The World Bank Pacific Healthy Islands Transformation project (P508550) @#&OPS~Doctype~OPS^blank@pidconcoverpage#doctemplate Project Information Document (PID) Concept Stage | Date Prepared/Updated: 26-Mar-2025 | Report No: PIDDC01222 The World Bank Pacific Healthy Islands Transformation project (P508550) @#&OPS~Doctype~OPS^dynamics@pidbasicinformation#doctemplate BASIC INFORMATION A. Basic Project Data Project Beneficiary(ies) Operation ID Operation Name Fiji, Kiribati, Tonga, Tuvalu P508550 Pacific Healthy Islands Transformation project Region Estimated Appraisal Date Estimated Approval Date Practice Area (Lead) EAST ASIA AND PACIFIC 16-Jun-2025 28-Aug-2025 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Ministry of Finance and Ministry of Health and Financing (IPF) Economic Development, Medical Services, South Mininstry of Finance and Pacific Community, Economic Development, Ministry of Health and Ministry of Finance, Social Welfare, Ministry of Ministry of Health and Finance, Strategic Planning, Medical Services, South National Development and Pacific Community, Statistics, Ministry of Ministry of Finance, Health Strategic Planning, National Planning & Development Proposed Development Objective(s) Improve access to quality health services within Pacific Small Island Developing States, with a focus on NCD prevention and control. @#&OPS~Doctype~OPS^dynamics@pidprojectfinancing#doctemplate PROJECT FINANCING DATA (US$, Millions) Maximizing Finance for Development Is this an MFD-Enabling Project (MFD-EP)? No Is this project Private Capital Enabling (PCE)? No SUMMARY Total Operation Cost 290.00 Total Financing 290.00 Page 1 The World Bank Pacific Healthy Islands Transformation project (P508550) of which IBRD/IDA 200.00 Financing Gap 0.00 DETAILS World Bank Group Financing International Development Association (IDA) 200.00 IDA Credit 30.00 IDA Grant 170.00 Non-World Bank Group Financing Trust Funds 10.00 The Pandemic Fund 10.00 Other Sources 80.00 Asian Development Bank 50.00 OPEC FUND 30.00 @#&OPS~Doctype~OPS^dynamics@envsocriskclassification#doctemplate Environmental and Social Risk Classification Concept Review Decision Substantial The review did authorize the preparation to continue B. Introduction and Context 1. The Pacific Small Island Developing States (SIDS) are diverse island economies, spanning 30 million square kilometers of the Pacific Ocean. They vary in size and topography, from small single island nations to Kiribati’s 811 square kilometers of land distributed over 3.5 million square kilometers of ocean, an area larger than India. The geographic diversity and wide population distribution across hundreds of islands generate diseconomies of scale, presenting shared challenge to finance, organize, and manage delivery of services. The "Blue Pacific Continent" refers to the Pacific SIDS and their shared commitment to regional cooperation and sustainable development, as articulated in the 2050 Strategy for the Blue Pacific Continent, a key framework for the Pacific Islands Forum (PIF) 1. PIF brings together Pacific leaders to address pressing issues and foster collaboration in the pursuit of shared goals. ‘Healthy Islands’ is one of the goals envisioned by Pacific leaders, where: Children are nurtured in body and mind; Environments invite learning and leisure; People work and age with dignity; Ecological balance is a source of pride; and, the ocean which sustains us is protected.’ Twelve Pacific SIDS are members of the World Bank.    1 Founded in 1971, PIF comprises 18 members who share a joint 2050 Strategy for a Blue Continent. https://forumsec.org/2050 Page 2 The World Bank Pacific Healthy Islands Transformation project (P508550) 2. Pacific SIDS are a hotspot for both climate change risk and natural hazard exposure . For most Pacific SIDS, infrastructure is not sufficiently resilient or prepared to effectively respond to and recover from the impacts of climate change such as the increasing frequency and intensity of tropical cyclones with associated flooding and high winds. In the period between 1951 to 2014, tropical storms making landfall were more frequent in the West Pacific Ocean (56 percent) compared to the global average (47 percent), with even higher rates in Fiji (69 percent), and Tuvalu (75 percent).2 With 97 percent of Pacific Islanders (excluding Papua New Guinea) living within 10 kilometers of coastal zones, the corresponding population’s service delivery infrastructure exposes buildings to climate events.3 Of the 78 hospitals in 14 Pacific Island Countries, 56 percent are physically vulnerable to hydrological threats with 63 percent of the population at risk of losing access to health care services if damaged.4 Annual financial losses are high in all countries. 3. Across the wider Pacific region, the post-pandemic economic recovery is losing momentum. In 2024, growth across 11 Pacific SIDS (PIC-11)5 was estimated to have slowed significantly to 3.6 percent, following a robust 5.8 percent expansion in 2023, reflecting the reducing impact of the post-pandemic recovery, particularly in the two largest PIC-11 economies, Fiji, and Solomon Islands. Fiji’s growth is projected to decelerate to 3.1 percent, down sharply from 8 percent in 2023, as economic activity returns to pre-pandemic levels while Solomon Islands is expected to see more moderate growth of 2.5 percent, compared to 3 percent in 2023.    Sectoral and Institutional Context    4. Pacific Island Countries are confronted by one of the world’s highest and most advanced burden of non- communicable diseases (NCDs), with diabetes, cardiovascular diseases, and cancer being the leading causes of ill- health and mortality. This high burden is expected to significantly increase due to unhealthy lifestyles and aging (Figure 1). NCDs are more complex and costly to manage for health systems, given the need for long-term care and the often-lifelong interaction between the patient and the health system. In the Pacific, NCDs impact the working age population the most, and as a result, NCDs not only strain public health systems but also impose significant economic costs—FJ$591 million annually in Fiji alone—resulting from treatment as well as absenteeism and premature disability. Global economic studies indicate that for every $1 invested in NCD prevention and control, at least $7 is generated in economic returns. 5. The Pacific’s healthcare systems are under increasing pressure due to workforce shortages, inadequate primary healthcare facilities, and high costs of overseas medical referrals for specialized treatment. Climate change further exacerbates these challenges by disrupting access to healthcare facilities and service delivery. Climate change also compounds NCDs through increased risk of heat stroke and reduced opportunities for safe physical activity. Many primary care facilities lack essential medical equipment, trained personnel, and even basic internet connectivity, further limiting access to quality healthcare. This manifests in poor quality of clinical management and high rates of complications. Available evidence suggests poor control of conditions like diabetes (with an average treatment rate of 4 percent) and cardiovascular diseases (with an average treatment rate of 9 percent) (Figure 1). 2 Climate Change Knowledge Portal. World Bank. https://climateknowledgeportal.worldbank.org/ 3 Andrew NL, Bright P, de la Rua L, Teoh SJ, Vickers M (2019) Coastal proximity of populations in 22 Pacific Island Countries and Territories. PLoS ONE 14(9): e0223249. https://doi.org/10.1371/journal.pone.0223249 4 Eileen Natuzzi, “Vulnerability of Pacific Island Country Hospitals: Be Addressed,� Georgetown University School of Foreign Service, Center for Australian, New Zealand, and Pacific Studies, Oceanic Critical Infrastructure That Must Currents Occasional Paper Series, January 2023, https://canzps.georgetown.edu/wp-content/uploads/sites/531/2023/01/Pacific-Island-Hospitals-are-critical-infrastructure.pdf 5 PIC-11: Federated States of Micronesia (FSM), Fiji, Kiribati, Marshall Islands, Nauru, Palau, Samoa, Solomon Islands, Tonga, Tuvalu, and Vanuatu. World Bank. Pacific Economic Update. 2024 Page 3 The World Bank Pacific Healthy Islands Transformation project (P508550) Figure 1: Diabetes and hypertension diagnosis to treatment cascade, select Pacific SIDS 90.00% On average, only 19% On average, only 22% On average, less of those who have a On average, less of those who have 80.00% than 49% of diabetes diagnosis are than 39% of hypertension are on those who have on treatment; those who have treatment; indicating a 70.00% diabetes are indicating a 4% hypertension are 9% treatment rate as a diagnosed treatment rate as a diagnosed proportion of 60.00% proportion of prevalence 50.00% prevalence 40.00% 30.00% 20.00% 10.00% 0.00% Prevalence of Diabetes On Treatment Prevalence of Hypertension On Treatment Diabetes Diagnosis for Diabetes Hypertension Diagnosis for Hypertension (among (among diagnosed) diagnosed Fiji Tuvalu Kiribati Samoa Solomon Islands Tonga Vanuatu Nauru Source: most recent population-based surveys (STEPs Survey for NCD surveillance) Relationship to CPF    6. Human Capital development is a key driver of economic growth in the Pacific. The proposed Pacific Healthy Islands Transformation (PHIT) is aligned to the World Bank’s regional strategy for nine Pacific Island countries (PIC9)6 through one of the three broader development pathways and associated development priorities. Pathway 2 of the Systematic Country Diagnostic (SCD) recommends maximizing human capital to leverage its economic returns.7  Within the SCD regional development pathway, a key recommendation is strengthening health systems to improve coverage, quality, and resilience through supporting health resilience (including emergency preparedness), focusing attention on the three domains of quality care (foundations, processes of care and quality impacts), strengthening primary and secondary prevention of NCDs, addressing health sector management challenges, strengthening health financing by efficiency gains, and improving accessibility and utilization of data for decision making. The 2023 PIC9 SCD Update informs the development of the PIC 9 Regional Partnership Framework which includes More Inclusive Human Development as a high-level outcome. The human development outcome prioritizes access to quality health services, with a focus on preventative measures and addressing chronic NCDs, as well as health financing efficiency for the PIC9. Fiji’s most recent country partnership framework (2021 – 2024) was extended for an additional 18 months and outlines building resilience as one of the two focus areas with an emphasis on supporting national and regional systems strengthening and public health preparedness, considering Fiji’s role as a regional hub for training of healthcare workforce and specialized care.      C. Proposed Development Objective(s)          Improve access to quality health services within Pacific Small Island Developing States, with a focus on NCD prevention and control. 7. The PDO will be measured by the following PDO indicators: Page 4 The World Bank Pacific Healthy Islands Transformation project (P508550) Regional-level health systems indicators: i. Formalized clinical pathways referrals and clinical care standards between levels of care (including OMR) for key NCD conditions are in place ii. Number of consultations delivered through Centres of Excellence for telemedicine iii. Number of students completing on-line learning for continued medical education, with focus on NCD prevention and control. iv. Number of primary care facilities having availability of first line hypertension and diabetes medication in the past six months National-level health systems indicators: ii. Number of upgraded PHC facilities that meet climate credentialing standards iii. Proportion of targeted populations screened for NCD risk factors such as obesity, physical inactivity and tobacco, disaggregated by sex and age (e.g., children, adolescents and women of reproductive age) referred for consultation and treatment iv. Percentage of diabetic patients who receive at least one HbA1c test every six months, disaggregated by sex age, and women of reproductive age)   D. Concept Description  8. The Pacific Healthy Islands Transformation (PHIT) Project is designed to address the diseconomies of scale that compound the lack of access to quality health services over six years of implementation. PHIT aims to tackle the significant and growing health challenges in Pacific Small Island Developing States (SIDS) by reforming and modernizing medical services, with primary health care as the foundation; enhancing workforce capabilities; strengthening health promotion and community outreach; revamping overseas patient referral schemes; and leveraging digital health solutions. In addition to Fiji, Kiribati, Tonga and Tuvalu, other Pacific SIDS are currently being confirmed for support by the PHIT project. The project establishes platforms that will be scaled up over time to expand the benefits that Pacific SIDS accrue from the project. By emphasizing preventive care, modernizing infrastructure across all levels of care, and investing in workforce training, the initiative aims to create a sustainable and effective regional healthcare ecosystem which will redefine healthcare access in the Pacific, offering a scalable model for other small island nations facing similar challenges.  Financing is indicative at concept stage, for further refinement during preparation. 9. PHIT establishes a co-financing platform that aims to reduce fragmentation of development partner financing, enabling a holistic approach to transformative interventions at scale. On the request of participating governments, the Asian Development Bank (ADB) and the World Bank will explore piloting a new co-financing arrangement, the Full Mutual Reliance Framework (FMRF), to apply a single set of operational policy requirements for better alignment and efficiency. The OPEC Fund for International Development (OFID) has proposed a concessional investment in PHIT and bilateral development partners, including Australia and New Zealand, play a critical role in the design of PHIT, through their investment in a Master Plan for the region’s largest referral and training facility, the tertiary Colonial War Memorial hospital, and through the Advance Universal Health Coverage (AUHC) trust fund, which finances analytical and advisory services that inform policy as well as strategic and operational investments across Pacific SIDS. @#&OPS~Doctype~OPS^dynamics@legalpolicyandscreeningrisk#doctemplate Page 5 The World Bank Pacific Healthy Islands Transformation project (P508550) Legal Operational Policies Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Area OP 7.60 No Summary of Screening of Environmental and Social Risks and Impacts @#&OPS~Doctype~OPS^dynamics@contactpoint#doctemplate CONTACT POINT World Bank Margareta Norris Harrit Senior Health Specialist Mickey Chopra Lead Health Specialist Borrower/Client/Recipient Page 6 The World Bank Pacific Healthy Islands Transformation project (P508550) Ministry of Finance and Economic Development Koin Uriam Permanent Secretary secretary@mfep.gov.ki Mininstry of Finance and Economic Development Nuausala Nuausala Permanent Secretary nnuausala@gov.tv Ministry of Finance Kilisitina Tuaimei'api Chief Executive Officer ktuaimeiapi@finance.gov.to Ministry of Health and Medical Services Jemesa Tudravu Permanent Secretary jemesa.tudravu@health.gov.fj South Pacific Community Dr Berlin Kafoa Director, Public Health Division berlink@spc.int Ministry of Finance, Strategic Planning, National Planning & Development Shiri Gounder Permanent Secretary shiri.gounder@finance.gov.fj Implementing Agencies Page 7 The World Bank Pacific Healthy Islands Transformation project (P508550) Ministry of Health and Medical Services Benny Teua Permanent Secretary secretary@mhms.gov.ki South Pacific Community Dr. Berlin Kafoa Director Public Health Division berlink@spc.int Ministry of Health and Social Welfare Natano Elisala Acting Permanent Secretary natano_elisala@yahoo.com Ministry of Finance, Strategic Planning, National Development and Statistics Shiri Gounder Permanent Secretary shiri.gounder@finance.gov.fj Ministry of Health Ofa Tukia Chief Executive Officer for Health o.tukia@gmail.com Reynold Ofanoa Chief Executive Officer for Health reynoldofanoa@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 @#&OPS~Doctype~OPS^dynamics@approval#doctemplate APPROVAL Task Team Leader(s): Margareta Norris Harrit, Mickey Chopra Approved By Page 8 The World Bank Pacific Healthy Islands Transformation project (P508550) Practice Manager/Manager: Ronald Upenyu Mutasa 23-Jan-2025 Country Director: Stephen N. Ndegwa 26-Mar-2025 Page 9