and maintenance are planned and budgeted adequately. While it is expected that DFAT will provide general technical advisory assistance in health sector planning, specific technical assistance for planning, budgeting and budget implementation of the increased operation and maintenance cost is expected to be needed. The draft NHSP identifies the need to have a prioritized and costed facility maintenance and repair plan and to establish an asset management system that would identify life cycle, repair and maintenance schedule for health assets. Since these would support the sustained operation and maintenance of the facilities supported by the Project, the subcomponent would also provide technical assistance to support the MoH with such plans. Also as a complement to the DFAT advisory support, the component may provide support for the generation of evidence on health system performance, provide feedback from the citizenry on the availability and quality of health services and provide a format through a national health assembly type of approach to engage with the citizens on the priorities for health. United Nations Development Programme (UNDP), with other partners, is providing support through a regional Project in strengthening climate information and early warning systems that includes Tuvalu. Though there is support from WHO and UNDP-financed by the Global Environment Facility to make progress according to the indicators listed in the Health and Climate Change Country Profile, the subcomponent may provide discrete technical assistance towards this progress as needed. Investments would include: (i) technical assistance; (ii) surveys; and (iii) meeting and workshop related expenses. 34. Component 3: Project Management, Monitoring and Technical Support (approximately $1.00 million). In order to facilitate the achievement of the Project objectives, activities and administrative procedures, this component would support the necessary full-time consultant team (as defined in the Project Implementation Arrangements) that would constitute the Project Management Unit (PMU) to support the MoH27 in its responsibilities as the Implementing Agency of the Project; short-term technical assistance in areas of project management as may be required, such as part-time consultants in specific areas to comply with the environment and social standards; the cost of equipping and furnishing a project office; and incremental operating costs in support of Project management, including travel related costs associated with Project management. It would also include key technical assistance particularly as it relates to the detailed functional and architectural design of the PMH Wing proposed under subcomponent 1a. 35. Component 4: Contingent emergency response component (CERC) (US$ 0.0 Million). The objective of this component is to improve the GoTv’s response capacity in the event of an emergency, following the procedures governed by World Bank Operational and Bank Policy (OP/BP) 8.00 on rapid response to crisis and emergencies. The component would support a rapid response to a request from the Ministry of Finance for urgent assistance in respect of an event that has caused, or is likely to imminently cause, a major adverse economic and/or social impact to Tuvalu associated with a natural or man-made crisis or disaster. In the event of an emergency, financial support could be mobilized by reallocation of funds from other components to support expenditures on a positive list of goods and/or specific works and services required for emergency recovery. A CERC operational manual, governing implementation arrangements for this component, will be prepared with support under the project. 27 This team of consultants would be in addition to those that will be part of a Central Project Management Office housed at the Ministry of Finance which would provide advice and support. Aug 12, 2021 Page 16 of 18 The World Bank Health System Strengthening Project (P175170) Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Summary of Screening of Environmental and Social Risks and Impacts . The Environmental and Social Risk Classification for the Project is 'Substantial'. The project is expected to result in positive environmental and social impacts as it seeks to strengthen Tuvalu's health system including investments into infection prevention and control and medical waste management improvements. Project activities also present environmental, social, health and safety risks for the project workforce, communities, and the environment. The project is not expected to involve any land acquisition or involuntary resettlement and works will be completed on previously disturbed land and no large-scale labor influx is expected in sensitive receiving environments. Key environment and social risks and impacts include: construction phase and labor influx and SEA/SH risks, along with equity in access to project benefits, human health risks that may result from misuse of, poor quality, and/or poorly managed medical equipment, materials and services, the generation of medical waste and impacts from demolition and construction activities such as dust and noise generation and to occupational and community health and safety. Activities are comparatively small in scale and complexity, impacts are generally known, low in magnitude and site specific, temporary, and reversible in nature with management measures that are predictable and likely to be effective. Operational risks largely relate to equitable access, waste management and occupational and community health and safety. The MoH will manage these risks and impacts through the preparation and implementation of a project wide environmental and social management plan, an environmental and social audit to assess any areas of concern where existing infrastructure is relied upon for project activities, an infection prevention and control and waste management plan, operational medical waste management plans, a stakeholder engagement plan and labor management procedures. Environmental and social risk management will also be considered in technical assistance activities. . CONTACT POINT World Bank Kari L. Hurt Senior Operations Officer Borrower/Client/Recipient Ministry of Finance and Economic Development Seve Paeniu Minister of Finance sevepaeniu@gmail.com Aug 12, 2021 Page 17 of 18 The World Bank Health System Strengthening Project (P175170) Implementing Agencies Ministry of Health, Social Welfare and Gender Affairs Elisala Natano Acting Director of Health healthpromotion.tv@gmail.com 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 APPROVAL Task Team Leader(s): Kari L. Hurt Approved By APPROVALTBL Practice Manager/Manager: Country Director: Stephen N. Ndegwa 31-Aug-2021 Aug 12, 2021 Page 18 of 18