Vol. 3, No.2 April–September 2020 NEWSLETTER Advance Universal Health Coverage: Multi-Donor Trust Fund for Integrating Externally Financed Health Programs Using MDTF Resources to Study COVID’s Longer-Term Impact on Fiscal Space for Health and Implications for UHC COVID-19 is not only requiring countries to respond Overseas Filipino workers undergo swab testing for COVID-19 at a quarantine facility in Manila, Philippines, on May 20, 2020. to the way they deliver health services during the ©Ezra Acayan/World Bank ofitkey immediate crisis, but impactand ministers will also space officials from the high-level the fiscal for health around the world for some time to come INSIDE PAGES with a forecast of international 5.2% contractionpartners discuss the transition to GDP in global in 2020. The disease is expected to result in a deep • Brief News 3, 6, 19 global economic contraction, surpassing in severity • Fifth Annual Health Financing Forum and Launch of the previous global and regional financial crises of COVID-19 Health Financing Resilience CoP 4 2008–2009 and 1997–1998. Almost all countries • Responding to COVID-19 in East Asia and the Pacific 5, 6 are projected to see some slowdown in economic • COVID-19 Response Activities 6, 7, 9 growth in 2020, regardless of the extent to which • US$195 Million Pandemic Funds for the coronavirus has spread within their borders. Poor Countries to Fight COVID-19 7 • Gavi Replenishment Exceeds Target for 2021–2025 Period 8 The extent and severity of the impact on health • Aparnaa Somanathan Takes on EAP Health Leadership Role 9 spending remains uncertain and needs to be • PMAC 2020 Ponders How to Advance UHC 9 Advance UHC In Focus What is the Advance UHC: MDTF? • Identifying the Gaps in Hypertension The Multi-Donor Trust Fund for Integrating Externally Financed Management in Samoa 10 Health Programs (MDTF) was established in 2015 to help • Review of Gender Mainstreaming countries transition from donor financed health programs to in Cambodia’s Health Sector 11 domestic health financing and service delivery systems. Its • IMPACT Health Project Improves Front Line overarching goal is to support countries in sustaining their Services in Papua New Guinea 12 commitment to advance toward universal health coverage • HFSA Advances Indonesia Toward UHC 13 (UHC) while managing this health financing transition. In 2020 the fund was rebranded to highlight the Advance UHC agenda • Solomon Islands Tackled COVID-19 and was renamed “Advance UHC: Multi-Donor Trust Fund for and a Cyclone at the Same Time 14 Integrating Externally Financed Health Programs”. The foundation • Profile: Almah Kuambu—Breaking Down for advancing the UHC agenda remains immunization, maternal Barriers in Papua New Guinea 15 and child health, and management of infectious disease. • Feeding Back NCD Taxation Evaluation Results COVID-19 has also shown that countries should integrate to Tonga’s Outer Islands 16 preparedness as the first step of this agenda. The MDTF is • Impact on the ground: DLIs Lift managed by the World Bank and its key donors are the Australian Immunization Rates in Remote Lao Districts 17 Department of Foreign Affairs and Trade (DFAT), Gavi, Global • PMAC 2020 Meeting Looks at Delivering Fund, and the Bill and Melinda Gates Foundation. The MDTF covers Results with DLIs 18 countries in East Asia and the Pacific, Africa, South Asia, • Furthering Collaboration on DRG Health Europe and Central Asia, and Latin America and the Caribbean. Payments at PMAC 2020 18, 19 April–September 2020 Vol. 3, No.2 page 2 MDTF NEWS A health clinic staff in Papua New Guinea stays safe with a mask. understood. To this end, the World Bank is utilizing of 1.7% in Central Asia. All industries are feeling MDTF funds, in partnership with the Global the impacts of COVID-19, with international travel Fund, International Monetary Fund (IMF), World restrictions limiting tourism, disruption to supply Health Organization (WHO) and Joint Learning chains, tightening of financial conditions delaying Network (JLN) to analyze the impact of COVID-19 investments and the plunge in oil prices all on health financing and service delivery in the contributing to global economic uncertainty and medium term. Key areas being studied are instability. the macro-economic context, public finance context, and the impact on public financing If public financing for health responds to the for health and health funding prioritization. economic shock the same way it has during previous contractions, levels of per capita public Preliminary estimates for East Asian economies spending on health are expected to decline and Pacific Island Countries show a significant across many countries. Even if the health sector’s economic shock in 2020, with regional growth share of general government spending remains projected to fall to 0.5% with a deep impact the same, countries may see a decline in health expected in Thailand, Timor-Leste, Palau, Fiji, spending in real terms, due to sharp declines in and Samoa—just to name a few countries. “The government revenue and associated cuts in pandemic will likely slow potential growth in the government spending. The significant economic region by weakening investment and the supply burden placed on governments to fund the chains that have been an important conduit for COVID-19 response at the moment will need to productivity gains over the last decade,” says the be recouped into the future, changing national new World Bank report Pandemic, Recession: the funding priorities and creating an even greater Global Economy in Crisis, which assesses the need for finding efficiencies within often stretched global economic outlook following COVID-19. health systems. In this emerging fiscal environment, countries will be further challenged in meeting Regions around the world are facing significant existing UHC targets and ensuring continued challenges with the economic activity for Sub- access to health services under greater financial Saharan Africa set to contract by 2.8% in 2020 and strain than previously experienced. similar contractions to be experienced in South Asia, with a projected GDP contraction of 2.7%. A Community of Practice (CoP) is being Latin America and the Caribbean are expected to established as part of the Global Annual Health experience significantly more severe economic Financing Forum. It will include JLN participants consequences in the future with regional economic from EAP as well as some participants who were activity predicted to plunge by 7.2% in 2020. The registered to attend the Pacific Flagship course impact experienced in Europe and Central Asia in May, cancelled due to COVID-19. This CoP is more varied, with GDP contractions in Central will provide opportunities to gain insights quickly Europe of 5% compared to a predicted contraction into both the responses to the COVID pandemic April–September 2020 Vol. 3, No.2 page 3 MDTF NEWS Projected impact on GDP growth in East Asia (middle-income countries) and Pacific Island Countries, 2009–2020 Source: WB/IMF staff estimates as well as the broader public financing implications However, this has not protected these fragile small experienced across the EAP region and how island economies from the substantial impact of countries are attempting to “move to the new normal” COVID. The loss of tourism and other key revenue to meet ongoing health service delivery demands. generating opportunities have taken a significant hit. The reorientation of the health sector has also Plans for further support are underway with partners resulted in many costs on service delivery and including monitoring country responses to the health outcomes. The negative impact is likely to pandemic, forecasting financing impacts and be felt for many years to come. As this monitoring curating knowledge. For example, Vietnam’s early and analytical work progresses the World Bank will and unequivocal decision to prioritize health over continue to draw on the experience of undertaking economic concern resulted in it initially having some of MDTF-funded Health Financial System Assessments the lowest COVID numbers (373 confirmed cases (HFSA) across the EAP region, adjusting the with no death as of July 16, 2020) despite sharing approach for the unique set of circumstances facing a long border with China. After the first case was us all today. detected in January 2020, Vietnam quickly halted passenger flights from high-risk areas, quarantined Analysis at a global level has already been international travelers, pursued targeted testing, undertaken, with recent publications including opted for aggressive contact tracing, and adopted Lives and Livelihoods: Estimates of the Global a multi-tier isolation system. Unfortunately, the Mortality and Poverty Effects of the Covid-19 disease is deceptive and a second round of Pandemic, examining the impacts on the global infection began spreading in late July, causing a community and the burden of poverty and number of fatalities. mortality due to COVID-19. Additionally, Pandemic, Recession: The Global Economy in Crisis , Another example is the experience in the Pacific, highlights the economic impacts and the policy where many countries acted early with travel options available to governments and global restrictions and remain COVID free at this point. institutions. BRIEF NEWS Vietnam Implemented New Grassroots Health Service Delivery Project The Investing and Innovating for Grassroots Health Service Delivery Project for Vietnam began its implementation stage on May 18, 2020. The project includes US$80 million of IDA Transitional Credit and US$23 million in grants, of which US$5 million is co-financed by the Australian government through the MDTF to Advance UHC. The International Development Association (IDA) is part of the World Bank Group. Retreat to Develop CPWC Guidelines in Cambodia A retreat was convened in Kampong Cham province in February 2020 for members of the National Committee for Sub- National Democratic Development (NCDD-S) and the National Center for Health Promotion (NCHP) to develop the Commune Program for Women and Children (CPWC) guidelines. The CPWC guidelines will bring together community programs to create a demand for services and mobilize community members for outreach activities. April–September 2020 Vol. 3, No.2 page 4 MDTF NEWS 5th Annual Global Health Financing Forum and launch of COVID-19 Health Financing Resilience CoP Registered Nurse, Jacqueline Sivili at C.H. Rennie Hospital in Kakata, Margibi County in Liberia. Photo © Dominic Chavez/World Bank The fifth Annual Health Financing Forum (AHFF) The COVID-19 Health Financing Resilience Program on the theme of Health Financing Resilience and Community of Practice (CoP) was also launched Sustainability was held virtually from 7-23 July during Part I of the AHFF, providing an opportunity 2020. Part I of the forum looked at health financing for participants to discuss and exchange ideas resilience, including steps countries have taken beyond the sessions through on and offline in their pandemic response and lessons learned interactions around the forum topics. Questions from to date. The six online sessions delivered over the AHFF sessions as responded to by presenters three weeks covered resource mobilization and and panelists have also been consolidated and prioritization, getting resources rapidly and flexibly will be accessible to all participants once they join to where they are needed, ensuring continuity of the CoP. Beyond the AHFF, the CoP provides a essential frontline services, telemedicine as a case space for vital dialogue and discussion, one-on-one study of purchasing agreements modification during interactions, the sharing of experiences, and the COVID-19, the private sector in lower-middle income deepening of collective knowledge on emerging countries (LMICs) and financial risk protection for priority areas on health financing for the COVID-19 COVID-19, and building back better in resilience response. It allows for the joint exploration of while learning from successes and mistakes. Each challenges and opportunities, and the sharing of week concluded with learning round-ups organized policy responses and lessons learned. Join the to bring participants together to share their thoughts COVID-19 HFRP CoP. and experiences in small group discussions about the week’s AHFF webinars. Part II, scheduled for later this year, will examine health financing vulnerability and sustainability in For those not able to join at the selected Washington the context of the new normal, and the need to DC time, these sessions were recorded and can be continue progress towards the SDGs. AHFF is viewed here. Session materials including background being hosted by the World Bank Group, the U.S. paper and presentations can be viewed here. Agency for International Development (USAID) and the Global Financing Facility (GFF). April–September 2020 Vol. 3, No.2 page 5 MDTF NEWS Responding to COVID-19 in East Asia and the Pacific Country FTCF PEF CERC Re-allocation TOTAL Cambodia 20.00 m. 1.21 m. 14.00 m. 35.21 m. Federated States of 2.50 m. 2.50 m. Micronesia Fiji 6.40 m. 1.00 m. 7.40 m. Indonesia 250.00 m. 250.00 m. Kiribati 2.50 m. 2.50 m. Lao PDR 18.00 m. 1.00 m. 19.00 m. Marshall Islands 2.50 m. 2.50 m. Mongolia 26.90 m. 1.00 m. 2.20 m. 39.10 m. Myanmar 50.00 m. 8.06 m. 58.06 m. Papua New Guinea 20.00 m. 1.25 m. 21.25 m. Philippines 100.00 m. 100.00 m. Samoa 2.90 m. 0.50 m. 5.20 m. 8.60 m. Timor-Leste 1.00 m. 1.00 m. Tonga 2.90 m. 2.90 m. Tuvalu 2.50 m. 2.50 m. Vanuatu 10.00 m. 10.00 m. Vietnam 6.50 m. 6.50 m. TOTAL 499.20 m. 21.08 m. 22.40 m. 17.40 m. 560.00 m. Note: Committed amount as of EOFY2020. “Reallocation” also includes funding under Catastrophic Deferred Drawdown Option (CAT-DDO). All funding is in US dollars. m. = US$ million As part of global efforts to combat COVID-19, 70% of the world’s population. This includes development partners are doing what they can to financing under the FTCF as well as other forms support governments across the world to prepare of financing, including redeployment of existing for and respond to this latest threat to health projects. In total, the World Bank Group will deploy security and UHC for all. Joining the efforts of as much as US$160 billion over a 15-month period, many others, the World Bank on March 17, 2020 tailored to the health, economic and social shocks provided a US$14 billion package of fast-track countries are facing. COVID-19 financing (FTCF) to assist countries in their efforts to prevent, detect and respond to the In the East Asia and Pacific (EAP) region, development pandemic. This funding is going through existing partners are collaborating to help countries cope and new projects to support the health sector with the impacts of this pandemic. They include and broader national responses to the pandemic, Australia’s Department of Foreign Affairs and recognizing the dual impact on health and Trade (DFAT), New Zealand’s Ministry of Foreign economic development. On May 19, the World Bank Affairs and Trade (MFAT), World Health Organization Group announced its emergency operations to fight (WHO), Pacific Community (SPC), UNICEF, the COVID-19 have reached 100 countries, representing World Bank, Asian Development Bank and numerous April–September 2020 Vol. 3, No.2 page 6 MDTF NEWS other institutions. Efforts are well underway to UHC to help inform investment decisions. The support health ministries to strengthen health FTCF was established specifically to support services and the systems that underpin them, to countries globally in responding to the disease. enhance disease surveillance, and the effective It complements existing financing mechanisms management and treatment of people with COVID-19 including the Pandemic Emergency Financing infections. They also aim to fill critical gaps in Facility (PEF) and the Contingent Emergency countries that include strengthening prevention Response Components (CERC) in some projects. activities, rapid detection, and preparedness and Eight countries in the East Asia Pacific region response to disease outbreaks. have received grants from PEF totaling US$21.08 million which was triggered to fund the world’s Countries in EAP are getting funding support poorest countries when facing cross-border, through a range of World Bank COVID-19 large-scale disease outbreaks. Additional funding Emergency Response Projects as well as has also been redirected through existing reallocated existing funding. The World Bank projects to help strengthen health systems and team has drawn on the analysis completed emergency response in the wake of COVID-19. over recent years under the MDTF to Advance COVID-19 RESPONSE ACTIVITIES APRIL 2 APRIL 6 APRIL 10 COVID-19 Emergency Response COVID-19 Response Project COVID-19 Response Project is Projects is approved for Cambodia and is approved for Lao PDR approved for Papua New Guinea Mongolia APRIL 14 APRIL 16 APRIL 21 COVID-19 Emergency Response COVID-19 Response Project is COVID-19 Emergency Response Project is approved for Myanmar approved for Marshall Islands Project is approved for Samoa APRIL 22 APRIL 27 COVID-19 Emergency Response COVID-19 and Tropical Cyclone Harold Emergency Funding through the Project is approved for the Philippines Catastrophic Deferred Drawdown Option is approved for Vanuatu BRIEF NEWS Dialogue on Integrated Outreach Guideline in Phnom Penh Cambodia’s Preventive Medicine Department held a retreat in Phnom Penh in February 2020 bringing stakeholders from the national programs together to enhance the dialogue on the outreach guidelines. Integrated outreach is important in shifting the ownership of the integrated package to the health center for delivery of outreach services. The Integrated Outreach Guideline, with the inclusion of the Minimum Package of Maternal and Child Health and Nutrition Services, will be implemented and routinely carried out by health centers. April–September 2020 Vol. 3, No.2 page 7 MDTF NEWS US$195 Million Pandemic Funds for Poor Countries to Fight COVID-19 The Steering Body of the Pandemic Emergency trigger conditions were met, 4,653 cases, or Financing Facility (PEF) has allotted US$195.84 0.62% of reported COVID-19 cases globally, million to 64 of the world’s poorest countries with were from the world’s poorest countries that are reported cases of COVID-19. Special attention members of the World Bank’s International will be given to areas with the most vulnerable Development Association (IDA). In the East Asia populations, especially in fragile and conflict- and Pacific region eight countries—Cambodia, affected countries. Fiji, Lao PDR, Mongolia, Myanmar, PNG, Timor Leste and Vietnam—have also received PEF The funds will provide additional support to these grants (see story page 5). countries in their COVID-19 response, including essential and critical lifesaving medical equipment, Specific funding allocations will be determined by personal protective equipment, therapeutics and population size and reported cases, with a minimum medicine, and support for health workers on the of US$1 million and maximum of US$15 million frontlines of the crisis. The PEF, a financing mechanism going to each country, and a heavier weight given housed at the World Bank, is designed to provide to countries classified as fragile or conflict-affected. an additional source of financing to help the world’s These countries face greater challenges with their poorest countries respond to cross-border, large- health systems and are home to the most vulnerable scale outbreaks. Established in 2016 to provide people. Before the COVID-19 crisis hit, it was financial support to low-income countries in case already estimated that up to two thirds of the of major multi-country disease outbreaks, the PEF world’s extreme poor would live in fragile and was designed to provide financing through either conflict affected areas by 2030. its cash or insurance windows, covering viruses that are most likely to cause a pandemic. This US$195.84 million funding, allocated on April 27, 2020 is in addition to the World Bank Group’s The allocation of US$195.84 million is the amount commitment of up to US$160 billion to fight received when the PEF insurance window triggered COVID-19 worldwide. for COVID-19 as reported by AIR Worldwide, an Press Release independent calculation agent. At the time all COVID-19 RESPONSE ACTIVITIES MAY 5 Tonga triggers the Transport Project Contingency Emergency Response Component (CERC) to address critical needs for COVID-19 response; the Federated States of Micronesia triggers the Maritime Investment Project CERC to respond to critical needs for COVID-19 response MAY 6 MAY 22 Tuvalu triggers the Maritime Investment in Climate Resilient Operations CERC COVID-19 Emergency Response to respond to critical needs for COVID-19 response Project is approved for Indonesia JUNE 18 JUNE 23 COVID-19 Emergency Response Project is approved COVID-19 Emergency Response Project is approved for China for Fiji April–September 2020 Vol. 3, No.2 page 8 MDTF NEWS Nurses at the Main Hospital in Tongatapu, Tonga, where vaccination is an important service, smile for the camera as they update their patients records. Gavi Replenishment Exceeds Target for 2021–2025 Period The Global Vaccine Summit, hosted virtually immunization is one of the most cost-effective by the United Kingdom on June 4, 2020, saw investments countries can make as they prioritize donors exceed the original request of US$7.4 benefits packages for UHC and build human capital billion with a final tally of US$10.5 billion for a more prosperous, equitable future. For every for Gavi’s 2021–2025 replenishment period. The dollar invested in vaccination in the world’s 94 Australian Department of Foreign Affairs and Trade lowest-income countries, US$16 are expected to (DFAT) has increased its Gavi contributions, be saved in healthcare costs, lost wages and lost committing AU$300 million (US$208.9 million) to productivity due to illness and death. The number this replenishment period. The latest replenishment rises to US$44 when we include broader economic will enable Gavi to remain a valued technical partner benefits and the value given to living longer. as well as investor in the MDTF to Advance UHC. Gavi is even more critically needed in the context The commitment expressed by the international of the COVID-19 crisis and is already playing donor community reflects the important role Gavi an important role in shaping markets for a new is playing now more than ever, by enabling COVID-19 vaccine when it is available. The newly universal health coverage (UHC) through increasing established COVID-19 Advance Market Commitment equitable use of vaccines in lower income countries. (the COVAX AMC) will focus on expanding vaccine Gavi is working through its alliance partners to access to the poorest countries. “The Gavi Covax mitigate the disruption of essential health services AMC increases the likelihood that when we have a and supply chains caused by the COVID-19 successful vaccine or vaccines, it will be available pandemic. Already, more than 80 million children in sufficient quantities and affordable to developing globally are at risk of becoming infected with countries,” says Ngozi Okonjo-Iweala, Chair of diphtheria, measles and polio due to disruptions, Gavi Board. particularly as they work to mitigate the secondary impact of COVID-19 by protecting essential Donors pledged US$600 million, including US$100 services and vaccine financing. Gavi is working million from the Bill and Melinda Gates Foundation, within the Global Action Plan (GAP) Health to this innovative financing mechanism at the Financing Accelerator, with other partners, to build summit. These upfront commitments from donors resilient, sustainable health systems. will allow countries to share vaccine development costs and support scaled manufacturing and In many of the poorest countries, vaccine- procurement of a COVID-19 vaccine once it is preventable illnesses still account for a large available. This will make the vaccine universally share of mortality and morbidity. Investing in and equitably accessible for all. April–September 2020 Vol. 3, No.2 page 9 MDTF NEWS Aparnaa Somanathan Takes on EAP Health Leadership Role Aparnaa Somanathan is the new Practice Manager for Health, Nutrition and Population for East Asia and the Pacific (EAP) at the World Bank, overseeing the direction and implementation of the MDTF in the region. She has worked on health financing and health systems strengthening issues for over twenty years in a range of countries including Bangladesh, China, Estonia, Georgia, Indonesia, Kazakhstan, Sri Lanka and Vietnam. She has also worked extensively on the implications of population aging on health financing and service delivery. Aparnaa read economics at Cambridge University and holds a doctoral degree in International Health Economics and Policy from Harvard University. Aparnaa is the lead author of the 2014 World Bank publication titled, “Moving Towards Universal Coverage of Social Health Insurance in Vietnam: Assessment and Options”. She is also the co-author of: “Financing Health Care in the East Asia and Pacific: Best Practices and Remaining Challenges” with Jack Langenbrunner; and the publication, “Live Long and Prosper: Ageing in the East Asia and Pacific Region” with Philip O’Keefe and others. PMAC 2020 Ponders How to Advance UHC pockets. This is why the Prince Mahidol Award Conference (PMAC) 2020 chose “Accelerating Progress Towards UHC” as its theme this year. At its plenary session the annual international forum on policy-related public health issues, held in Bangkok from January 28–February 2, 2020, a panel of stakeholders conferred on how to advance UHC to meet its 2030 Agenda for Sustainable Speakers discuss how to increase momentum toward UHC. Development in the remaining 10 years. Thai Deputy Prime Minister Anutin Charnvirakul told the session It has been five years since the world adopted in his key note speech that it took “sweat, toil and the Sustainable Development Goals (SDGs) in tears” for Thailand to kickstart its UHC scheme in 2015 and pledged to end poverty and ensure that 2002 when it was not yet a middle-income country. all people enjoy peace and prosperity by 2030. Achieving universal health coverage (UHC) is The MDTF to Advance UHC supports PMAC each key to this agenda since it offers all individuals year through funding of selected participants and the health services that they need without meeting sessions to stimulate debate and share suffering financial hardship. But about half of the lessons on effective approaches to UHC. world’s population still have no access to basic Read Feature Story health care services and must pay out of their own PMAC 2020 Report COVID-19 RESPONSE ACTIVITIES JUNE 25 JULY COVID-19 Emergency Cambodia, Fiji, Lao PDR, Mongolia, Myanmar, PNG, Timor Leste and Vietnam to Response Project is receive grant from the Pandemic Emergency Financing Facility (PEF) totaling US$ 21.08 approved for Kiribati million. Vietnam and Timor Leste are also to receive assistance from the Japan Social Development Fund (JSDF) April–September 2020 Vol. 3, No.2 page 10 MDTF NEWS Advance UHC in Focus Identifying the Gaps in Hypertension Management in Samoa Gaps along the continuum of NCD care: the most significant are in the “screening” and “screening-to-diagnosis” stages As in many Pacific Island Countries, non-communicable The barriers to successful hypertension care differed diseases (NCDs) are the major threat to the health at each stage and ranged from psychological and of the Samoa population. To support Samoa’s cultural barriers, to human resource constraints national NCD action plan, the Samoan Ministry within health facilities, limited access to drugs of Health and the World Bank jointly conducted and equipment and sub-optimal clinical hypertension an implementation cascade study in 2019 to management in the rural health facilities. While systematically identify the gaps and bottlenecks the barriers differed by individual and community, in the continuum of NCD care. This work, funded the result is the same—a lack of universal through the MDTF to Advance UHC, used access to health services for all people. Addressing hypertension as a tracer condition and examined these gaps and the barriers along the NCD ways to address them. The study looked at care continuum is vital to ensure appropriate hypertension screening, diagnosis, treatment, access for all Samoans to effective and people- patient monitoring, and blood pressure (BP) centered care. Interventions to address barriers control as indicators for treatment success. to access, identified at each stage on the care continuum, were proposed. They include: The first key finding of the study raised concerns, • Stepping up public awareness campaigns on NCD as it showed that the rates of hypertension in risk factors including obesity, healthy diet, physical Samoa albeit already significant, are still increasing. activities, alcohol, and psychological and cultural The study found 38% of Samoan adults are factors hypertensive, a 9% increase from the STEPS • Scaling up and broadening the scope of the 2013 study (28.9%). The risk factors are also PEN Fa’a Samoa (Package of Essential NCD increasing; with 90% surveyed classified as interventions) program to more villages and overweight or obese. individuals • Reforming the primary health care facilities in “The study found that at each stage individuals the communities to improve NCD care provision were falling through the gaps, so in the end • Addressing hypertension treatment systematically only one in twenty hypertensive adults reach and adhering to a people-centered approach. the BP target,” says Team Lead Shuo Zhang. The World Bank will continue to work with the Samoan “The reasons for this are numerous, and the government in their ongoing efforts to address NCDs research team spent much of their time talking and provide support for the government to evaluate with residents, patients, health professionals the impacts of health tax on NCD risk behaviors. and other community members to understand Full Report what the barriers at each stage might be.” April–September 2020 Vol. 3, No.2 page 11 MDTF NEWS Indigenous people having a group discussion about health care services in Pechreada commune, Busra district, Mondulkirri province. Advance UHC in Focus Review of Gender Mainstreaming in Cambodia’s Health Sector A progress review is being finalized of the 2018 Among the MOH’s priority actions achieved are Gender Assessment of the Health Equity and the national guidelines for new health center Quality Improvement Project (H-EQIP), which is designs to ensure additional space for pre- and co-funded by the government of Cambodia, the post-delivery waiting rooms. The MOH also World Bank, the Australian Department of Foreign incorporated several recommendations from Affairs and Trade (DFAT), the German Development the H-EQIP gender assessment into its Gender Bank (KfW), and the Korean International Mainstreaming Strategic Plan 2020–2024. The Cooperation Agency (KOICA). national Gender Mainstreaming Action Group (GMAG) will implement the strategic plan in The partners and Cambodia’s Ministry of Health coordination with all MOH departments. Since (MOH) are assessing the ministry’s progress in many of the H-EQIP project team members are also implementing priority actions for the H-EQIP’s GMAG members, gender mainstreaming should three main components—strengthening health be better coordinated in future project activities. service delivery, improving financial protection and equity, and ensuring sustainable and responsive The MOH recognizes that challenges remain in health systems—as well as the inclusion of implementing priority actions and acknowledges that indigenous peoples, ethnic minorities, and people gender mainstreaming is hindered by insufficient with disabilities in the health system. capacity, budget, and technical support for gender analysis and activities. Gender is intrinsic to the question of equity which looms large in the effort to advance universal health coverage. The ministry also acknowledges the need to strengthen its Health Management Information System (HMIS) and Patient Management Registration System (PMRS) to generate sufficient data for gender analysis and the social inclusion aspects of the health service sector. The MOH is eager to work with development partners on an action plan with specific benchmarks The health center at the Pechreada commune visited during the to implement agreed upon priority actions from assessment the H-EQIP’s gender assessment during the remaining project period through June 2021. April–September 2020 Vol. 3, No.2 page 12 MDTF NEWS Advance UHC in Focus IMPACT Health Project Improves Front Line Services in PNG Improving the services delivered in provincial areas of Papua New Guinea (PNG) is critical to meet the health needs of the communities, yet provincial health services are currently faced with complex funding arrangements, lack of transparency and delays in budget disbursement that mean the delivery of basic quality healthcare remains a challenge. The US$30 million IMPACT Health project aims to address these challenges by increasing the quality and use of essential health services through direct province-level funding at Provincial Health Authorities. This improvement in the quality of services provided should promote greater access and community utilization helping PNG to ensure more people have health coverage in the remote provinces. The new project aims to address the quality and efficiency of health services being delivered in community health posts, health centers, and district hospitals across the country, with a focus on the frontline to ensure the project delivers Delivering health care service to a mother and her child improvements to the most urgent need. in a rural province The key components of the project are: community level,” said Edith Kariko, World Bank • Service delivery readiness and community-based Senior Health Specialist in PNG. service delivery • Frontline service delivery performance Critical to the IMPACT Health project’s success • Project management will be the use of Disbursement Linked Indicators • Contingent emergency response. (DLI), a funding approach in which results need to be demonstrated before funding is released. The project will initially be piloted in two PNG The performance targets under the DLI modality provinces—Enga and East New Britain—with the is designed to address areas that strengthen plan to expand to further provinces by the project’s health service delivery quality. The approach has third year. The project also includes additional funding been used globally in other World Bank projects, (US$2 million) to support trial of innovations however it is a relatively new approach to health for community-level health service delivery in funding in PNG and the Pacific. partnership with non-governmental organizations. The combination of the new funding approach “This project comes at a critical time for Papua and working directly with health services in the New Guinea’s health system. We hope this provinces, aims to deliver significant, sustain- project will be able to provide necessary able improvements in service delivery quality and services to mothers, to babies and at the same utilization of health services in rural areas, where time strengthen our health system where we can an estimated 80% of Papua New Guineans live. see the better results from this funding at the Video on project April–September 2020 Vol. 3, No.2 page 13 MDTF NEWS Advance UHC in Focus Health Financing System Assessment Advances Indonesia Towards UHC The graph shows that DAK, an intergovernmental grant transfer for improving infrastructure, seems to have no correlation with the readiness of health facilities to deliver basic services. This supports the HFSA recommendation to improve linkages between DAK funds and supply side readiness with better evidence to show that DAK is allocated according to needs, and include features that link grant transfers with local government performance. Indonesia is making remarkable advance toward PERs remind the country to keep putting resources universal health coverage (UHC) with its national into strengthening primary health care (spend health insurance scheme, Jaminan Kesehatan right), and that improving the efficiency of program Nasional (JKN), rapidly expanding coverage implementation by identifying public financial to 85% of its population to date. One diagnostic management (PFM) issues is essential for ensuring assessment tool that has proven invaluable in the quality of public spending (spend better). this endeavour was the Health Financing System Assessment (HFSA) used to identify critical The HFSA, along with the public expenditure constraints and opportunities facing Indonesia’s tracking (PET) and the quantitative service delivery health financing system. survey (QSDS), have informed health sector reviews of the sustainability of priority programs— The MDTF-financed Indonesia HFSA also including AIDS, TB, malaria and immunization provided instrumental analytics for the design which are transitioning away from external finance. of vital health sector programs such as the World Importantly, the HFSA helps key stakeholders at Bank’s new US$150 million Indonesia–Supporting the Ministry of Finance, the Ministry of National Primary Health Care Reform (I–SPHERE) project. Planning, and the Ministry of Health to have a The HFSA’s main messages for Indonesia are to comprehensive picture of the health financing “spend more, spend right, and spend better” for situation in Indonesia that is often complex and health. Furthermore, with the support of the Australian fragmented. Consequently, the government of Department of Foreign Affairs and Trade and Indonesia has been spending more on the health the Global Fund, three rounds of health public sector which has reached almost nine percent of expenditure reviews (Health PER) have been total public spending in 2018. It also increased the conducted since the HFSA was being completed in excise tax on tobacco and mandated that local 2016–2017. The reviews continued to emphasize governments use 37.5% of local cigarette tax to the HFSA messages and provide policy options finance the subsidy for social health insurance to mobilize resources for the health sector given premium as part of efforts to raise public financing the country’s comparatively low health spending. for health. The “spend better” recommendation They used analytics to guide a tobacco excise tax to strengthen linkages between intergovernmental increase and advised capacity building through fiscal transfers with health performance at the domestic resource mobilization (DRM) as a source local level has also gained traction with the Ministry of financing (spend more). Additionally, the Health of Finance. April–September 2020 Vol. 3, No.2 page 14 MDTF NEWS Solomon Islands Tackled COVID-19 and a Cyclone at the Same Time A road sign points the way to emergency services. Solomon Islands has so far avoided COVID-19 but 27 people lost their lives when a boat transferring that hasn’t stopped the government from initiating people from Honiara to the provinces to flee the its preparedness plans and declaring a state of coronavirus was caught in the cyclone. Responding emergency. Emergency committees were activated, to the damage left in the wake of Harold, while schools were closed and international flights maintaining COVID-19 restrictions has been a were restricted in order to prevent COVID-19 particular challenge, but one that has shown the from entering the country. But while doing all of resilience of the Solomon Islands government and this, Cyclone Harold hit the country in April and people. the government has had to simultaneously deal with the deaths and destruction left in its trail. “Collaboration, communication and strong leadership have all been a necessity at this difficult time. To hold COVID-19 at bay, the Solomon Islands Furthermore, the Ministry of Health and Medical initiated quarantine procedures for suspected cases, Services (MHMS) through the Partnership Coordination with samples from 13 cases tested at a laboratory Unit is continuing to coordinate development partner in Australia. All returned negative results. However, support for COVID-19 in light of this dual challenge,” the broader impacts of COVID-19 have been World Bank Health Team Lead Wayne Irava said. felt throughout the country with great economic consequences. The government is projecting a Even without positive cases in the country, -4.9% GDP growth, job losses and disruption to COVID-19 is impacting the health systems ability imports and supplies due to the lack of inbound flights. to ensure universal coverage, and it is important The government has responded with a US$36.9 that routine public health programs and access million stimulus relief package (309 million to quality health services are able to continue for Solomon Islands dollars) that includes subsidies communities. These include health promotion and for households, loan relief for businesses, inter- prevention programs, vaccination, maternal health, island transfers and grants to provincial health malaria, tuberculosis and non-communicable authorities. disease services. The MHMS is focusing on ensuring minimum disruption to these vital national programs Like the rest of the world, the Solomon Islands is and to ensure testing, monitoring activities and facing this unprecedented threat from COVID-19, childhood immunization continue to occur. “Having and in addition it is also cyclone season in the managed to successfully keep COVID-19 at bay Pacific, a difficult period for the country under while responding to a natural disaster, Solomon normal circumstances. Cyclone Harold raised Islands does not want to see the population suffer immediate concerns about food security, shelter, from preventable health issues due to a disruption and water and sanitation needs. Most tragically, in the delivery of these vital and routine public health programs,” Wayne said. April–September 2020 Vol. 3, No.2 page 15 MDTF NEWS PROFILE Breaking Down Barriers in Papua New Guinea Every International Women’s Day (8th March) the Almah’s dedication to her job is evident: “Each World Bank Pacific recognizes and celebrates the day, I try to provide the best technical advice to the extraordinary women creating change, breaking department and work with other partners, locally down barriers and supporting their communities and internationally, to build and strengthen existing all across the region. Almah Kuambu is one of systems for assistive technologies … having support these women. She is the Technical Advisor to the from my superiors inspires me each day to keep National Orthotic & Prosthetic Services in Papua working. My job is about improving the quality New Guinea (PNG) and knows firsthand the of life for people with mobility disabilities. This challenges people in PNG face when living with a is quite demanding and it’s challenging as the disability. She was disabled at age 11 and uses a service is not available in all provincial health prosthetic leg herself. authorities across the country.” Yet Almah has never let her disability hold her back: Almah continues to break down barriers for women “Growing up with my physical disability was and for people living with disabilities as she challenging, but my parents inspired me to keep advocates for rights and encourages and builds pressing forward and not to give up. My father has up her colleagues. When asked what she hopes been the main driving force behind me because for Pacific women of the future, she said: “That he believed that I had the potential to be just like Pacific women are protected, their rights are my siblings despite my physical disability.” promoted and respected, and equal opportunity is given to all regardless of gender, age or disability.” Her father encouraged her to study, to be strong and independent, a lesson she has demonstrated The incredible work Almah and the other trail- throughout her life. Almah went on to study at the blazing women are doing now is making this Cambodian School of Prosthetics and Orthotics hope more a reality. and after graduating joined the PNG National Department of Health in 2012. She worked on To learn more about the fantastic work women various Australian Aid projects before becoming are doing all over the Pacific visit the World Bank the Technical Advisor for the National Orthotic and IWD2020 page. Prosthetic Service in 2017. April–September 2020 Vol. 3, No.2 page 16 MDTF NEWS Feeding Back NCD Taxation Evaluation Results to Tonga’s Remote Islands Government Representative for ‘Eua Sunia Havea, sitting fifth from left, joins a group photo when he presided over the dissemination of report findings and recommendations on the outer island of ‘Eua. With the formal launch of the report Using Taxation The study found that taxation generally decreases to Address Noncommunicable Diseases: Lessons consumption of cigarettes, alcohol and unhealthy from Tonga held in Nuku’alofa in October 2019, a foods. However, unhealthy substitutes need Tongan government and World Bank team visited to be tackled, and the taxation policy needs the Outer Islands of Tonga to share the findings to be complemented with the promotion of healthy and policy recommendations with officials and behaviors among consumers. NCDs pose a communities. In January 2020, the team visited substantial social and economic challenge for the island of ‘Eua, meeting with the Island’s offi- Tonga and place significant strain on the existing cials, government officers, health staff and com- health services in ensuring universal coverage munity representatives. The stakeholder knowl- for tertiary-level treatment. The study focused on edge sharing sessions confirmed the support prevention through a combination of strategies for report findings and recommendations from aimed at reducing this longer-term health service the communities, including their desire to see demand and keeping the community healthier for that the government uses increased revenues longer. In the process they also contribute to advancing from the excise taxes to improve the health UHC. Progress continues in Tonga with the report and well-being of the population. Government and associated findings and recommendations representatives also appreciated a variety of informing the country’s National NCD Strategy, issues raised during the sessions that were unique currently under development. The study was to the challenges and experiences of life in an co-funded by the governments of Australia, Outer Island, which will support future policy Japan, New Zealand, and the World Bank. design. The World Bank is continuing to work with the The team also held a series of community Tongan government and other development consultation sessions across different villages partners to strengthen the country’s response which were open to everyone. “These public to NCDs, including the development of nutrient knowledge sharing sessions are an important profile model to guide future food tax design and component of the project,” says Sutayut the development of Social and Behavior Change Osornprasop, World Bank Team Lead, “both in Communication Strategy and Action Plan, which order to feedback results to those communities will be part of the new National NCD Strategy which participated in the initial research, but also to 2021–2025. communicate to the public the importance of Full Report changing behaviors and combatting NCDs in Tonga.” Policy Notes on: NCDs, Food, Tobacco, Alcohol April–September 2020 Vol. 3, No.2 page 17 MDTF NEWS Impact on the Ground DSIs Lift Immunization Rates in Remote Lao Districts Disbursement Linked Indicators (DLIs), a results-based financing instrument, is effectively addressing the problem of inequity in Lao PDR’s immunization efforts by boosting vaccination rates in 50 remote districts that have historically been lagging behind the rest of the country. A US$4 million grant from the Australian Department of Foreign Affairs and Trade (DFAT) via the MDTF to Advance UHC has been pivotal to increasing immunization rates in the 50 targeted districts by an average of 22% for MCV (measles-containing vaccine) and 30% for Pentavalent-3 vaccine (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type b) over the 2016– 2017 baseline. These substantial increases were achieved through focused performance-based measures, set under the DLI instrument, compared to the 1% and 4% respective increase over the same period in the remaining districts of the country. The grant complements a broader project supported with funds from Gavi, the Vaccine Mothers and their babies in a remote village of Lao PDR Alliance, and the resources of the World Bank’s International Development Association (IDA). better health outcomes. Funds are released when a set of agreed upon results are verified. They are This DLI approach is a valuable example of how linked not only to outcomes and outputs but also analytical information is being used to implement other critical program performance criteria. evidence-based activities. After the health financing and immunization assessment (with support from Lao PDR has adopted the policy goal of attaining DFAT and Gavi) identified the lowest performing UHC by 2025. However, there are challenges of districts, grant funds were added during the low and inequitable health service coverage as well additional financing of the World Bank’s Health as disparities between poor and geographically Governance and Nutrition Development Project isolated areas in the country. This World Bank health (HGNDP) undertaken in late-2017. HGNDP, which project has brought a strong equity dimension is co-financed by the government of Japan, uses to immunization and outreach services in the remote the DLI approach to implement key reforms for districts of Lao PDR and improved sustainability. April–September 2020 Vol. 3, No.2 page 18 MDTF NEWS Panelists at the DLI session listen to comments from the floor. PMAC 2020 Meeting Looks at Delivering Results with DLIs Everybody wants results. Governments, development development objectives. At the same time, as a partners, civil society and the general public all new modality, it needs to be understood better demand development programs that deliver real and some of the implementation lessons and and lasting results. One instrument in development challenges could inform future design of DLIs. financing that helps keep this focus on results is Disbursement Linked Indicators (DLIs), which The World Bank, World Health Organization, were the focus of a side meeting at the Prince Global Fund, Gavi, and Global Financing Facility Mahidol Award Conference (PMAC) 2020. jointly organized this deep dive on DLIs in Bangkok as a side meeting of PMAC 2020, an annual DLIs constitute a development financing modality international conference on policy-related health that releases funds from the funding agency to issues. Government officials, development partners the government as and when an agreed upon and experts from around the world participated in set of tangible and verifiable results—rather than sessions that sought to link development inputs (expenditures)—is achieved by countries assistance to health systems strengthening for implementing a development program. DLIs have universal health care through DLIs. Underscoring effectively incentivized governments to achieve their importance, panelist Jane Pepperall of critical program milestones and improve program the Australian Department of Foreign Affairs and performance since they can be linked not only Trade (DFAT), called Di bursement Linked Indicators to outcome and outputs, but also to key actions the “litmus test for the broader development agenda”. on processes that constrain the realization of Furthering Collaboration on DRG Health Payments at PMAC 2020 Experts sharing knowledge at one of the DRG sessions April–September 2020 Vol. 3, No.2 page 19 MDTF NEWS As countries advance toward UHC many have excessive service provision. In sum, DRGs are successfully adopted Diagnosis-Related Group introduced into a financing system to enhance (DRG) payments as an efficient and sustainable efficiency and sustainability of health spending. method to pay for their health services. To further these reforms, the 3rd Experts Meeting on The objectives of the meeting, which was organized Collaboration for DRG Development and Reform by the World Bank and Thailand’s National Health in South-East Asia (SEA-DRG) was held in Security Office, included: improving technical Bangkok to share knowledge and experience, knowledge about diagnosis and procedure and advance collaboration among experts in the classification systems and how they are updated region. and used in the DRG grouping algorithm modifications; increasing awareness of how other The two-day event was held on January 28-29, countries approach regulations about data gathering 2020 as a side meeting of the Prince Mahidol and sharing in relation to DRG development and Award Conference (PMAC 2020) whose theme implementation; and advancing opportunities was “Accelerating Progress Toward Universal for intra-regional collaboration in diagnostic Health Coverage”. Many countries in Southeast and procedure coding systems, information Asia are transitioning to DRG which is a system gathering and regulations, and grouping. that classifies hospital cases into clinically similar groups where payment per episode of care is At the meeting, the World Bank also launched fixed for patients within a single DRG category its new book on Transition to Diagnosis-Related regardless of actual costs. By paying a fixed Group (DRG) Payments for Health which includes amount for a given diagnosis, DRGs can help nine case studies, from early adopters like Australia overcome escalating health care costs, hospital and US Medicare through European countries to inefficiencies, low admission rates as well as regional trailblazers like Thailand. BRIEF NEWS Support Mission Went Well for Cambodia Nutrition Project The Cambodia Nutrition Project (CNP) had a productive first implementation support mission in January 2020, meeting with key stakeholders in the Ministry of Health and the National Committee for Sub-National Democratic Development (NCDD-S) in Phnom Penh. The mission reviewed the status of project covenants and readiness of implementing agencies, the implementation preparedness of key project activities, and review the progress and status of CNP Disbursement-Linked Indicators. To receive the MDTF e-newsletter please contact: Sutayut Osornprasop, World Bank Thailand, sosornprasop@worldbank.org, +1 202 3783383 Chadin Tephaval, World Bank Thailand ctephaval@worldbank.org, +66 86 600 0715 For more information find us on WB Facebook, WB Twitter, and WB Health Twitter