Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD3018 PROGRAM APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 6.9 MILLION (US$ 9.3 MILLION) TO THE INDEPENDENT STATE OF SAMOA FOR SAMOA HEALTH SYSTEM STRENGTHENING PROGRAM November 12, 2019 Health, Nutrition and Population Global Practice East Asia and Pacific Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective September 30, 2019) Currency Unit = Samoa Tala (SAT) SDR 1 = USD 1.36331 US$ 1 = SAT 2.65 FISCAL YEAR July 1 – June 30 ABBREVIATIONS AND ACRONYMS ACG Anti-Corruption Guidelines ADB Asian Development Bank BMI Body Mass Index CEO Chief Executive Officer COA Chart of Accounts CTSSU Centralized Technical Service Support Unit DFAT Australia Department of Foreign Affairs and Trade DHS Demographic and Health Survey DLI Disbursement-Linked Indicator EBU Extra Budgetary Unit EFA Expenditure Framework Assessment ESHS Environment, Social, and Health and Safety ESSA Environment and Social System Assessment EU European Union GDP Gross Domestic Product GoS Government of Samoa HCW Health Care Waste HCWM Health Care Waste Management HPAC Health Program Advisory Committee HSCRM Health Sector Coordination, Resourcing and Monitoring HSP Health Sector Plan ICD-10 International Classification of Diseases, Version 10 IMR Infant Mortality Rate IVA Independent Verification Agency KSA Key Strategic Area M&E Monitoring and Evaluation MESC Ministry of Education, Sports, and Culture NZ-MFAT New Zealand Ministry of Foreign Affairs and Trade MICS Multiple Indicators Cluster Survey MOF Ministry of Finance MOH Ministry of Health MTII Malietoa Tanumafili II NCD Noncommunicable Disease NGO Nongovernmental Organization NHS National Health Services OOP Out of Pocket PAP Program Action Plan PATIS Patient Information System PDO Program Development Objective PEFA Public Expenditure and Financial Accountability PEN Package of Essential Tools for Non-Communicable Disease Interventions PforR Program for Results PFM Public Financial Management PFMA Public Financial Management Act PHC Primary Health Care PICs Pacific Island Countries POM Program Operations Manual PPA Programmatic Preparation Advance SAO Samoa Audit Office SBS Samoa Bureau of Statistics SCRTP Samoa Climate Resilient Transport Project SDS Strategy for the Development of Samoa STEPS Stepwise Approach to Surveillance SWAp Sector Wide Approach THE Total Health Expenditure TOR Terms of Reference TTM Tupua Tamasese Meaole VWC Village Women’s Committee WHO World Health Organization Regional Vice President: Victoria Kwakwa Practice Group Vice President: Annette Dixon Regional Director: Daniel Dulitzky Country Director: Michel Kerf Practice Manager: Enis Barış Task Team Leader(s): Shuo Zhang, Carol Atieno Obure The World Bank Samoa Health System Strengthening Program (P164382) BASIC INFORMATION Is this a regionally tagged project? Financing Instrument No Program-for-Results Financing Bank/IFC Collaboration Does this operation have an IPF component? No No Proposed Program Development Objective(s) The Program Development Objective (PDO) is to improve the quality and efficiency of NCD prevention and control in Samoa. Organizations Borrower: Ministry of Finance Implementing Agency: Ministry of Health COST & FINANCING FIN_SUMM_WITH_IPF SUMMARY (USD Millions) Government program Cost 40.54 Total Operation Cost 40.54 Total Program Cost 40.54 Total Financing 40.54 Financing Gap 0.00 Financing (USD Millions) Counterpart Funding 31.24 National Government 31.24 International Development Association (IDA) 9.30 Page 1 of 103 The World Bank Samoa Health System Strengthening Program (P164382) IDA Grant 9.30 IDA Resources (in US$, Millions) Credit Amount Grant Amount Total Amount Samoa 0.00 9.30 9.30 National PBA 0.00 9.30 9.30 Total 0.00 9.30 9.30 Expected Disbursements (USD Millions) Fiscal Year 2020 2021 2022 2023 2024 2025 2026 Absolute 0.50 0.50 1.40 1.50 1.80 1.80 1.80 Cumulative 0.50 1.00 2.40 3.90 5.70 7.50 9.30 INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening Yes PRI_PUB_DATA_TBL Private Capital Mobilized No Page 2 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Gender Tag Does the program plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified through SCD and CPF Yes b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment Yes c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  Moderate 2. Macroeconomic  Moderate 3. Sector Strategies and Policies  Moderate 4. Technical Design of Project or Program  Moderate 5. Institutional Capacity for Implementation and Sustainability  High 6. Fiduciary  Substantial 7. Environment and Social  Moderate 8. Stakeholders  Moderate 9. Other  Moderate 10. Overall  High COMPLIANCE Policy Does the program depart from the CPF in content or in other significant respects? [ ] Yes [✔] No Page 3 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Does the program require any waivers of Bank policies? [ ] Yes [✔] No Safeguard Policies Triggered Safeguard Policies Yes No Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Legal Covenants Sections and Description Financing Agreement, Schedule 2, Section I.A 1. The Recipient shall maintain, at all times during the implementation of the Program, with a mandate, composition, and resources satisfactory to the Association: (a) the HPAC, which shall: (i) consist of representatives of relevant line ministries and key stakeholders; and (ii) be responsible for providing overall policy guidance, strategic direction, and cross-sectoral coordination; and (b) the National NCD Committee, which shall: (i) consist of representatives of relevant line ministries and key stakeholders; (ii) be responsible for providing technical guidance and oversight for the implementation of NCD control programs; and (iii) be equipped with a secretariat at the relevant division of MOH. 2. The Recipient shall vest the overall responsibility for the management of the Program, including coordination, planning, ensuring budget availability, addressing cross-divisional issues, hiring of the independent verification agent, and Program monitoring and reporting, in the MOH. Sections and Description Financing Agreement, Schedule 2, Section I.B DLR Verification Arrangements 1. The Recipient, through MOH, shall enter into a verification arrangement with SBS, by not later than June 30, 2020, for carrying out the verification for the Program in accordance with the terms of reference acceptable to the Association. 2. The Recipient shall ensure that SBS shall: (a) verify the data and other evidence supporting the achievement(s) of one or more DLRs in accordance with the Verification Protocol agreed with the Association; and (b) submit to the Association the corresponding verification reports in a timely manner and in form and substance satisfactory to the Association. Sections and Description Page 4 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Financing Agreement, Schedule 2, Section I.D Operations Manual 1. The Recipient shall adopt, by not later than three (3) months after the Effective Date, a manual (“Operations Manual”), in form and substance satisfactory to the Association, which shall include the detailed institutional, administrative, financial, technical (including the Program technical implementation roadmap), and operational arrangements and procedures for the implementation of the Program, and thereafter carry out the Program in accordance with the Operations Manual. 2. The Recipient shall not amend, abrogate or suspend, or permit to be amended, abrogated, or suspended, any provision of the Operations Manual, without the prior written agreement of the Association. Sections and Description Financing Agreement, Schedule 2, Section I.C Program Action Plan The Recipient shall: 1. undertake the actions set forth in the Program Action Plan in a manner satisfactory to the Association; 2. except as the Association and the Recipient shall otherwise agree in writing, not assign, amend, abrogate, or waive, or permit to be assigned, amended, abrogated, or waived, the Program Action Plan, or any provision thereof; and 3. maintain policies and procedures adequate to enable it to monitor and evaluate, in accordance with guidelines acceptable to the Association, the implementation of the Program Action Plan. Sections and Description Financing Agreement, Schedule 2, Section I.E Annual Work Plans 1. The Recipient shall: (a) for the Fiscal Year 2021, prepare and furnish to the Association by not more than one (1) month after the Effective Date a proposed Program’s consolidated annual work plan; (b) subsequently, for the following Fiscal Years, prepare and furnish to the Association by December 15 in each year – beginning in December 15, 2020 – a proposed Program’s consolidated annual work plan; (c) taking into account the Association’s comments and no-objection, finalize the plan, seek approval of HPAC, and furnish the approved plan to the Association not later than June 15 in each year – beginning in June 15, 2020; and (d) adopt the plan as shall have been approved (“Annual Work Plan”) and thereafter ensure that the Program is carried out in accordance with each of such Annual Work Plan, in a manner satisfactory to the Association. 2. The Annual Work Plans may be revised, as needed, during the implementation of the Program, subject to the Association’s agreement thereof in writing. Conditions Page 5 of 103 The World Bank Samoa Health System Strengthening Program (P164382) TASK TEAM Bank Staff Name Role Specialization Unit Team Leader(ADM Shuo Zhang Senior Health Specialist HEAHN Responsible) Carol Atieno Obure Team Leader Health Economist HEAHN Procurement Specialist(ADM Eric Leonard Blackburn Procurement Specialist EEAR2 Responsible) Zhentu Liu Procurement Specialist Senior Procurement Specialist EEAR2 Janet Virginia Gamarra Financial Management Financial Management EEAG2 Rupa Specialist(ADM Responsible) Specialist Environmental Specialist(ADM Nicholas John Valentine Environmental Aspects SEAE1 Responsible) Social Specialist(ADM Rachelle Therese Marburg Social Aspects SEAS1 Responsible) Anuja Utz Social Specialist Social Aspects HEAED Baktybek Zhumadil Team Member Operations HECHN Carlos Marcelo Bortman Peer Reviewer Lead Health Specialist HLCHN Chau-Ching Shen Team Member Disbursement WFACS David Wilson Peer Reviewer Lead Health Specialist HHNDR Administrative and Client Lynn Ioana Malolua Team Member EACNF Support Maeva Natacha Betham Team Member Liaison Officer EACNF Vaai Senior Financial Management Mai Thi Phuong Tran Team Member EEAG2 Specialist Neesha Harnam Peer Reviewer Health Specialist HLCHN Ria Nuri Dharmawan Counsel Legal Affairs LEGES Administrative and Client Sabrina Gail Terry Team Member HEAHN Support Son Nam Nguyen Peer Reviewer Lead Health Specialist HAFH1 Page 6 of 103 The World Bank Samoa Health System Strengthening Program (P164382) SAMOA HEALTH SYSTEM STRENGTHENING PROGRAM TABLE OF CONTENTS I. STRATEGIC CONTEXT ...................................................................................................... 8 A. Country Context .................................................................................................................. 8 B. Sectoral (or Multisectoral) and Institutional Context ......................................................... 8 C. Relationship to the CAS/CPF and Rationale for Use of Instrument .................................. 14 II. PROGRAM DESCRIPTION............................................................................................... 16 A. Government Program ....................................................................................................... 16 B. PforR Program Scope ........................................................................................................ 18 C. Program Development Objective(s) (PDO) and PDO Level Results Indicators ................. 28 D. Disbursement Linked Indicators and Verification Protocols ............................................ 29 III. PROGRAM IMPLEMENTATION ...................................................................................... 29 A. Institutional and Implementation Arrangements ............................................................. 29 B. Results Monitoring and Evaluation ................................................................................... 31 C. Disbursement Arrangements ............................................................................................ 34 D. Capacity Building ............................................................................................................... 36 IV. ASSESSMENT SUMMARY .............................................................................................. 36 A. Technical (including program economic evaluation) ........................................................ 36 B. Fiduciary ............................................................................................................................ 38 C. Environmental and Social .................................................................................................. 39 D. Risk Assessment ................................................................................................................ 40 ANNEX 1. RESULTS FRAMEWORK MATRIX ........................................................................... 44 ANNEX 2. DISBURSEMENT LINKED INDICATORS, DISBURSEMENT ARRANGEMENTS AND VERIFICATION PROTOCOLS .................................................................................................. 50 ANNEX 3. (SUMMARY) TECHNICAL ASSESSMENT ................................................................. 59 ANNEX 4. (SUMMARY) FIDUCIARY SYSTEMS ASSESSMENT ................................................... 72 ANNEX 5. SUMMARY ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT ....................... 85 ANNEX 6. PROGRAM ACTION PLAN ..................................................................................... 91 ANNEX 7. IMPLEMENTATION SUPPORT PLAN ...................................................................... 95 ANNEX 8. CLIMATE AND DISASTER RISK CONSIDERATIONS .................................................. 99 Page 7 of 103 The World Bank Samoa Health System Strengthening Program (P164382) I. STRATEGIC CONTEXT A. Country Context 1. Samoa, classified as an upper-middle-income country with a gross national income per capita of US$ 4,120 in 2018,1 is a small Polynesian island state located in the South Pacific. The population of Samoa in 2019 is approximately 197,097 people distributed among the two main (Upolu and Savaii) and two smaller islands (Apolima and Manono). The major drivers of the Samoan economy are tourism, agriculture and fishing, remittances, and aid flows. The economy expanded by an annual average of 4.3 percent between 2002 and 2007, before the global financial crisis, but over the last decade, growth has slowed to an average of 1 percent per year, due in large part to a sequence of economic shocks and natural disasters that have hit the country over this period. Samoa’s economic development opportunities are constrained by remoteness from large markets and foreign suppliers, the small size of the domestic market, as well as the high frequency and intensity of natural disasters, the risk of which is expected to be exacerbated by climate change. These challenges have translated into comparatively low and volatile gross domestic product (GDP) growth rates, a structural gap between domestic revenues and expenditures, elevated public debt, high vulnerability to external shocks, and, subsequently, a significant reliance on development aid. 2. The Strategy for the Development of Samoa (SDS), which covers fiscal years 2016/17 through 2019/20, focuses on ‘Improved Quality of Life for All’ and outlines the Government of Samoa (GoS) vision for country’s economic and social development. It is being implemented through development strategies across 14 key national outcomes within 4 broad priority areas, namely, economic, social, infrastructure, and environment. Samoa values health as a critical component of well-being/quality of life and assigns it as the second priority area of ‘Social Policies’ with the sixth key outcome being ‘A Healthy Samoa and Well-Being Promoted’. This is also reflected in Samoa’s commitment to international and regional agreements that prominently feature health outcomes as critical indicators of well-being and development, including the Agenda 2030 for Sustainable Development, the Sustainable Development Goals, the Samoa Pathway, and the Pacific Framework for Regionalism. A key objective under the social priority is “an inclusive, people-centered health service with emphasis on health prevention, protection and compliance through; a national immunization program; a screening program for rheumatic fever; and noncommunicable disease (NCD) control and management programs.”2 B. Sectoral (or Multisectoral) and Institutional Context 3. Health outcome indicators have been steadily improving over the past three decades in Samoa, with Samoa having achieved the highest life expectancy in the Pacific and among the lowest infant mortality rates (IMRs). Samoa’s life expectancy increased from 65 years in 1990 to 75 years in 2015; women have higher life expectancy, at 78 years, compared to men, at 71.8 years. The under-five mortality rate declined from 37 per 1,000 live births in 1985 to 18 per 1,000 in 2015, and the IMR has halved since 1985, down to 15 per 1,000 live births in 2015. These indicators are better than might be expected for the country’s income level and compare favorably to the East Asia and the Pacific region, in general, and the 1Source: World Development Indicators 2018. 2 “Strategy for the Development of Samoa 2016/17–2019/20: Accelerating Sustainable Development and Broadening Opportunities for All.” December 2016. Page 8 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Pacific Island Countries (PICs) on average, in particular. Even though Samoa only recently graduated to upper-middle-income group status with an income level at the lower boundary of the income group, life expectancy and the IMR in Samoa are almost on par with upper-middle-income country averages (see Figure 1). Figure 1. Selected Health Indicators, 1985–2015 Source: World Bank task team analysis based on World Development Indicators 4. Health financing in Samoa has seen an overall increase, driven by increases in public spending on health. Over the past decade, public health spending has increased relative to GDP and as a proportion of the total GoS spending, as well as per capita. The GoS spending on health care constitutes a large proportion of total health expenditure (THE) in Samoa, with public health spending per capita increasing Page 9 of 103 The World Bank Samoa Health System Strengthening Program (P164382) by 30 percent in nominal terms between FY2006–08 and FY2014–16. Private and out-of-pocket (OOP) expenditures in Samoa are low in absolute and relative terms. In 2014, the OOP expenditure in Samoa represented only 5.9 percent of THE, the majority of the 9.4 percent total private spending on health in that year. In comparison, the OOP share of THE in low- and middle-income countries and PICs was, respectively, 56 percent and 13 percent3 in 2014. Like many other PICs, Samoa depends on a substantially higher share of external development partner financing than would be expected for a country with its income level: the external share of THE is around 20 percent (see Figure 2). Figure 2. Selected THE Indicators Versus Income, Samoa, 2014 THE per capita THE share of GDP Source: World Bank task team analysis based on World Development Indicators 5. The low growth rates and the constrained fiscal situation suggest a limited scope for additional health financing in the future, underlining the necessity to increase allocative and technical efficiency to meet the growing needs. The World Bank’s recent studies focusing on Samoa’s health expenditures identified a significant scope for efficiency gains and better value for money. Samoa’s health public expenditure reviews in 2014 and 2017 highlighted the following: (a) substantial increase in non-direct service-related spending since the creation of the National Health Services (NHS) 4 and a considerable 3Source: WDI database. 4 Naturally, the splitting of an institution results in duplication and cost increases through the need for two separate governance and administrative arrangements. The rationale for such a split was that this increase will be overcompensated through efficiency gains in other areas (for example, through more flexible human resource policies or the introduction of competition among providers that lead to cost savings when contracting particular services). The increase in non-service-related spending has also been the case with the split of the MOH and the NHS, for example, with the creation of the Board of Directors and the purchase and subscription for separate financial management information and payroll systems, but it is unclear to what extent efficiencies have materialized. Page 10 of 103 The World Bank Samoa Health System Strengthening Program (P164382) expansion of the Ministry of Health (MOH) governance and support functions; (b) substantial payroll expansions observed in both the MOH and the NHS which implies the risk of crowding out other input factors such as medicines; (c) the GoS heavily invests on curative services, leaving more cost-effective preventive and primary health services underfunded; (d) out of the total SAT 79.3 million health budget allocation in 2015/16, SAT 6.1 million was earmarked for the Samoa National Kidney Foundation and SAT 63.8 million was provided to the NHS for the hospitals’ operations, accounting for 88 percent; and (e) overseas treatment accounted for 10–15 percent of THE in 2009/10 while benefiting only 0.1 percent of the population. The National NCDs Cost Analysis Study found that utilization of essential NCD medicines is low in Samoa compared to other developing countries, and that the NHS paid on average three to six times the World Health Organization (WHO) benchmark price for their NCD medicines. 6. Despite the positive health outcomes, Samoa faces the dual challenge of an unfinished Millennium Development Goals agenda and rising NCDs. While the immunization rates at 68 percent are still below full coverage, morbidity and mortality patterns show that rising NCDs have become the top cause of mortality in the country. NCDs account for 75 percent of the total disease burden in 2016 and more than half of all premature deaths in the country. NCDs are also the major driver of overseas medical treatment. The major NCDs affecting Samoa are diabetes, ischemic heart disease, cardiovascular disease, asthma, chronic obstructive pulmonary disease, and cancers. The 2013 Stepwise Approach to Surveillance (STEPS) survey found that 28.9 percent of the Samoa population are hypertensive- and 24.8 percent have diabetes. Alarmingly, these rates are still going up, rather than down. The World Bank Samoa Hypertension Implementation Cascade study5 conducted in year 2018 reported that 38.1 percent of the adults surveyed have hypertension. 7. Lifestyle-related risk factors drive most of the death and disability related with NCDs, underscoring the importance of changing behaviors. Overall, the top risk factors that account for the most disease burden in Samoa in 2016 were closely linked to NCDs and included high body mass index (BMI), high fasting plasma glucose, dietary habits, and high blood pressure. Since 2005, these four risk factors, plus impaired kidney function and high total cholesterol, have seen double digit increases of around 20 percent (see Figure 3). Samoa is among the countries with the highest obesity rates in the Pacific; overweight rates have grown from 25.5 percent in 1978 to 67.5 percent in 2001, with higher obesity prevalence among women (see Figure 4). It is of particular concern that several studies on Samoan children have shown an increasing trend of childhood obesity, with the BMI increasing after moving from preschool to primary.6 Studies also show that at the early ages (4–7 years) boys have a higher prevalence of obesity, whereas school girls have faster growing obesity than school boys as they age. In addition, tobacco smoking as a risk factor remains high, with smoking rates of 35.8 percent for men and 15.5 percent for women over the age of 15 years.7 Furthermore, there is a real concern that, like in other PICs, climate change in Samoa may be influencing other risk factors driving the burden of NCDs, such as physical inactivity, food insecurity, and poor nutrition8 (see Annex 8 for details). 5 The study is a collaboration between the World Bank and Samoa MOH, under the finance of World Bank Decision and Delivery Science Program. The study was commenced in June 2018, and the study report has been completed. 6 “Study on Nutrition and Health in Modernizing Samoans: Temporal Trends and Adaptive Perspectives .” 2007, Brown University, USA and Ola Tuputupuaé Study conducted by Yale School of Public Health in 2017. 7 Source: Samoa HIES 2013/14. 8 “Health Impacts of Climate Change in Pacific Island Countries: A Regional Assessment of Vulnerabilities and Adaptation Priorities.” Environment Health Prospect 2016 124 (11): 1707–1714. doi: 10.1289/ehp.1509756. Page 11 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Figure 3. Top Ten Risk Factors in Samoa, 2005–2016 Source: Institute of Health Metrics and Evaluation. Figure 4. Samoa Obesity Rate 8. While the country is facing significant challenges of rising NCDs, the current health service delivery system, with capacity, quality, and efficiency as main concerns, is not well poised to tackle the challenges. The current health care service delivery system in Samoa is largely publicly owned and heavily hospital centric, with patients bypassing primary health care (PHC) and overcrowding in the main national referral hospital in Apia. The country has two referral hospitals: Tupua Tamasese Meaole (TTM) hospital is the main national referral hospital located in Apia, Upolu; and Malietoa Tanumafili II (MTII) hospital is another referral hospital on Savaii Island. There are 11 rural health facilities comprising 6 rural district hospitals (3 on Upolu and 3 on Savaii) and 5 community health centers (3 on Upolu and 2 on Savaii). The rural health facilities are strategically placed based on population size and distance (see Map 1). The rural district hospitals operate 24 hours and 7 days and provide outpatient, inpatient, and emergency services; antenatal, postnatal, and delivery services; family planning services; immunization services; community and school outreach programs; home care and home visits for directly observed treatment - short course. Page 12 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Community health centers are open only during working hours, with days of operation varying between facilities from two to five days a week. They provide outpatient and emergency services, antenatal and postnatal services, family planning services, and immunization services. The allocation of resources (personnel, equipment, supplies, infrastructure, and vehicles) is skewed toward TTM national hospital, with the PHC facilities largely underresourced and understaffed. Staff numbers are insufficient to cater for the increasing number of the coverage population. There is also a disproportionate distribution of staff per rural health facility. Doctors are concentrated in the main referral hospital in Apia. The other 11 health facilities are staffed mainly by nurses,9 with physicians from the main referral hospital visiting only one day a week, or less, in district hospitals. Basic infrastructure, diagnostic equipment, and competencies are lacking in the rural health facilities and, therefore, the facilities lack the capacity to diagnose and manage chronic NCDs. In this setting, the laboratory samples are carried back to the main hospital by the visiting physicians for testing and final diagnosis. The staff shortage at the primary care level affected the ability of rural district hospitals to identify NCD cases, provide consultation and treatment for the patients, and provide health education services necessary for prevention. 9. Samoa used to have a service delivery model with a strong focus on health prevention, community empowerment, and PHC, and the Village Women’s Committee (VWC) was the cornerstone of community engagement on health promotion, hygiene inspection, and public health. Regular outreach programs to villages, schools, and workplaces were institutionalized and provided by nurses from PHC facilities. The medical doctors were deployed in the rural district hospitals working with other health workers in the facilities, as well as with VWCs, to facilitate the access to health services. Unfortunately, this Fa’a Samoa model gradually evolved into a mainly hospital-centric system, with all the doctors pulling back from the rural facilities and deployed in the national hospital and referral hospital, compromising the quality and capacity of the service delivery system. The split of the MOH and the NHS a decade ago (even though not intended) has, in fact, weakened the focus on public health and primary care. 10. The country is also facing human resource constraints with a clear shortage of physicians, including continued emigration of medical professionals to countries such as Fiji, New Zealand, and Australia. Long-term workforce planning is yet to be established, and there is a lack of career path for PHC doctors/general practitioners, nurses, and nutritionists working at primary care settings. The MOH/NHS institutional split has further exacerbated the human resource constraints by separating medical treatment and public health service and nurses and doctors, resulting in the lack of coordination of care delivered by a team. 11. Lack of an effective care model for NCDs is a significant system weakness. Gaps along the NCD control cascade have been identified (see Figure 5), including low screening rate, weak follow-up and referrals, and the lack of a patient tracking system. These gaps indicate the lack of systematic NCD disease management in the country and, thus, poor quality of NCD care provision. The GoS, in collaboration with the WHO, has initiated a Samoan version of the WHO’s Package of Essential Tools for Non-Communicable Disease Interventions (PEN). 9District hospitals’ staff includes a nurse manager, nurse specialist, midwives, registered nurses, and some auxiliary staff such as security staff and driver. Staffing of health centers varies among health centers as also the case for district hospitals. Page 13 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 12. However, after three years of Figure 5. Hypertension Control Cascade implementation, PEN Fa’a Samoa 10 has been rolled out to only 17 villages out of 431 villages in Samoa. As a result, most of the patients in Samoa have not been diagnosed and/or put under regular treatment. Among the 300 hypertension patients reviewed in the Samoa Hypertension Cascade study, 36 percent had stage II and 35 percent had stage III hypertension at registration, suggesting late diagnosis and acute cardiovascular risks. Without effective early detection and disease management, the diseases will further progress to comorbidity (such as stroke, cardiovascular diseases, and kidney failure) leading to an increase in the cost of care and exacerbated disease burden. In fact, the country faces a high burden of premature death and considerable increase in kidney dialysis cases. C. Relationship to the CAS/CPF and Rationale for Use of Instrument 13. The proposed operation is consistent with one of the four focus areas set out in the Pacific Regional Partnership Framework, FY2017–21 (Report No. 120479).11 Objective 3.2 of focus area 3 is to strengthen the country’s health system and to address NCDs with the aim of helping countries implement the Regional NCD Road Map adopted by a joint meeting of Pacific finance and health ministers in Honiara in June 2014. Health systems in the Pacific, including Samoa, need to reorient themselves from focusing on acute communicable disease responses toward more effective long-term chronic health care service for NCDs. This objective also explicitly includes the intention to strengthen primary care as well as to adopt a multisectoral approach for risk factor controls. By addressing the NCD crisis in Samoa, the proposed operation is fully aligned with, and will directly contribute to, the achievement of this development priority outlined in the Regional Partnership Framework. It is also consistent with the World Bank’s Health, Nutrition and Population Global Practice’s overarching objective of ending preventable deaths and disability through universal health coverage and the World Bank Group Approach and Action Plan for Climate Change and Health, which aims to improve the climate resilience of the health sector. Specifically, the proposed Program will contribute to the GoS’ climate policy goal of ‘a climate and disaster resilient 10 The GoS in collaboration with the WHO has initiated the PEN Fa’a Samoa program based on the WHO Package of Essential Tools for Non-Communicable Disease Control (PEN). The purpose of this community engagement strategy is to highlight the country’s return to the family-oriented community engagement and Fa’a Samoa ways of delivering PHC to its communities. The village-based intervention empowers and trains VWCs to measure key NCD metrics and provide referrals to individuals with identified risk to the district hospitals for further care. Rollout of PEN Fa’a Samoa to all villages is a government priorit y for prevention, early detection, and diagnosis of NCDs at the community level. 11 Pacific Islands - Regional Partnership Framework: FY17-FY21 (English). Washington, DC: World Bank Group. Report No. 120479. January 1, 2017. http://documents.worldbank.org/curated/en/137341508303097110/Pacific-Islands-Regional- partnership-framework-FY17-FY21. Page 14 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Samoa’,12 which envisages respective planning and implementation actions to be integrated into all sector plans and implementing agency corporate plans. The health sector is among the nine highly vulnerable sectors prioritized in Samoa’s National Adaptation Programme of Action. The proposed operation will also contribute to Samoa’s National Climate Adaptation Strategy for Health,13 which aims to move toward the ‘Health of all People in Samoa’ being resilient to climate change. 14. There is a strong rationale for the World Bank’s engagement in this operation. First, the World Bank has had a long-term engagement with Samoa and has built a track record of development experience in Samoa. Since Samoa became a member in 1974, the World Bank has provided assistance supporting agriculture, finance, telecommunications, power, transport, and the health sector. The proposed Program-for-Results (PforR) would represent the World Bank’s third phase of assistance to Samoa’s health sector, following the Health Sector Management Program Support Project (2008–2016). Second, the increased support available to small island states under IDA18 can have a potentially transformative impact on the ongoing development agenda in the region, including tackling the NCD crisis. The proposed PforR represents a sustained and strengthened engagement with the health sector in Samoa by continuing to build institutional capacity and government ownership. Finally, the World Bank has extended its support through its Development Policy Operations to enhance the GoS’ efforts to curb unhealthy diets through introducing excise duties for alcohol, tobacco, sugary, and salty products. The proposed PforR will complement the macro-level policy interventions through implementation of interventions at the sector level. The World Bank’s engagement in Samoa’s health sector (at both macro and sector levels) provides a unique opportunity for linking health sector development efforts within a whole-of- government context and addressing the NCD crisis in a systematic manner. 15. Use of the PforR instrument. To better leverage the unique opportunity that the World Bank’s engagement can provide, the proposed operation intends to support the GoS’ NCD control program through the PforR financing instrument. The Implementation Completion and Results Report for the previous engagement in the health sector, which was designed as a Sector Wide Approach (SWAp) and financed through Investment Project Financing, stated that the SWAp “has been able to move towards the use of country systems…including use of national policy, planning, budgeting, and reporting procedures to the extent possible.” 14 However, it also acknowledged that the focus of the SWAp concentrated on the capital resources provided by development partners and how these were being utilized, rather than on the full range of development assistance to health sector agencies and how this assistance supports the achievement of the country plans. The PforR instrument, which by default is designed to focus on results and institutional capacity building, would be appropriate for the proposed operation because it incentivizes a focus on results, promotes systematic approach to NCD management, and supports institutional strengthening of the country systems for sustainability. More specifically,  By linking disbursements to achievement of results, the PforR can be an effective instrument to shift focus toward policy and sector results, and away from the financing of inputs through Investment Project Financing; 12 Key Outcome 14: Climate and Disaster Resilience; Strategy for the Development of Samoa 2017–2020. 13 Update of the strategy is currently in draft status. 14 Implementation Completion and Results Report (IDA-44320 and IDA-47210); Report No: ICR00003642. Page 15 of 103 The World Bank Samoa Health System Strengthening Program (P164382)  The GoS management and implementation capacity will be enhanced by use of the PforR instrument as it is designed to support the use of the GoS’ own technical, management, and fiduciary systems and build the implementation capacities at all levels; and  The PforR is an effective instrument for system strengthening and reform which provides a great opportunity for the country to build its service delivery system to tackle the NCD challenges in a systematic manner. 16. As noted, a systematic approach and a focus on results are particularly needed for Samoa at this stage to step up its efforts on NCDs management. Both the Ministry of Finance (MOF) and the MOH acknowledge the need for the country to move from focusing on inputs to focusing on results, and both have noted their enthusiasm for using a result-based financing modality for this new health operation. The PforR instrument is new to Samoa as well as to the Pacific region. Although the proposed operation will be the first World Bank PforR in the Pacific, it is not the first result-based financing in Samoa. Two result-based financing programs are currently being implemented in the country: (a) a European Union (EU)-financed Water Sector Results-Based Financing program, which has been under successful implementation for nearly a decade; and (b) an Australia Department of Foreign Affairs and Trade (DFAT)- and New Zealand Ministry of Foreign Affairs and Trade (NZ-MFAT)-supported Education Sector Program. II. PROGRAM DESCRIPTION A. Government Program 17. The GoS NCD policy is founded on the Government’s priorities articulated in its SDS which identifies health as a priority and highlights the priorities of the health sector with the vision of a ‘Healthy Samoa’. This vision translates into the overarching goal for health sector development which calls for building an inclusive, people-centered health service with emphasis on prevention, protection, and compliance. Samoa’s previous Health Sector Plan (HSP) 2008–2018 identified the rapidly increasing levels of NCDs as a major challenge to the health system, community mortality and morbidity, and the economy of Samoa. 18. The Government’s new HSP (2019–2029) recognizes that NCDs continue to pose a challenge to Samoa and prioritizes improved prevention, control, and management of NCDs as one of its seven key strategic outcomes. Other strategic outcomes of the HSP 2019–2029 include (a) improved health systems, governance, and administration; (b) improved prevention, control, and management of communicable and neglected tropical diseases; (c) improved sexual and reproductive health; (d) improved maternal and child health; (e) improved healthy living through health promotion and primordial prevention; and (f) improved risk management and response to disasters, public health emergencies, and climate change. The new HSP prioritizes the revival of Samoa’s public health system and defines the PEN Fa’a Samoa15 initiative as its centerpiece. A landmark reorganization, merging the MOH and NHS back together is a 15The GoS in collaboration with the WHO has initiated the PEN Fa’a Samoa program based on the PEN. The purpose of this community engagement strategy is to highlight the country’s return to the family-oriented community engagement and Fa’a Samoa ways of delivering PHC to its communities. The village-based intervention empowers and trains VWCs to measure key NCD metrics and provide referrals to individuals with identified risk to the district hospitals for further care. Ro llout of PEN Fa’a Samoa to all villages is a government priority for prevention, early detection, and diagnosis of NCDs at the community level. Page 16 of 103 The World Bank Samoa Health System Strengthening Program (P164382) critical step the GoS has taken to reform its health sector. On January 29, 2019, the Samoa Parliament passed the Ministry of Health Amendment Act 2019 (Amendment Act), which legislated for the merger. 19. To face the NCD challenges, the GoS started the formulation of the National NCD Policy and corresponding action plans in 2010 and implemented them on a multiyear rolling basis. The recently adopted National NCD Policy 2019–2023 is the second multiyear National NCD Policy, which was developed in line with the strategic goals of the HSP 2019–2029. The new NCD policy is operationalized through an action plan, which details five key strategic areas (KSAs). (a) Governance, Leadership, and Partnership. The specific activities are (i) establishing multisectoral mechanisms to plan, guide, monitor and evaluate, and enact NCD multisectoral plans, policies, and legislations; (ii) strengthening partnerships with health service providers of NCD health screenings and counseling; (iii) strengthening partnership with sports agencies and other recreational programs to promote healthy lifestyles in communities; (iv) strengthening policies and legislations for NCDs; (v) strengthening leadership, political commitment, and coordination; and (vi) strengthening partnership with the education sector. (b) Health Promotion, Advocacy, and Risk Reduction. The new HSP focuses on (i) strengthening NCD awareness programs in communities to promote the importance of a healthy lifestyle; (ii) developing and implementing the school health program (including health promotion, nutrition, oral health education, rheumatic heart disease, and immunization); (iii) strengthening breastfeeding counseling and education to community nurses to convey the benefits of breast milk to women in the villages; (iv) strengthening access to mental health services; and (v) improving health services targeted toward people with disabilities relating to NCDs. (c) Health System Strengthening to Address NCDs. This KSA focuses on (i) strengthening the health system through improvement of infrastructure; (ii) strengthening workforce development and capacity building for NCD management, prevention, and control; (iii) integrating and scaling up NCD awareness and screening; (iv) strengthening referral systems for management of NCDs; (v) improving overall systematic planning of procurement of essential drugs, diagnostic equipment, and supplies; (vi) ensuring follow up with patients who are referred, in terms of treatment, management, and outcome; and (vii) integrating cervical, breast, and prostate cancer screening into NCD programs. (d) Surveillance and Monitoring and Evaluation (M&E). The activities under this KSA are (i) strengthening national NCD registration systems, (ii) strengthening the vital and civil registration systems to improve medical cause of death in reporting, (iii) strengthening the M&E system on NCDs, and (iv) enforcing policies and legislations to promote healthy lifestyles. (e) Disaster Preparedness and NCDs. The two activities under this KSA focus on strengthening the health and climate change action plan and strengthening emergency responses to prepare for increased NCD risk associated with climate change. Page 17 of 103 The World Bank Samoa Health System Strengthening Program (P164382) B. PforR Program Scope 20. The proposed Program-for-Results (referred to as the PforR or Program) will support a subset of the Government’s National NCD Policy and Action Plan 2019–2023 over a five-year period (March 2020–December 2025) with the focus on scaling up the essential interventions of NCD control at the PHC and community setting. The PforR, which is expected to become effective in late March 2020, will support the scaling-up of NCD interventions from June 2020 to June 2025. Thereafter, the Program will focus on knowledge generation, dissemination of lessons learned, and evaluation in the second half of year 2025, with the closing date of December 31, 2025. The PforR will continue to be implemented until December 2025 after the completion of the Government’s NCD Policy and Action Plan in 2023, because the proposed interventions will need adequate time to fully function and produce intended impact. The Program corresponds to all five KSAs of the Government’s action plan elaborated earlier. Table 1 illustrates the relationship between the government program and the PforR. Table 1. Technical Scope of the Government Program and the PforR Program Subareas not Government Program Supported by National NCD Policy and Action Plan 2019–2023 PforR KSA 1: Governance, Leadership, and Partnership 1.1 Establish multisectoral mechanisms to plan, guide, monitor and evaluate, and enact NCD multisectoral plans, policies, and legislations. 1.2 Strengthen partnerships with health service providers of NCD health screenings and counseling 1.3 Strengthen partnership with sports agencies and other recreational programs to promote healthy lifestyles in communities 1.4 Strengthen policies and legislations for NCDs 1.5 Strengthen leadership, political commitment, and coordination 1.6 Strengthen partnership with education sector KSA 2: Health Promotion, Advocacy, and Risk Reduction 2.1 Strengthen NCD awareness programs in communities to promote the importance of a healthy lifestyle 2.2 Develop and implement the school health program, including health promotion, nutrition, oral health education, rheumatic heart disease, and immunization 2.2.2 Conduct oral health education and treatment program in primary schools No 2.2.3 Conduct immunization of school children No 2.3 Strengthen breastfeeding counseling and education to community nurses to convey the benefits of breast milk to women in the villages 2.4 Strengthen access to mental health services No 2.5 Improve health services targeted toward people with disabilities relating to NCDs No KSA 3: Health System Strengthening to Address NCDs 3.1 Strengthen health system through improvement of infrastructure 3.2 Strengthen workforce development and capacity building for NCD management, prevention, and control 3.3 Integrate and scale up NCD awareness and screening 3.4 Strengthen referral systems for management of NCDs 3.5 Improve overall systematic planning of procurement of essential drugs, diagnostic equipment, and supplies Page 18 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Subareas not Government Program Supported by National NCD Policy and Action Plan 2019–2023 PforR 3.5.1 Revise List of Essential Drugs for the Management of NCDs 3.5.2 Procure diagnostic equipment and supplies for NCD management at all district hospitals 3.5.3 Procure Pharmaceutical Warehouse Management System No 3.6 Ensure the patients who are referred are followed up in terms of treatment, management, and outcome 3.6.1 Scale up treatment and management of NCDs in district hospitals and community health centers 3.6.2 Develop and sustain NCD clinics in Savaii and Upolu No 3.6.3 Sustain treatment and management of NCDs in the main referral hospital No 3.7 Integrate cervical, breast, and prostate cancer screening into NCD programs No KSA 4: Surveillance and Monitoring and Evaluation 4.1 Strengthen national NCD registration systems 4.2 Strengthen vital and civil registration systems to improve medical cause of death in reporting No 4.3 Strengthen M&E system on NCDs. 4.4 Enforce policies and legislations to promote healthy lifestyle KSA 5: Disaster Preparedness and NCDs 5.1 Strengthen health and climate change action plan 5.2 Prepare for increased NCD risk associated with climate change Note: PforR (‘P’) approximately US$ 40.54 million. 21. The Samoa health sector budget has historically been structured by outputs reflecting the functional divisions of the MOH. The existing national budgeting system does not have program-specific classification and identifiers. The expenditure framework of the Program is therefore based on budgets of divisions carrying out the NCD activities. Specifically, the government NCD program as defined in Table 1 is implemented under 10 out of the 21 divisional outputs by the MOH with a combined estimated budget of US$ 64.64 million (SAT 167.43 million) over the next five years. These divisional outputs are Health Protection and Enforcement; Health Services Performance and Quality Assurance for Medical, Dental, and Allied Health Services; Health Information System and Information, Communication, and Technology; National Health Surveillance and International Health Regulations; Health Sector Coordination, Resourcing, and Monitoring; Clinical Laboratory Services; Clinical - Pharmaceutical Services; Savaii Health Services (PHC) and MTII Hospital; Other Allied Health and Support Services; Primary Health Care and Outreach Services; Pharmaceuticals and Medical Consumables; and Supply of Pharmaceutical/Medical Drugs. 22. The Program cost includes costs of the ongoing activities and operational costs attributable to the new operation. These Program activities include macro-policy interventions, population-based health promotion, scaling up NCD screening and diagnosis, and strengthening primary care and improving the quality of NCD management. Expenditures associated with tertiary care at the Samoa Kidney Foundation, overseas treatment, and investments at the main referral hospital are not included in the PforR expenditure boundary. 23. The overall expenditure framework of the PforR over the five-year period is US$ 40.54 million (SAT 104.60 million) of which the World Bank financing through the PforR is US$ 9.30 million, or 23 percent of the total Program financing (Table 2). Page 19 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Table 2. Program Financing Amount Percentage of Source (US$, millions) Total IDA (PforR) 9.30 23 GoS 31.24 77 Total PforR financing 40.54 100 24. Results areas. Building on the global practice and regional strategies, the proposed PforR Program will support the Government’s national NCD action plan focusing on essential interventions along the NCD service cascade through four results areas. Figure 6 illustrates the corresponding link between each results area and the key NCD control interventions. Figure 6. Link between Results Areas and Key NCD Control Interventions Results Area 1: Address behavioral risk factors through population-based health promotion 25. This results area targets the first step of NCD control cascade focusing on disease prevention in the general population through macro-policy intervention and health promotion programs. The goal of this results area is to support the GoS’ efforts to address the risk factors for leading chronic conditions in the country and thereby curbing the rising prevalence of NCDs. The proposed PforR will finance two sets of actions:  Enhancing the effectiveness of macro-policy interventions through impact assessment of NCD taxation policies.  Promoting healthy lifestyle through community engagement and school-based intervention. 26. Enhancing the effectiveness of macro-policy interventions through impact assessment of NCD taxation policies. As previously mentioned, tobacco, alcohol, and unhealthy diets (for example, sugar Page 20 of 103 The World Bank Samoa Health System Strengthening Program (P164382) sweetened beverages, trans-fats, and sodium) are the leading risk factor for cardiovascular diseases and diabetes-induced deaths in Samoa. As one of the interventions to address these risk factors, the GoS has introduced an excise tax of 8 percent on a range of products with high sugar or high salt content, including syrups, confectionary, biscuits, and instant noodles. The GoS also increased the excise tax on tobacco and alcohol products (in 2017 by 5 percent and 6.5 percent, respectively, and by an additional 5 percent and 3 percent, respectively, in 2018). The increase in excise taxes is expected to lead to price increases in these products, thus disincentivizing consumption. To ensure and improve the effectiveness of this core intervention, a mechanism needs to be established to monitor the implementation effects of these taxation polices on prices, imports, and eventually the consumption by citizens. This will allow policy makers in Samoa to be better informed about the effect of these taxes and provide solid evidence for further adjustments. 27. The PforR Program will support the establishment and institutionalization of this mechanism to monitor the implementation of NCD taxation policies aiming to help strengthen the use of the taxation policy as a response to the NCD crisis. Quantitative studies (including household surveys and retail surveys) will be conducted regularly to generate evidence. A qualitative study, including focus group discussions and in-depth key informant interviews with policy makers and communities, will be carried out to understand the constraints to behavior change and the enabling environment needed, considering the differences between men and women. Capacity building of national staff and domestic entities will be essential for the institutionalization and sustainability of this work. The World Bank will also work closely with the GoS and provide technical assistance during implementation. 28. Promoting healthy lifestyle through community engagement and school-based interventions. As noted earlier, the most prominent risk factors for NCDs in Samoa are overweight and obesity, which are largely lifestyle related. Samoa has one of the highest adult obesity rates in the Pacific region. Nutrition is probably the most critical among the modifiable risk factors in Samoans across all age groups. All the evidence in the Cascade Study points to overnutrition as an important factor for NCD risk, level of disease severity, and treatment success. The population needs to have much higher awareness and knowledge about the risks of overweight and obesity. The PforR will focus on strengthening health promotion activities to address overweight and obesity through the following activities, targeting the priority population groups:  Capacity building of VWCs to provide health education and conduct NCD risk assessment. The current PEN Fa’a Samoa training will be enhanced to build capacity of the VWCs to provide information and education on the four risk factors for NCDs—smoking, nutrition, alcohol consumption, and physical activity—as well as early signs and symptoms of NCDs and ways to address unhealthy behavior. Training will be provided for the VWCs on how to measure BMI, blood sugar, and blood pressure levels. Special health promotion and weight reduction programs targeting women at reproductive age will be developed and provided within communities.  BMI screening in primary school children and health interventions for the at-risk groups. The School Nurse Program, which has completed the pilot in some primary schools, will be enhanced based on the pilot and rolled out gradually to all the primary schools. The program assesses the health of children including the prospective screening of BMI at the start of the program with continuous monitoring on a semiannual basis. Children who are Page 21 of 103 The World Bank Samoa Health System Strengthening Program (P164382) overweight/obese and identified at risk of NCDs will be referred for nutrition interventions and physical activity programs. This will include engaging nongovernmental organizations (NGOs), such as Nobesity,16 to provide physical activity camps for the overweighted school kids.  School nutrition standards compliance enforcement. The primary schools in the country will be monitored on their compliance with the School Nutrition Standards, which were developed in 2012. Other indicators to monitor include tobacco smoking, restriction of the advertisement of unhealthy food in school premises, and sanitation. Emphasis will be placed on enforcing compliance by targeting the schools failing in compliance and introducing interventions to support them to become compliant.  Healthy lifestyle mass campaigns incorporating healthy lifestyle ambassadors and champions. Informational and education materials on the prevention of NCDs will be developed to create awareness of NCDs and its risk factors within the community. In addition, a national multimedia campaign package targeting mass population, including school students on healthy diet and physical activity, will also be developed. Healthy lifestyle champions/leaders will be identified to promote and advocate for positive healthy behavior. 29. The Cascade Study found that the primary prevention interventions need to become more effective to reduce risk behaviors fueling the NCDs and obesity epidemics. This results area will focus on designing new health promotion interventions or scaling up pilot programs after evaluation and enhancement, targeting the priority groups. The community and school-based disease prevention and health promotion activities will also raise awareness on the health impacts of climate change and build capacity of communities to implement climate change mitigation and adaptation actions, such as making their diets more climate resilient (see Annex 8 for more details). 30. Results Area 1 has one disbursement-linked indicator (DLI). DLI 1: Percentage of children (5–12 years old), screened as overweight through the School Nurse Program, referred to and managed under a health promotion program 31. Through the School Nurse Program, primary school children will be provided with health education and preventive and screening services including prospective screening of BMI at the start of the school year with continuous monitoring of child health indicators on a semiannual basis. Children who are overweight/obese and identified at risk of NCDs will be referred to special nutrition and physical activity programs with the aim to change their diet and lifestyle and reduce the overweight. The parents/guardians of the children will also be involved in the relevant programs. Results Area 2: Increase screening, referral, and diagnosis of NCD high-risk groups and NCD patients 32. This results area focuses on the second step of the NCD control cascade, which is to enhance screening and early detection of major chronic conditions in Samoa. There are two major approaches for 16Nobesity Samoa: Launched in 2015 by an NGO whose main objective is to encourage and inspire kids to start making good healthy choices at a young age and install healthier habits while they are young. Page 22 of 103 The World Bank Samoa Health System Strengthening Program (P164382) screening of NCD patients in the country: PEN Fa’a Samoa community-based NCD screening program and screening through health facility visits. The focus of this results area is on enhancing the country’s screening and referral capacity on these two fronts. 33. Accelerated expansion of PEN Fa’a Samoa screening to rural villages. Early detection, referral, treatment, and care of NCD patients are vital and have a direct impact on the reduction of preventable disability and death. Two major issues resulting in the slow progress of expanding PEN Fa’a Samoa, as explained before, are lack of funding and lack of manpower. The MOH, after the split of the MOH and NHS, was responsible for implementing public health programs in the country, including community- based disease screening. The MOH Health Services Performance and Quality Assurance unit, with five staff, has been working on PEN Fa’a Samoa screening in the villages, in addition to other daily duties of service quality assurance. Clearly, the health facilities, rather than a MOH unit, need to be at the frontline for screening and early detection. The merger of the two institutions makes it possible to engage rural health facilities in this screening. Therefore, the proposed operation will finance and support the expansion of PEN Fa’a Samoa screening through  Refining and updating the PEN protocol for community-based screening;  Having the district hospitals perform the screening, working together with the VWCs, while the quality assurance unit in the MOH provides technical guidance, training, and supervision; and  Holding the district hospitals and community health centers responsible for ensuring that the high-risk groups, identified through the screening, go to the health facilities for diagnoses. 34. Institutionalization of routine screening at the health facility level. In addition to community- level screening, NCD screening and diagnosis will be integrated into the routine health facility visits of all publicly funded health facilities. Everyone, ages 20 and above, who visits a publicly funded health facility, will be screened for NCD risk factors including BMI, blood pressure, and blood glucose. Screening protocols for NCDs will be updated and enhanced, and training will be provided to the health service providers. 35. Referral and diagnosis. The proposed PforR will support the strengthening of the country’s referral and diagnostic capacity as necessary and enhance the referral and diagnosis through registration and tracking of persons identified as high-risk or diagnosed as NCD patients. 36. There are two DLIs for Results Area 2. DLI 2: Number of districts with PEN Fa’a Samoa rolled out according to the updated protocol (at least 70% of citizens and at least 60% of men aged 20 years old and older in the district screened) 37. PEN Fa’a Samoa is a community-based NCD screening program which is being implemented by the MOH in the rural villages through working with the VWC. It is the major approach in the country to roll out screening and early detection of hypertension, cardiovascular diseases, and diabetes. Progress is measured based on the number of rural districts where the screening has been performed. Rural district Page 23 of 103 The World Bank Samoa Health System Strengthening Program (P164382) hospitals, and MOH supervision teams, will implement the screening and will report on the progress. The screening will be rolled out in coordination with the deployment of multidisciplinary teams in the district hospitals. The verification will be done by the Samoa Bureau of Statistics (SBS) annually, based on verification protocols and criteria specified in the updated protocol for screening. DLI 3: Percentage of high-risk people, identified through PEN Fa’a Samoa screening, diagnosed within 60 days at designated health facility 38. PEN Fa’a Samoa screening will identify citizens with high risk for NCDs and refer them to the health facility for diagnosis. Currently for the 17 villages where PEN Fa’a Samoa has been implemented, there is no follow-up on whether the citizens referred have ended up in the health facility for diagnosis. This indicator aims to improve the referral and diagnosis after the screening. Progress is measured based on the percentage of the high-risk group identified who actually go to the designated health facility to get the diagnoses within 60 days after the screening. Two rosters will be established: one for confirmed NCD patients and another for NCD high-risk groups. Results Area 3: Strengthen primary care and quality of NCD management 39. This results area aims at strengthening and reorienting the service delivery system to address secondary prevention of NCDs through integrated service provision with the rural district hospitals at the center. The PforR will focus on hypertension and diabetes, as cardiovascular diseases are the leading cause of morbidity and mortality in the country. The PforR Program will aim to achieve its objectives through a set of reform actions explained in the following paragraphs. 40. Establishment of a multidisciplinary team stationed at district hospitals. This is a core strategy of the GoS to achieve the country’s return to its family-oriented, community-based engagement and Fa’a Samoa ways of delivering PHC to its communities. The multidisciplinary team will include a primary care physician, nurses, nutrition assistant (where available or function performed by a nurse trained with relevant knowledge and skill), allied health workers, and VWC; they will have clearly defined functions to provide a continuum of care in a coordinated manner. This multidisciplinary team will play a central role in the service delivery chain covering screening, early detection, chronic disease management, infectious disease control, immunization, and community outreach, serving as the care coordinator/care provider for NCD patients as well as the NCD high-risk groups. The multidisciplinary team will take on the responsibility to manage and track the NCD patients in their catchment area to ensure full compliance with the treatment. The team will also register and track the high-risk groups in their catchment area, providing proactive health promotion and disease prevention services to these high-risk citizens, with the aim of maintaining their health and reducing the risk of them becoming NCD patients. 41. Need-based infrastructure and equipment investments. These will be provided to enhance service accessibility and diagnostic and treatment capacity at the district hospitals. During the PforR preparation, a health facility readiness survey was conducted, which provided a comprehensive inventory check on the service capacity of the PHC facilities in the country. The survey aimed at identifying gaps, including both hardware and software, in these facilities that the PforR Program might be able to address. The infrastructure investment needs identified at this stage are for construction and upgrading of two community health centers into district hospitals and building doctors’ accommodation residence in the rural district hospitals to accommodate the redeployment of physicians to those rural district hospitals. Page 24 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Also, the lack of physical resources was a shared experience of providers as maintenance of existing equipment and ordering of new equipment are challenging. Failure to obtain drugs due to stock-outs was another identified barrier for NCD treatment. The infrastructure and equipment investments will include a range of climate-smart health care investments to boost resilience and energy efficiency of those investments (see Annex 8 for details). 42. Development of evidence-based NCD management pathways to guide health workers through the clinical decision-making process. Substantial gaps were identified by the health facility readiness survey with respect to the standard operating procedures and clinical guidelines. Clinical practice guidelines and documentation for reference do not exist at all district hospitals. Standard operating procedures and guidelines currently available are scattered, most facilities rely heavily on the doctor in charge, when available, or rely on the nursing manager/senior nurse specialist’s skill set. This creates inconsistency in clinical practice and health care provision. Samoa Hypertension Control Implementation Cascade Study17 found that the advice for patients focused on medication; advice on risk factors such as nutrition or weight loss was not common. About a quarter of diagnosed hypertension cases did not receive counseling when commencing treatment, and for many counseling was a one-off service despite the chronicity of NCDs. As patients recalled the content of their hypertension education, topics such as medication schedule, long-term adherence, managing missing doses, side effects, switching regimens seemed poorly covered. Overall, only 13 percent of the hypertension patients had their body weight recorded when put onto the hypertension register, and body weight was poorly monitored during follow- up with 93 percent of the patients. An important finding of the same study is that only 19 percent of the patients who were managed in the rural district hospitals surveyed had their blood pressure under control. All these findings indicate the need to enhance disease management following evidence-based treatment protocols. This finding underscores the importance and urgency for developing and equipping the facilities with evidence-based gender-sensitive standardized clinical protocols and disease management pathways, which will also emphasize appropriate prevention and management of climate- related health issues and risk factors. Intensified systematic training will be provided to the health care workers on the management of NCDs using the chronic care model, with emphasis on a people-centered approach. 43. Ensuring reliable, uninterrupted, and affordable essential drug supply. The World Bank Samoa NCD costing study found that utilization of WHO-recommended essential NCD medicines is low in Samoa compared to other developing countries, and the NHS paid on average three to six times the WHO benchmark price for the NCD drugs. The Samoa Hypertension Control Implementation Cascade Study18 found that the most frequently indicated reason for chronic patients stopping medical treatment is the challenge for providers to ensure continuity of drug supplies, especially outside Apia. Furthermore, substantial gaps were identified in the health facility survey on stocking, supply, and planning of the essential drugs. The spot-check found that the rate of stockout and expired drugs can be as high as 52 percent in certain facilities, which implies a significant barrier on access to services for the patients needing the medicines. The GoS has taken actions, including updating the national essential drug list to be aligned with WHO recommendations and developing an Electronic Pharmaceutical Logistics 17 The study is a collaboration between the World Bank and Samoa MOH, under the finance of World Bank Decision and Delivery Science Program. The study was commenced in June 2018, and the study report has been completed. 18 The study is a collaboration between the World Bank and Samoa MOH, under the finance of World Bank Decision and Delivery Science Program. The study was commenced in June 2018, and the study report has been completed. Page 25 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Information Management System with financing from DFAT. However, more needs to be done, including creating a facility-specific essential NCD drug list, improving drug supply planning through linking the coverage and patient treatment data with drug utilization forecasting, and enhancing the compliance with standard operating procedures for daily monitoring of these essential drugs. Accountability mechanism should also be established for drug management and supply planning. 44. There are two DLIs for Results Area 3. DLI 4: Number of rural district hospitals with a multidisciplinary team in place 45. Rural district hospitals will play a central role in NCD control in the country. The proposed PforR Program will support the investments in strengthening the service delivery capacity of the rural district hospitals, including deploying a multidisciplinary team (with a primary care physician) to the district hospitals. This will be done gradually over four years because it takes time to build up the health workforce in a health-human-resource-constrained small island state country. The terms of references (TORs) of the multidisciplinary team is being developed under the World Bank Programmatic Preparation Advance (PPA). These TORs will define the composition, functionality, and responsibilities of this team. DLI 5: Percentage of hypertensive patients, managed by rural health facilities, having their condition under control following WHO definition 46. Standardized disease management will be developed for managing hypertension and diabetes patients. The rural district hospitals will be responsible for disease management, tracking, follow-up of patients in their catchment areas, and managing the referral, if needed, to the main hospitals. This DLI, however, will use hypertension as a tracer condition by measuring only the outcomes of hypertension management at the rural facilities. Results Area 4: Strengthen multisectoral NCD program stewardship and build institutional capacity 47. This results area will focus on strengthening the policy formulation and program implementation capacity of the GoS, in particular the multisectoral National NCD Committee (see section III.A), to ensure the achievement of intended PforR Program results. The actions to be supported by the PforR Program in this results area include the following: (a) strengthen Program stewardship and build implementation capacity of the GoS, (b) build up Program M&E capacity, and (c) support health workforce development and training. 48. Strengthen Program stewardship and build implementation capacity. The proposed PforR will rely on the existing institutional framework of the country to manage implementation. Through supporting the country system, the PforR will strengthen the focus on institutions and build capacity of the whole NCD control program. Successful implementation of the NCD control program is premised on a robust, coordinated policy formulation and joint efforts of relevant stakeholders, which will require strong institutional capacity. The National NCD Committee, which is chaired by the MOH and consists of at least nine government agencies (see section III.A), provides technical guidance and oversees the implementation of multisectoral NCD control programs in the country. Page 26 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 49. The technical assessment has identified capacity gaps in a few areas, including procurement, M&E, budget planning, technical capacity of rural district hospitals for NCD management, and health care waste management (HCWM). The PforR Program will support capacity building and technical assistance needed through formulation and execution of an annual capacity-building plan for the national NCD control program. The plan will also enhance capacities for data-driven strategic planning in the health sector to prepare for, mitigate, adapt and respond to the impacts of climate change and disasters on the health and well-being of the Samoan population. The annual capacity-building plan needs to be reviewed and endorsed by Samoa Health Program Advisory Committee (HPAC). DLI 6 (implementation completion rate of annual capacity building plan for NCD program approved by the HPAC) has been designed for and dedicated specifically to institutional capacity building. 50. Build up Program M&E capacity to monitor Program implementation progress and evaluate where and how improved outcomes can be achieved. In anticipation of the comprehensive e-Health system, the PforR will support GoS’ plan and efforts to build a routine data reporting and collection system for the implementation of the NCD control program. It will also include the use of early warning systems for prediction, preparedness, and prevention of both climatic hazards and related disease burden. This activity will also include managing the contracting of the independent verification agency (IVA). 51. An important component of the Program M&E system is to establish an essential patient tracking system to track patients from screening to treatment. The patient management system at the 11 rural district hospitals and health centers still uses paper-based patient records and logbooks, with the former sorted by family name (not personalized) and with no link between facility or related domains. The logbooks are facility based and often have incomplete records of patients. Data from both logbooks and medical records are flawed with diagnosis codings,19 and therefore are ill-suited for patient tracking and analysis. The Asian Development Bank (ADB) e-Health Project has been delayed for four years and is unlikely to be up and running for another two years. In anticipation of further potential delays of the e- Health Project, development of an interim mobile app-based patient management system, which will be compatible with the envisioned e-Health system, is being considered at the district hospital level to ensure the management of NCD patients. In parallel, the existing paper-based data collection and reporting system will be enhanced as well. 52. Support health workforce development and training. The PforR will support the GoS program’s efforts to strengthen human resources for health. This will include development of TORs for the multidisciplinary team to be stationed at the district hospitals, training of health workers at rural health care facilities on NCD management, and establishment of the health workforce planning mechanism in the country to inform the development of a health workforce that is more responsive to the needs of the health sector and the Samoan population, including those most vulnerable to the impacts of climate change and natural disasters. 53. Results Area 4 has one DLI which is designed to support institutional strengthening and capacity building. 19 International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Page 27 of 103 The World Bank Samoa Health System Strengthening Program (P164382) DLI 6: Implementation completion rate of annual capacity building plan for NCD program approved by the HPAC 54. The PforR Program will support capacity building and technical assistance needed through formulation and execution of an annual capacity-building plan for the national NCD control program. The plan will be an integrated component of the annual workplan, which the Government will prepare and submit to the Association for review each year. The annual capacity-building plan needs to be reviewed and endorsed by Samoa HPAC. The completion rate will be measured by the number of activities being fully implemented out of total activities planned. C. Program Development Objective(s) (PDO) and PDO Level Results Indicators 55. The PDO is to improve the quality and efficiency of NCD prevention and control in Samoa. 56. Progress toward meeting the PDO will be assessed using the following PDO indicators: (a) Percentage of children (5–12 years old), screened as overweight through the School Nurse Program, referred to and managed under a health promotion program (b) Number of districts with PEN Fa’a Samoa rolled out according to the updated protocol (at least 70% of citizens and at least 60% of men aged 20 years old and older in the districts screened) (c) Percentage of high-risk people, identified through PEN Fa’a Samoa screening, who are diagnosed within 60 days at designated health facility (d) Percentage of hypertensive patients, managed by rural health facilities, having their condition under control following WHO definition (e) Percentage of health sector budget allocated to primary health care and health promotion 57. Program beneficiaries. The whole population of Samoa will benefit from the Program activities focusing on NCD prevention and management. As mentioned earlier, women are disproportionately at risk of NCD risk factors, particularly obesity. The high prevalence of obesity among women is not only a risk factor for NCDs but also has negative implications for women in labor, childbirth, neonatal mortality and malformations, and breastfeeding. Therefore, women will benefit more from awareness and prevention programs for NCDs and related risk factors as well as from proper care and treatment of NCDs. The Program will also support capacity building of VWCs on NCD risk assessment, adoption of healthy lifestyles in relation to family food production, nutrition, and physical activity through the PEN Fa’a Samoa. A focus on primary school children will ensure support to actions facilitating long-term sustainable behavior change to prevent the development of risk factors and subsequent disease onset later in life. The Program also aims to enhance institutional capacity for NCD control through supporting the National NCD Committee, a multisectoral NCD governance body, in its decision making and strategic guidance, and Page 28 of 103 The World Bank Samoa Health System Strengthening Program (P164382) financing the capacity building of the MOH in overall program implementation. The health workers in the PHC facilities will also benefit from the training on standardized NCD management protocols. D. Disbursement Linked Indicators and Verification Protocols 58. The following principles were applied in formulating the six DLIs that have been agreed with the GoS as the basis of disbursement: (a) ensuring that the DLIs correspond to the key priorities in the results areas, which are, in turn, aligned with the KSAs of the National NCD Control Policy; (b) facilitating scaling- up of the essential interventions; and (c) ensuring the desired results are within the control of the GoS. 59. Verification agency. Several agencies, including the Samoa Audit Office (SAO), South Pacific Community headquartered in New Caledonia, WHO, and SBS, were proposed to be the IVA for DLIs. Discussions were held with the MOH and MOF regarding these candidates against the following criteria: (a) absence of conflict of interest, (b) relevant technical expertise and experience, and (c) adequate capacity. In addition, the GoS emphasized the need to build domestic capacity and to save costs to the extent possible. Following the due diligence carried out by the World Bank team as part of the technical assessment to evaluate the credibility, qualification, and capacity of the proposed agencies, SBS was identified as the most appropriate verification agency and is proposed for verification of all the DLIs. Specifically, SBS has been engaged in implementing several health sector surveys,20 and, thus, has the required technical expertise, experience, and necessary implementation capacity for the proposed verification tasks. Furthermore, SBS has been performing the results verification role for the EU-funded Water Sector Results-Based Financing Program and, hence, is familiar with results-based operations. Finally, engaging SBS satisfies the following considerations that are important from both the PforR policy and the country perspectives: (a) use of existing country systems and processes; (b) building and strengthening of local capacity and keeping it in-country to ensure sustainability; and (c) the cost of the SBS verification services being potentially much lower compared to any other international or regional organization, such as, the South Pacific Community. 60. The detailed information regarding definition, measurement, verification and scalability, targets, and value of the DLIs is provided in Annexes 1 and 2. III. PROGRAM IMPLEMENTATION A. Institutional and Implementation Arrangements 61. The technical assessment confirmed the strong political commitment of the GoS on NCD control. The Honorable Prime Minister of Samoa has been at the forefront, acting as a key advocate, for healthy lifestyles and has initiated various health-related campaigns over the years, for example, the Physical 20 These include the Demographic and Health Survey (DHS), Multiple Indicators Cluster Survey (MICS), and Salt Intake surveys. Page 29 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Activity Challenge in 2006–2012 program and Beat Diabetes by 2021. He has also advocated the ‘Eat A Rainbow’ and ‘Go Local Campaign’. The prime minister also has a passion for the health of young children, which was evidenced by his full support to the ‘Nobesity Program’ and launching of the ‘Sugar Crush Campaign’ in 2016 targeting young children. At the United Nations Summit on NCDs in September 2018, the prime minister made a strong commitment to fight rising NCDs. The proposed PforR with the focus on tackling NCDs is, therefore, timely in terms of providing financial and technical support to this important undertaking by the GoS. 62. The PforR supports Samoa’s National NCD Control Policy and Action Plan. Therefore, the existing institutional framework of the country will be followed to implement the PforR-supported Program. At the national level, the HPAC, currently chaired by the Chief Executive Officer (CEO) of the Samoa Ministry of Foreign Affairs and Trade, comprising representatives of relevant line ministries and key stakeholders, is in place to provide overall policy guidance, strategic direction, cross-sectoral coordination, and critical decision making. 21 The National NCD Committee, as a multisectoral decision-making body, provides technical leadership and implementation oversight functions to ensure appropriate strategies and interventions are in place for NCD prevention and control in Samoa.22 Chaired by the MOH, the National NCD Committee includes representatives of the Ministry of Women, Community, and Social Development; Ministry of Education, Sports, and Culture (MESC); Ministry of Agriculture and Fisheries; National Council of Churches; Samoa Medical Association; Samoa Red Cross; Samoa Family Health Association, and National Kidney Foundation. The Public Health Service of the MOH provides technical leadership and secretariat functions for the National NCD Committee. The MOH will implement the Program as the implementing agency of the GoS and engage health sector agencies and facilities at all levels, communities, schools, churches, youth groups, and civil society organizations in supporting Program implementation, as needed. 63. At the MOH level, the Health Sector Coordination, Resourcing, and Monitoring (HSCRM) Division is responsible for coordinating and managing development assistance that is channeled through the MOH for health sector development. This division works to pool the resources of the whole health sector, focusing on the coordination, distribution, and monitoring of resources and finances as well as the progress of the HSP. It also has the NCD coordination function through its Non-Communicable Disease Coordination, Programming, and Implementation Unit headed by the Principal NCD Officer. The primary function of the HSCRM Division regarding the PforR will be to perform day-to-day program management by coordinating, planning, ensuring budget availability, addressing cross-divisional issues, hiring of the IVA, and overall monitoring of and reporting on the PforR progress. The latter function will be performed in collaboration with the Strategic Planning Policy and Research Division, whose core functions include monitoring the progress of the HSP and the implementation of Cabinet-endorsed policies, including the National NCD Control Policy. Apart from the MOH technical implementation/coordination role, the MOF Aid Coordination and Debt Management Division will be the direct borrower-level counterpart for the World Bank at the central level. It will be closely involved in 21 The HPAC’s existing advisory tasks include the following: provide overall policy and strategic guidance on Health Sector Program implementation and propose corrective action, if needed; approve Health Sector Program progress reports; endorse plan of works; ensure that priority programs, including the National NCD Policy, are sufficiently resourced; ensure that externally supported Health Sector Programs are in accordance with GoS’ policies, priorities, and plans; provide advice on way forward with regard to problematic concerns in the health system; and provide advice on technical assistance reports and recommendations. 22 Terms of Reference, National Non-Communicable Diseases Committee, November 22, 2018. Page 30 of 103 The World Bank Samoa Health System Strengthening Program (P164382) overall PforR coordination to ensure efficient communication and coordination among the key stakeholders involved. This PforR governance structure (presented in Figure 7) is aimed at ensuring government ownership and alignment of the PforR with the National NCD Control Policy and Action Plan. 64. Effective tackling of NCDs and related risk factors requires concerted, continuous, multisectoral efforts; therefore, the intended outcomes of the PforR will, to a large extent, depend on the PforR implementation and coordination capacity. In this regard, given the relatively recent establishment of the National NCD Committee, special attention will be paid to strengthening such capacity under the PforR to effectively cope with this challenging task. This critical need, acknowledged through inclusion of a dedicated indicator in the Results Framework (DLI 6), will be addressed under the PforR through the annual capacity-building plan and Program Action Plan (PAP) and through the World Bank’s implementation support. Figure 7. Program Institutional and Implementation Arrangements Note: MFAT =Ministry of Foreign Affairs and Trade; MWCSD = Ministry of Women, Community, and Social Development; MESC= Ministry of Education, Sports, and Culture; SFHA = Samoa Family Health Association; SRC = Samoa Red Cross; NKF = National Kidney Foundation.; DP =development partners; and SMA=Samoa Medical Association B. Results Monitoring and Evaluation Page 31 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 65. The Program is designed to have two sets of indicators. The Program’s Results Framework will have five PDO level results indicators and eight intermediate results indicators to measure the overall progress toward achieving the PDOs (details in Annex 1). Out of these indicators, six are DLIs, which means the World Bank funds will be disbursed against the achievement of the yearly targets of these six DLIs (see Annex 2). Measurement and verification of these results will rely on the country’s data collection and reporting system. 66. Samoa has in its health sector an existing data collection and reporting system, which produces regular reports as needed. The system, however, has a few critical limitations: (a) Samoa’s health information system is predominantly paper based and where automated remains fragmented, unstandardized, and lacking in connectivity between different information systems across health facilities; (b) Samoa lacks unique patient identification, which is a prerequisite for tracking NCD patients across facilities; and (c) the MOH has a unit for information collection and reporting on health services, but the collected data are not being collected and analyzed systematically at the program level (for instance, national NCD program). These weaknesses pose a substantial risk for the implementation of the PforR (see details in box 1). One important lesson learned from the previous engagements, especially the last World Bank support to the health sector (2008–2016) where the unsatisfactory rating at project closing was largely due to the failure of the country system to provide data to demonstrate the attainment of the Project Development Objectives, underscores the critical need for having a robust M&E system in the country and, more specifically, in the health sector. This is even more important with the proposed PforR as it will rely on the existing institutional framework of the country to implement and manage the operation as well as monitor, evaluate, and report on its results. Box 1. Data Availability Challenges and Statistics Capacity in Samoa As in many PICs and low-middle-income countries, access to timely data is a substantial challenge in Samoa, specifically, in the health sector. Samoa’s health information system is predominantly paper based and where automated remains fragmented with a lack of connectivity between different information systems across health facilities. The patient information system (PATIS), a patient management system originally developed in 1996 with support from the Government of Australia in response to a request from the GoS, is currently only used in the main hospital in Upolu: TTM. It has an admission-based, backlogged data entry. While reportedly being a costly system to implement, the PATIS does not have the expected functionality, therefore, limiting its value for patient tracking and monitoring. The patient management at the 11 rural district hospitals and health centers still uses paper-based patient medical records and logbooks, with the former sorted by family name (not personalized), and with no links between facilities or domains, for example, pharmacy. The logbooks are facility based and often have incomplete records of patients, and lack of standardization of data entry across facilities is a significant challenge. Data from both logbooks and medical records are flawed by ICD-10 coding issues, difficult to collect and analyze, do not provide for real-time surveillance, and, therefore, are ill-suited for patient tracking and public health analysis. Also, the lack of data-trained staff and a culture valuing health information as an essential part of medicine and the aging health care workforce present additional challenges. Given this, and the lack of continuous Internet connectivity, there are no information flows among rural district hospitals and health centers or with the two main hospitals. Until recently, the institutional fragmentation had also manifested itself in the lack of coordination and information flows between health facilities operating under the former NHS and the MOH, which was in charge of PHCs and PEN Fa’a Samoa program. There was no link between community-based screening and diagnoses performed in the health facilities. On top of all these shortcomings, Samoa does not have a single identifier system for its citizens; thus, there is no unique patient identification which is a prerequisite for tracking NCD patients across facilities is. Regular population-based surveys are being administered in Samoa. Population census is conducted once in every Page 32 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 10 years with a mini-census being done in-between occasionally based on the need; DHS and MICS for Women and Children are published once in five years. One reliable source of information for NCDs is the STEPS survey, which is supported by the WHO and, it is also implemented once every 10 years. As the major implementer of almost all population-based surveys in Samoa, all sectors considered, SBS has adequate capacity and ample experiences in performing these surveys and providing statistics analysis. 67. There are several ongoing efforts commissioned by the GoS with support from development partners to build Samoa’s information systems, including for improving the service delivery and M&E system in the health sector. First of all, the GoS has planned to build the national ID system before the upcoming general election in March 2021, using the savings from the Samoa Submarine Cable Project cofinanced by the World Bank and the ADB. The unique ID system will enable the establishment of a unique patient ID system. The Australian Government is currently financing the development of an Electronic Pharmaceutical Logistics Management Information System. Moreover, a comprehensive e- Health Information System is currently being designed under ADB’s Samoa Submarine Cable Project, which has commenced in November 2015. By design, the e-Health system will be able to provide the platform for patient tracking and health care management as well as to support GoS’ administrative needs. The project has, however, been delayed with little progress made in four years after its commencement. 68. The recent merger of the NHS and the MOH provides a good opportunity to address the key M&E system weaknesses through regulation, coordination, data standardization, and reporting. The World Bank is committed to build up Samoa’s M&E capacity through the ongoing engagement. The short- term actions include (a) development of a tailor-made results-based M&E training course organized by the World Bank Independent Evaluation Group; (b) development of an M&E framework for the NCD control program, which would provide an overall plan and implementation road map for Samoa to build a routine data reporting and collection system for the implementation of the NCD control program; (c) review, update, and enhancement of the existing paper-based patient tracking registry as a backup for data collection and reporting; and (d) development of a mobile phone-based application for tracking and managing NCD patients. The application would be compatible with the forthcoming e-Health system and serve as an interim solution for the patient tracking system, which is critical for NCD management, in general, and for the ability of the MOH to reliably measure and report on the tracking and management of NCD patients by health facilities. 69. In the longer term, the PforR Program will support capacity building and technical assistance needed through formulation and execution of an annual capacity-building plan for the national NCD control program, which includes building the M&E capacity in the health sector, with dedicated DLI 6 formulated to incentivize continuous and sustainable institutional capacity building. All these actions are summarized in Table 3. Table 3. M&E Action Summary Action Issue to Address Timetable Partner Short term Development of Electronic To support planning, procurement, Scheduled to be DFAT and MOH Pharmaceutical Logistics inventory management of completed by Page 33 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Action Issue to Address Timetable Partner Management system medications as well as the drug June 30, 2020 distribution management to supply essential medications to PHC facilities Training on results-based M&E Building capacity and knowledge of December 2019 MOH and organized by World Bank the M&E task force regarding World Bank Independent Evaluation Group result-based M&E framework PPA Development of M&E framework Lack of overall M&E framework in Before March World Bank for NCD program the health sector 2020 PPA WHO app named HEART Mobile phone-based app for NCD Early 2020 WHO West screening and management Pacific Region Review, update, and enhance the For tracking and managing NCD March 2020 World Bank existing paper-based data patient and NCD high-risk groups PforR collection and reporting system Patient tracking app Mobile phone-based app for NCD 2020 World Bank patient tracking as backup of the PforR WHO app Medium term National ID system To generate a unique ID for each Complete before Samoa citizen the general Submarine election in March Cable Project 2021 cofinanced by the World Bank and the ADB Long term Formulation and implementation Continuously build capacity and Yearly World Bank of annual M&E capacity-building enhance the M&E system PforR plan for the national NCD program e-Health project Comprehensive health information n.a. ADB and DFAT management system C. Disbursement Arrangements 70. Disbursements will be made once reported achievements of the DLIs are verified by the IVA according to the verification protocols. Details of disbursement arrangements are in Annex 2. The following is a brief summary: (a) Disbursements for all DLIs will be made on an annual basis; the World Bank funding proceeds will be disbursed against achieved DLIs and released to the bank account designated by the GoS. No disbursement will be made if the minimum DLI value for triggering disbursement is not met. (b) Targets for DLIs 2 and 4 are cumulative and the disbursement will be made for each additional district or rural district hospital (scalable). Yearly disbursement is not capped. The disbursement can be made up to the maximum allocation for these two DLIs. Any Page 34 of 103 The World Bank Samoa Health System Strengthening Program (P164382) undisbursed allocation is carried over to the next year and can be disbursed once the targets are achieved. (c) For DLIs 1, 3, 5, and 6, disbursements are made based on percentage points (scalable). Yearly disbursement is capped at the yearly allocation. For DLI 6, the undisbursed allocation can be carried over to the next year and be disbursed once the target is achieved. (d) Upon request of the Government, advance may be available under the PforR to support the implementation of the program, in particular for the first year. Advances will be available in an amount not to exceed 25 percent of the total financing (minus PPA financing of US$ 800,000) unless a higher percentage is approved by World Bank management. When the DLIs are achieved, the amount of the advance is deducted (recovered) from the amount due to be disbursed. The advance amount recovered by the World Bank is then available for additional advances (‘revolving advance’). The World Bank requires that the borrower refunds any advance (or portion of the advance) if the DLIs have not been met (or have only been partially met) by the PforR closing date. 71. SBS, to be engaged by the MOH using appropriate GoS procedures, will carry out the verification of all the reported DLIs using the defined verification protocols. The process will be as follows: (a) The MOH will be responsible for collecting and consolidating all the results data, submitting results achievement report to SBS, and requesting results verification, based on which SBS will carry out the verification. (b) The MOH will be responsible for facilitating the verification process and submitting the results achievement report and the verification report to the MOF. (c) The MOF will inform the World Bank through a Results Achievement Notification Letter and provide the IVA’s verification report. The World Bank will review the submitted documentation and request any additional information, as may be necessary for the review. (d) The World Bank Country Director will inform the Government of the World Bank’s acceptance of the evidence of results achievement and the amount of the corresponding proceeds to be disbursed. The MOF will then submit the withdrawal application to the World Bank. (e) To ensure regularity and predictability of disbursements, all efforts will be made to conform to an annual schedule with provisional dates for (i) The MOH to submit reports on the achievement of the DLIs; (ii) SBS to complete verification of results; (iii) The World Bank to complete its due diligence review; and (iv) The MOF to complete the withdrawal application submission. Page 35 of 103 The World Bank Samoa Health System Strengthening Program (P164382) D. Capacity Building 72. The World Bank's assessments have identified capacity gaps in several areas including procurement, budget planning, M&E, technical capacity of PHC facilities on NCD management, and HCWM. Specifically, capacity building and institutional strengthening is required for (a) evaluating and scaling up effective NCD control initiatives, such as the school nurse program; (b) developing evidence- based disease management pathways; (c) creating effective NCD drug management and supply management; (d) building a routine data collection and an interim patient management system for the implementation of the NCD control program; (e) strengthening human resources for health; (f) establishing and institutionalizing mechanisms to monitor the overall implementation of NCD taxation and appropriate tools to generate the needed evidence. The reliance on the MOH for Program performance necessitates the capacity building of national staff and local entities to ensure adequate capacity to implement all those initiatives and make them sustainable. With regard to environmental and social considerations, considerable capacity building will be required to improve the medical waste management. To address these gaps, an annual capacity-building plan for the national NCD control program has been developed and the World Bank will work closely with the Government, as well as other development partners, to provide technical assistance to the extent possible. DLI 6 under Results Area 4 is specifically formulated to improve the Government’s implementation capacity. 73. Given that the World Bank’s PforR instrument is new to the MOH, Program preparation has benefited from capacity building on the PforR with key staff of the MOH and MOF attending PforR training in July 2018 and in May 2019 with additional participation from the SAO. A study tour will also be organized for the Samoa country team to have first-hand exposure to the instrument. Additional and continuous capacity building around the particularities of the PforR lending instrument, including budget planning, financial reporting, auditing, social and environment safeguards, and monitoring and verification of the DLIs and results, will be prioritized throughout the Program implementation period. The Program preparation funds (PPA) have been used to finance the technical assistance in developing evidence-based NCD disease management protocol, TORs for multidisciplinary teams, a patient tracking system, and health workforce planning. The World Bank team will also work closely with the multisectoral members of the HPAC and National NCD Committee to support them with technical and policy advice, as needed, along the critical reform themes, such as the integrated NCD disease management with patient tracking system, essential drug supply, health workforce development, and M&E. The World Bank experts will provide technical assistance, implementation support, and supervision on their respective focus areas. IV. ASSESSMENT SUMMARY A. Technical (including program economic evaluation) 74. The technical assessment established the rationale for Program interventions, defined the boundary, and formulated the DLIs. The proposed health PforR operation builds on the World Bank’s previous analytical work on NCD control and NCD costing in Samoa. The overall vision and policy interventions listed are well aligned with GoS policy directives and, importantly, build on lessons learned from past World Bank operations in Samoa as well as operations of other development partners. The technical soundness of the proposed PforR is underpinned by its reliance on the findings and Page 36 of 103 The World Bank Samoa Health System Strengthening Program (P164382) recommendations of international best practice and global knowledge for NCD control.23 As noted earlier, Samoa is not the only country in the Pacific that faces a high NCD burden. The countries in the region have worked together and formulated the Pacific NCD Road Map which identified four core strategies to fight the epidemic that were deemed necessary, and achievable, in the Pacific context, namely strengthening tobacco control; taxing products that are linked to obesity, diabetes, heart disease, and other NCDs; improving efficiency and the impact of the existing health dollar by reallocating scarce health resources to targeted primary and secondary prevention of cardiovascular diseases and diabetes; and strengthening the evidence base for better decision making. The proposed PforR will support the Government’s national NCD action plan focusing on essential interventions along the NCD service cascade with a focus on strengthening prevention, early detection, PHC, NCD patient management, and community engagement. The PforR is also aimed to strengthen the country system and build institutional capacity, including the stewardship role of the Government, policy development and technical guidance for implementation, budget planning and execution, and monitoring of results. 75. The PforR boundary is defined in line with the core policy of the Government’s HSP, which prioritizes the revitalization of Samoa’s public health and PHC systems. Thus, the Program will cover prevention, community-based health promotion, early detection, community-based screening, and NCD management in the primary care setting. The key milestones along the NCD cascade are defined by DLIs based on three criteria: (a) they correspond to the key priorities in the results areas, (b) they allow for scaling-up of essential interventions, and (c) the desired results are within the control of the Government. 76. Economic rationale. The proposed PforR will facilitate improvements in both allocative and implementation efficiency. Specifically, the PforR seeks to achieve allocative efficiency and value for money by supporting a combination of NCD interventions that are cost-effective through its focus on primary and secondary prevention of NCDs. Implementation efficiencies will also be achieved through the establishment of multidisciplinary teams to ensure that NCD services are delivered in a way that achieves maximum output with given resources. 77. By focusing on primary and secondary prevention of NCDs, the PforR will contribute to saving health care costs related to NCD treatment as well as to increasing the quality of life of citizens. These effects will be obtained through the following: (a) Reduced incidence of NCDs. A deliberate focus on reducing exposure of the population to modifiable risk factors of major NCDs, such as tobacco smoking, unhealthy diets, physical inactivity, and harmful use of alcohol, would contribute to reducing the incidence of all four main NCDs. (b) Reduced NCD-related morbidity and mortality. An increase in the number of people screened and referred for secondary prevention would result in lower NCD-related morbidity and premature death due to NCD-related causes, as measured by life years gained. 23 Such as Pacific NCD Road Map, key strategies committed at the inaugural Joint Forum Economic and Pacific Health Ministers Meeting in July 2014, WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020. Page 37 of 103 The World Bank Samoa Health System Strengthening Program (P164382) (c) Reduced overseas referrals for NCD treatment. An increase in the number of patients with controlled blood pressure and blood sugar would not only result in reduced NCD morbidity but also the reduced need for overseas referrals for NCD comorbidities. 78. The return on investment analysis shows that the impact of these essential investments indicates a return on investment of 1.7 (indicating that for every dollar invested in the limited NCD interventions, the expected return is US$ 1.7). B. Fiduciary 79. The Program fiduciary systems risk is assessed as Substantial. Financial management risks have been identified due to the lack of Program identification in the current health sector budgeting and financial reporting, which may result in (a) uncertainty in the adequacy of Program medium term and annual budget allocation, which may adversely impact Program implementation and prevent timely achievement of Program results; and (b) absence of a Program-specific audit report, which may lead to the lack of timely identification of errors/misrepresentation in Program expenditures for corrective action and no assurance on the financial statistics provided to Program management and oversight bodies. 80. Procurement related risks include (a) capacity challenges: with the NHS being recently merged back into the MOH, there is a potential for delays in procurement due to capacity constraints and (b) procedural issues: (i) the procurement complaint handling system has not been operationalized, (ii) thresholds for open tendering are low, and (iii) the review and approval for high-value contracts follow a lengthy process (in the context of Samoa these are contracts in excess of SAT 50,000, which requires open tendering and approval by the Government of Samoa Tenders Board). 81. To mitigate the risks in financial management, the following recommendations are made: (a) A new budget line item for the Program identification will be created under ‘Transactions on Behalf of the State’ category of the MOH’s budget, so that the country's financial information system can generate annual Program-specific Budget and Expenditure Reports. Personnel expenditures and indirect costs will be allocated to the Program on the basis described in the Program Operations Manual (POM). (b) Program-specific financial statements, covering all Program sources of revenues and expenditures need to be developed, prepared, and submitted to the SAO for audit. Audit opinions on Program financial statements and the Program’s effectiveness of internal control and compliance are to be provided by the SAO while enforcement of audit recommendations must be in place and be documented. (c) Performance audit is to be conducted by the SAO twice for the Program: once during the midterm review and the second time no later than six months before the Program closing date. 82. To mitigate the risks in procurement, the following recommendations are made, or actions are being undertaken: Page 38 of 103 The World Bank Samoa Health System Strengthening Program (P164382) (a) A capacity-building plan has been approved under the PPA to assist with Program preparation and institutional capacity strengthening, aside from the procurement professional developments supported by DFAT. In addition, DFAT is currently financing a Procurement Specialist within the MOH to, among other things, provide hands-on capacity building to ministry staff. (b) The MOH will utilize the services of the Procurement Specialist hired to the Centralized Technical Service Support Unit (CTSSU), which is financed by the Internatioal Development Association under the Samoa Climate Resilient Transport Project (SCRTP). (c) The MOH will develop a Program-specific complaint handling procedure in the POM to be utilized until the GoS complaints-handling procedure becomes effective (approved by the Tenders Board on May 8, 2018). (d) Procurement performance will be closely monitored through the Program semiannual progress reports, and any issue relating to low thresholds or lengthy review and approval processes will be identified and resolved. C. Environmental and Social 83. The Program has a strong positive social, environmental, and health and safety net benefit. Overall, the negative impacts of the Program are expected to be moderate as the adverse consequences of Program activities are limited. Environmental impacts include a potential small increase in medical waste in villages and clinics where NCD screening will be increased. Some minor impacts of construction works may be experienced; however, these can be managed through the application of standard mitigation measures, which, along with community health and safety measures, will be regulated through adherence to the Samoa, New Zealand, and Australian Building Codes. 84. Nevertheless, the Environment and Social System Assessment (ESSA) identified several gaps in the handling and management of health care waste (HCW), with implications for environmental protection and community and worker safety. The key issues associated with treatment and disposal of hazardous waste are hazardous emissions from the incinerator at Tafaigata due to non-optimal burning temperatures and poor treatment and disposal of HCW on Savaii. Aside from waste handling and disposal, there are many opportunities for improvement in the HCWM system, including training for MOH waste management staff, awareness raising about HCWM among frontline MOH employees, and adoption and commitment to a HCWM Strategy by the MOH management. 85. The Program is envisioned to include the needed construction to upgrade two existing community health centers to rural district hospitals as well as the housing for physicians to be deployed to district hospitals. These are small-scale structures, not much larger than typical Samoan dwellings. Potential environmental and social impacts associated with the construction and operation of these facilities include dust, noise, waste management, and wastewater during operation. These impacts are expected to be low and can be readily mitigated by adopting recognized good practices. 86. The Program is expected to result in social benefits through improved health outcomes. The ESSA considered the issues associated with involuntary land acquisition and found that construction of Page 39 of 103 The World Bank Samoa Health System Strengthening Program (P164382) doctors’ accommodations and two regional district hospitals would take place on existing hospital sites, which are leased by the MOH. As such, no new land will be required for the implementation of the Program. The PforR approach, however, means that this may evolve during implementation and additional needs are identified. Based on this potential, the ESSA considered the legislative regime in Samoa and found a number of gaps between World Bank processes and Samoa legislation. Program actions required to mitigate these risks are adequately managed and include provision for enhanced consultation, brief assessment of impacts for sites proposed to be leased, and exclusion of sites where a primary residence is affected, or land acquisition would result in significant impacts. The ESSA also considered any potential impacts on indigenous peoples: the implementation of the Program has been designed and developed with the needs of the Samoan people in mind and incorporates practices and processes, which are closely aligned with the needs of all groups within the community. D. Risk Assessment 87. The overall risk of this operation is considered High as the assessments undertaken by the World Bank have identified significant risks associated with political and governance, institutional capacity for implementation and sustainability, and fiduciary. (a) Political and governance: Moderate. The National NCD Policy and Action Plan was finalized during the preparation of this PforR, with the engagement of the World Bank team and other partners. By engaging in this process, the World Bank team was able to help enhance the national policy formulation so as to improve the overall prospects for achieving the intended results. The ongoing institutional reform, which integrates the policy development and public health roles of the MOH with the service delivery role of the NHS, is critical for streamlining the service delivery in the country as well as for revitalizing the country’s previous focus on PHC and community-based health promotion. It also offers an opportunity to remove any remaining fragmentation in health sector governance. The Merger Taskforce Organizational Structure has been approved by the Cabinet and the MOH has been tasked to lead the Transitional Implementation Plan since merger effectiveness—February 2019— for a year together with the Public Service Commission, MOF, and Office of Attorney General. As this landmark institutional reorganization takes time to realize, given that it needs to be worked in synergy with the development of the Health Human Resource Strategy and MOH Workforce Plan, the institutional reform could have a potential impact on the Program implementation. (b) Institutional capacity for implementation and sustainability: High. Although the MOH team has experience implementing World Bank-financed health projects, the previous support was rated unsatisfactory at completion due to the weak M&E system, which failed to provide data to show the attainment of the PDO. Given the delay of the e-Health project, the weak M&E system in the country continues to pose significant risk for Program implementation. In addition, the procurement capacity of the MOH needs to be strengthened. The use of the PforR instrument, which is new not only to the GoS but also to the Pacific region, also poses a challenge to the MOH in terms of Program implementation. Page 40 of 103 The World Bank Samoa Health System Strengthening Program (P164382) (c) Fiduciary system risk, for both financial management and procurement, is Substantial. The fiduciary assessment report provides additional detailed analysis of the procurement and financial management systems, key risks, and mitigation measures. E. Gender Considerations 88. The Program seeks to narrow the existing gender gaps in NCD risk factors and case detection and treatment outcomes. Globally, disparities exist in the prevalence and treatment of NCDs among men and women. In Samoa, two gender-related gaps were identified based on the STEPS 2014 survey and the Samoa Hypertension Control Implementation Study.5 The first gap is the much higher overweight and obesity rates in women than men. Women showed a higher proportion (90.4 percent) than men (79.8 percent) of the overweight population and 2 in every 3 women between ages 18 and 64 years are obese (68.6 percent) while about half (44.8 percent) of men in the same age range are obese. The rate of increase in obesity appears to be greatest between ages 25 and 54, during which time pregnancy and menopause onset may both have an impact. The high prevalence of obesity among women is not only a risk factor for NCDs but also poses a risk to women in pregnancy and childbirth. Additionally, women with NCD risk factors are at higher risk for adverse reproductive health outcomes for themselves and their infants, such as gestational diabetes, gestational hypertension, preeclampsia, increased risk of neonatal mortality, and malformations. 89. Addressing the observed gender gaps is in line with the actions identified in the Consolidated Gender Action Plan (CGAP) for FY2017–21,24 which was developed to support the implementation of the Regional Partnership Framework. The action plan supports actions to address the disproportionately high percentage of women affected by NCDs as one of the five priority areas of gender inequality. The proposed PforR aims to narrow the gender gap in overweight prevalence through intensified efforts including the following: (a) providing a specially designed health promotion program on healthy diet and physical activities targeting women of reproductive age, the VWCs, who have traditionally been important for community engagement will play a critical role in spreading the knowledge and facilitating behavior change among women in the villages; (b) given that women receiving antenatal care have most frequent clinic visits, knowledge on overnutrition and NCD prevention and control will be integrated into antenatal care programs, with multidisciplinary teams in rural health facilities carrying out the interventions; and (c) developing scripts and special messages in mass media campaigns to be included on the health consequences of obesity to women. 90. All these interventions are expected to increase women’s knowledge regarding NCD risk factors including obesity and overnutrition as well as ways to reduce weight and live a healthy lifestyle. The impact of these interventions will be monitored using a gender-specific intermediate indicator on ‘Percentage of residents in PEN Fa’a Samoa districts with improved knowledge and awareness of NCD risk factors’. It is hypothesized that the increased knowledge could lead to more sustainable changes in desired behavior. Therefore, increased knowledge and awareness rather than change in behavior is used given the challenges in sustaining behavior change. In addition, the self-reporting of behavioral outcomes, 24CGAP for FY17–FY21. The action plan was developed in line with the framework laid out in the East Asia and Pacific Region’s Companion Report to the World Development Report 2012 (World Bank 2011). Page 41 of 103 The World Bank Samoa Health System Strengthening Program (P164382) such as levels of reported tobacco and alcohol use, improved fruit and vegetable intake, and physical activity, is subject to bias, making measurement of change difficult. 91. The second gender gap is the lower NCD screening coverage of men compared to women. In the 2018 Samoa Hypertension Implementation Cascade Study 25 household survey, the self-reported coverage of blood pressure screening during the last 12 months was much higher in women compared to men in PEN villages (60 percent versus 49.5 percent). The same was reported for the coverage of glucose testing for diabetes screening: men had lower glucose screening levels (48 percent) than women (non- pregnant: 63 percent). Figure 8 Figure 8. Hypertension Cascades in Samoa Men and Women shows that among people classified as hypertensive (first column, 100 percent), the coverage of blood pressure screening was much higher in women compared to men (for example, 72 percent versus 52 percent measured blood pressure during last 12 months, screening column). Due to better screening, more of the hypertensive women (38 percent) have been told that they have high BP compared to men (13 percent, diagnosis column). The lower screening coverage in men combined with the lower level of diagnosis lead to a very poor link to hypertension care of hypertensive men: only an estimated 10 percent of hypertensive men were on treatment compared to 29 percent of hypertensive women. 92. Therefore, it is critical to close the gender gap on NCD screening. The rollout of PEN Fa’a screening will aim to narrow down this gap through targeted follow-up with men in the villages to ensure they participate in the PEN screening. This will be performed by VWCs as well as the rural health facilities who will carry out the screening in the villages. DLI 2: Number of districts with PEN Fa’a Samoa rolled out according to the updated protocol (at least 70% of citizens, and at least 60% of men, aged 20 years old and older in the district screened) will be used to monitor the progress. Figure 9 summarizes the theory of change for these gender gaps within the Program. 25The study is a collaboration between the World Bank and Samoa MOH, under the finance of World Bank Decision and Delivery Science Program. The study was commenced in June 2018, and the study report has been completed. Page 42 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Figure 9. Theory of Change for Closing Gender Gaps F. Climate and Disaster Risk Considerations 93. This Program has been screened for short- and long-term climate change and disaster risks and the overall risk rating is High. The geographic location and physical environment of Samoa makes the country prone to a number of natural and human-induced hazards. The major climate risks and natural hazards that are likely to affect the country’s sustainability are tsunamis, tropical cyclones/strong winds, prolonged periods of droughts, heavy rainfalls/flooding, and sea level rise. The Program mainly targets NCDs that are not as directly and substantially subject to climate change-induced risks as communicable diseases (for example, zoonotic, water-borne, vector-borne, and food-borne diseases, which may break out in extreme weather events such as flooding). Along with that, the Program aims at an overall strengthening of Samoa health care system, especially preventive capabilities of the PHC system, thereby increasing its adaptive capacity to be better prepared for existing and new climate-induced health risks and reducing vulnerability of the population it serves. While trying to improve the quality and capacity of the service delivery for tackling the rising NCDs, the Program will also closely and directly engage communities, including the most vulnerable, which will, in turn, increase the overall disaster and climate change resilience of those communities. At the community level and primary and secondary care levels, the population will not only receive critical essential health care services but also climate-relevant health knowledge. Health worker training will include topics on impacts of climate change and disaster events on human health, and the multisectoral NCD Committee will discuss climate-related health issues in its quarterly meetings. In addition, for any construction and upgrading of health facilities (such as planned upgrade of two health centers into district hospitals and building of accommodation quarters for doctors in the district hospitals [estimated at US$ 2.0 million]), climate-smart interventions to limit greenhouse gas emissions will be used, such as solar panels, LED bulbs, and purchase and use of low-emitting equipment and supplies. The climate and disaster risks have been addressed in the Program design through both mitigation and adaptation measures, as briefly elaborated under the four complementary results areas in respective sections of the main text and in more detail in Annex 8. . Page 43 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 1. RESULTS FRAMEWORK MATRIX COUNTRY : Samoa Samoa Health System Strengthening Program Program Development Objective: to improve the quality and efficiency of NCD prevention and control in Samoa. Target Values Unit of Baseline Results Indicators DLI June 30, June 30, June 30, June 30, June 30, Measure (2018) 2021 2022 2023 2024 2025 Results Area 1. Address behavioral risk factors through population-based health promotion PDO Level Indicators 1. Percentage of children (5–12 years old), screened as overweight through the School Nurse Program, 1 % 0 60 60 70 70 70 referred to and managed under a health promotion program Intermediate Indicators 2. Percentage of residents in PEN Fa’a Samoa Male 70 Male 70 Male 70 Male 70 Male 70 districts with improved knowledge and awareness of % 0 NCD risk factors, disaggregated by gender Female 75 Female 75 Female 75 Female 75 Female 75 3. Percentage of primary schools, identified in the previous year inspection as non-compliant with % 0 50 50 50 50 50 School Nutrition Standards, becoming compliant Results Area 2. Increase screening, referral, and diagnosis of NCD high-risk group and NCD patients PDO Level Indicators 4. Number of districts with PEN Fa’a Samoa rolled out according to the updated protocol (at least 70% 2 Number 2 6 10 15 20 26 of citizens, and at least 60% of men aged 20 years old and older in the district screened) 5. Percentage of high-risk people, identified through 3 % 0 50 55 60 65 70 Page 44 of 103 The World Bank Samoa Health System Strengthening Program (P164382) PEN Fa’a Samoa screening, who are diagnosed within 60 days at designated health facility, disaggregated by gender26 Intermediate Indicators 6. Percentage of non-NCD patients aged 20 and above, who present to a rural health facility, % 0 40 45 50 55 60 screened for NCD annually according to the screening protocol Results Area 3. Strengthen primary care and quality of NCD management PDO Level Indicators 7. Percentage of hypertensive patients, managed by rural health facilities, having their condition under 5 % 19 25 30 40 50 60 control following WHO definition, disaggregated by gender27 Intermediate Indicators 8. Number of rural district hospitals with a 4 Number 0 2 4 6 8 - multidisciplinary team in place 9. Percentage of patients in the hypertension and diabetes registry tracked and managed by rural % 0 40 45 50 55 60 health facilities following standardized disease 28 management protocols, disaggregated by gender Protocols and 10. Percentage of people, identified as high-risk programs through screening, tracked and managed by rural % 0 40 45 50 55 addressing health facilities following standardized protocols risk factors developed 11. (Reduction of) Stock-outs (more than 2 weeks) % 40 <40 <30 <20 <20 <20 of all essential drugs in rural health facilities Results Area 4. Strengthen multisectoral NCD program stewardship and build institutional capacity 26 The targets for male and female are the same for this indicator. 27 The targets for male and female are the same for this indicator. 28 The targets for male and female are the same for this indicator. Page 45 of 103 The World Bank Samoa Health System Strengthening Program (P164382) PDO Level Indicators 12. Percentage of health sector budget allocated to 15 % Increase every year primary health care and health promotion (FY2019) Intermediate Indicators 13. Implementation completion rate of annual capacity building plan for NCD program approved by 6 % 0 60 70 70 70 70 the HPAC Monitoring & Evaluation Plan: PDO Indicators Responsibility Methodology for Data Indicator Name Definition/Description Frequency Datasource For Data Collection Collection Percentage of children (5–12 Numerator: Number of children classified as Semiannually Routine Regular monitoring data; MOH years old), screened as overweight, referred and managed under a reporting the school nurses will be overweight through the School health promotion program. responsible for Nurse Program, referred to and Denominator: Total number of children ages measuring and recording managed under a health 5–12 screened in school as overweight the weight of the children promotion program ages 5–12. They will also collect and record the data on school children completing the health promotion programs Number of districts with PEN Number of districts with PEN Fa’a Samoa Semiannually Routine VWC and rural health MOH Fa’a Samoa screening rolled out screening implemented. At least 70% of the reporting facilities report and MOH according to the updated citizens and at least 60% of men ages 20 and aggregates protocol (at least 70% of citizens older in the district must be screened for it and at least 60% of men aged 20 to be qualified as completed years old and older in the . . district screened) . Page 46 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Numerator: Number of NCD high-risk people Semi Routine Rural health facilities MOH Percentage of high-risk people, identified, presented to a health facility annually reporting implementing PEN Fa’a identified through PEN Fa’a within 60 days for diagnosis by health Samoa report regularly Samoa screening, who are Denominator: Total number of residents facilities and MOH aggregates diagnosed within 60 days at screened as high-risk group for NCDs designated health facility, The yearly targets are same for male and disaggregated by gender female. Percentage of hypertensive Numerator: Number of hypertensive Semiannually Rural Routine reporting of rural MOH patients, managed by rural patients, managed by the district hospitals health health facilities and MOH health facilities, having their following standardized disease management facility =- aggregates condition under control protocols, who have their blood pressure patient following WHO definition, under control. The WHO definition will be records disaggregated by gender used to define the blood pressure is under and control registry Denominator: Number of hypertensive patients, managed by the district hospitals following standardized disease management protocols Yearly targets are same for male and female. Percentage of health sector Numerator: Annual health sector budget Semiannually MOF The MOF published MOH budget allocated to primary allocated to PHC and health promotion yearly budget and mid- health care and health Denominator: Total health sector budget year adjustment promotion Monitoring & Evaluation Plan: Intermediate Results Indicators Responsibility Methodology for Data Indicator Name Definition/Description Frequency Datasource for Data Collection Collection Percentage of residents in The residents screened in PEN Fa’a Samoa Annually PEN Fa’a Samoa Baseline will be conducted MOH and SBS PEN Fa’a Samoa districts screening are assessed on their screening with PEN Fa’a Samoa with improved knowledge knowledge and awareness of NCD risk Program screening. SBS, as part of and awareness of NCD risk factors during the screening and one year and SBS the verification, will factors, disaggregated by after the screening verification conduct mini-survey in the gender Numerator: Total number of screened survey PEN villages at the end of residents who have improved knowledge each year to measure the Page 47 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Monitoring & Evaluation Plan: Intermediate Results Indicators Responsibility Methodology for Data Indicator Name Definition/Description Frequency Datasource for Data Collection Collection and awareness knowledge and awareness Denominator: Total number of residents gains screened Percentage of primary Numerator: Number of primary schools, Annually Routine MOH schools, identified in the identified in the previous year inspection monitoring and previous year inspection as as noncompliant with School Nutrition reporting by The MOH collects and non-compliant with School Standards, becoming compliant the MOH monitors the progress of Nutrition Standards, Denominator: Total number of primary the enforcement becoming compliant schools identified in the previous year inspection as noncompliant with School Nutrition Standards Percentage of non-NCD Numerator: Number of non-NCD patients Monthly Rural health Monthly reporting from the MOH patients aged 20 and ages 20 and above screened at rural facility registry, rural health facilities and above, who present to a health facility for NCDs patient record MOH aggregates rural health facility, Denominator: Total number of non-NCD screened for NCD annually patients ages 20 and above presented at according to the screening rural health facility protocol Number of rural district Number of rural district hospitals staffed Semiannually Routine MOH reports MOH hospitals with a with multidisciplinary team according to reporting multidisciplinary team in the defined TORs place Percentage of patients in Numerator: Number of registered Quarterly Rural health Rural health facility reports, MOH the hypertension and hypertension and diabetic patients report facility registry, MOH aggregates diabetes registry tracked followed up and managed by rural health patient medical and managed by rural facilities records health facilities following Denominator: Total number of registered standardized disease hypertension and diabetic patients Page 48 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Monitoring & Evaluation Plan: Intermediate Results Indicators Responsibility Methodology for Data Indicator Name Definition/Description Frequency Datasource for Data Collection Collection management protocols, Yearly targets are same for male and disaggregated by gender female Percentage of people, Numerator: Number of NCD high-risk Quarterly Rural health Rural health facility reports, MOH identified as high-risk people tracked and managed by rural facility registry MOH aggregates through screening, tracked health facilities following standardized and patient and managed by rural protocols records health facilities following Denominator: Total number of people, standardized protocols identified as high risk through screening (Reduction of) Stock-outs Numerator: Number of essential Semiannually Routing Pharmaceutical inventory MOH (more than 2 weeks) of all medicines in rural health facilities that reporting logistics management essential drugs in rural were out of stock for more than 4 months information system and health facilities in a year rural health facilities reports Denominator: Total number of essential and MOH aggregates medicines in rural health facilities in accordance with Essential Medicines List Implementation Numerator: Number of capacity-building Semiannually MOH The MOH, as the chair of MOH completion rate of annual activities in the annual capacity-building implementation the National NCD capacity building plan for plan that have been fully implemented progress Committee, will report on NCD program approved by and completed according to the reporting the status of the HPAC completion format/standard defined in implementation/completion the plan. of the plan Denominator: Number of capacity- building activities defined in the annual capacity-building plan for NCD program approved by the Samoa HPAC. Page 49 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 2. DISBURSEMENT LINKED INDICATORS, DISBURSEMENT ARRANGEMENTS AND VERIFICATION PROTOCOLS Disbursement-Linked Indicators, Targets, and Timelines Total Financing Target and Timeline for DLI Achievement As % of DLI Allocated to DLI Total Basel June 30, June 30, June 30, June 30, June 30, Formula DLI (US$, Financing ine 2021 2022 2023 2024 2025 millions) DLI 1: Percentage of children Disbursement = Current (5–12 years old), screened as year achievement × unit overweight through the price School Nurse Program, — — 0 60 60 70 70 70 Unit price = US$ 6,000 per referred to and managed 1 percentage point under a health promotion program Allocated amount 1.98 21.3 — US$ 360,000 US$ 360,000 US$ 420,000 US$ 420,000 US$ 420,000 DLI 2: Number of districts with Disbursement = (Current PEN Fa’a Samoa screening year achievement− rolled out according to the baseline × unit price) − updated protocol (at least cumulative disbursed — — 2 6 10 15 20 26 70% of citizens and at least amount. 60% of men aged 20 years old Unit price = US$ 70,000 and older in the district per an increase by 1 screened). district Allocated amount 1.68 18.1 — US$ 280,000 US$ 280,000 US$ 350,000 US$ 350,000 US$ 420,000 DLI 3. Percentage of high-risk Disbursement = Current people, identified through year achievement × unit PEN Fa’a Samoa screening, — — 0 50 55 60 65 70 price diagnosed within 60 days at Unit price = US$ 5,000 per designated health facility29 1 percentage point Allocated amount 1.5 16.1 — US$ 250,000 US$ 275,000 US$ 300,000 US$ 325,000 US$ 350,000 29 As a DLI, this indicator is not disaggregated by gender. Page 50 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Total Financing Target and Timeline for DLI Achievement As % of DLI Allocated to DLI Total Basel June 30, June 30, June 30, June 30, June 30, Formula DLI (US$, Financing ine 2021 2022 2023 2024 2025 millions) Disbursement = (Current year achievement − baseline) × unit price − DLI 4: Number of rural district cumulative disbursed hospitals with a amount — — 0 2 4 6 8 — multidisciplinary team in place Unit price = US$ 120,000 per an increase by 1 rural district hospital with a multidisciplinary team in place Allocated amount 0.96 10.3 — US$ 240,000 US$ 240,000 US$ 240,000 US$ 240,000 DLI 5: Percentage of Disbursement = Current hypertensive patients, year achievement × unit managed by the rural health price — — 19 25 30 40 50 60 facilities, having their Unit price = US$ 8,292 per condition under control 1 percentage point following WHO definition30 Allocated amount 1.70 18.3 — US$ 207,300 US$ 248,760 US$ 331,680 US$ 414,600 US$ 497,660 DLI 6: Implementation Disbursement = Current completion rate of annual year achievement × unit capacity building plan for NCD — — 0 60 70 70 70 70 price. program approved by the Unit price = US$ 2,000 per HPAC 1 percentage point Allocated amount 0.68 7.3 — US$ 120,000 US$ 140,000 US$ 140,000 US$ 140,000 US$ 140,000 PPA 0.8 8.6 Total financing allocated 9.3 100 — US$ 1,457,300 US$ 1,543,760 US$ 1,781,680 US$ 1,889,600 US$ 1,827,660 30 The target for male and female are the same for this indicator. Page 51 of 103 The World Bank Samoa Health System Strengthening Program (P164382) . DLI Verification Protocol Table (details are to be further defined by SBS and the protocol needs to be approved by the World Bank) Scalability of Protocol to evaluate achievement of the DLI and data/result verification Definition/Description of # DLI Disbursements Data Verification achievement Procedure (Yes/No) source/agency Entity Percentage of The School Nurse Program will The school nurse will report on the data at children (5–12 provide prospective screening of least twice a year. The MOH will aggregate. years old), child indicators, including BMI The verification will be done by SBS annually screened as monitoring, to students in the based on the final verification protocol. SBS overweight primary schools. The program will will visit the primary schools where the through the be rolled out gradually each year. program has been implemented, verify the 1 School Nurse The school nurse will monitor Y MOH SBS records by interviewing the school children Program, children’s BMI and refer children and parents depending on which referred to and who are screened as overweight interventions the overweighed students have managed under and obese to specifically designed participated in. Sampling might be needed a health intervention program. depending on total number of schools and promotion the total number of students screened. program Number of PEN Fa’a Samoa is a community- Rural district hospitals, community health districts with based NCD screening program, center, and MOH teams will implement the PEN Fa’a Samoa which is being implemented by screening and will report on the progress. screening rolled the MOH in the rural villages The verification will be done by SBS annually out according to through working with VWCs. The based on verification protocol and criteria the updated screening protocol is currently specified in the updated protocol for PEN protocol (at least under review by the WHO and the Fa’a Samoa. Sampling will be used to select 2 Y MOH SBS 70% of citizens MOH to revise the metric chart villages that SBS will visit to verify the results. and at least 60% for the special country context of Survey of the residents will be conducted by of men aged 20 Samoa. At least 70% of the SBS in the villages sampled. years old and citizens and at least 60% of men older in the ages 20and older in the district district have to be screened for it to be screened) qualified as completed Percentage of PEN Fa’a Samoa screening will The rural district hospitals and VWCs, which 3 Y MOH SBS high-risk people, identify citizens with high risk for provide the screening, will refer the high-risk Page 52 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Scalability of Protocol to evaluate achievement of the DLI and data/result verification Definition/Description of # DLI Disbursements Data Verification achievement Procedure (Yes/No) source/agency Entity identified NCDs and refer them to citizens to the district hospital for diagnosis. through PEN Fa’a designated health facilities for The multidisciplinary team is responsible for Samoa, confirmation of whether they following up with citizens to ensure they will diagnosed within have an NCD or not. Currently for go to the designated facility for diagnoses. 60 days at the 17 villages where PEN Fa’a The team will subsequently report on the designated Samoa has been implemented, outcomes of referrals and diagnostics. The health facility there is no follow-up on whether verification will be done by SBS which will the citizens referred have ended provide on-site check on the record of up in the health facility for services in the health facilities and will also diagnosis. This indicator is aimed verify with the patients. Sampling will be to improve the referral and used for verification when necessary. diagnosis after the screening. Number of rural The rural district hospitals will The MOH will report on the progress of district hospitals play a central role in the NCD deployment of multidisciplinary teams. SBS with a control in the country. A will visit the hospitals to verify based on the multidisciplinary multidisciplinary team (with a verification protocol and against the criteria team in place primary care physician) will be specified in the TOR for multidisciplinary deployed to the rural district teams. 4 Y MOH SBS hospitals to strengthen the service delivery capacity of the rural district hospitals. This will be done gradually over four years based on MOH’s implementation road map. Percentage of Standardized disease The rural district hospitals, which provide hypertensive management will be developed disease management and follow up with patients, for managing hypertensive citizens on referrals to the referral hospitals, managed by patients. The rural district will report on patient outcomes. SBS will 5 Y MOH SBS rural health hospitals will be responsible for verify according to the agreed verification facilities, having disease management, tracking, protocols. SBS will provide on-site checks on their condition follow-up of the patients in their the record of hypertension management under control catchment areas, and managing services provided by the rural health facilities Page 53 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Scalability of Protocol to evaluate achievement of the DLI and data/result verification Definition/Description of # DLI Disbursements Data Verification achievement Procedure (Yes/No) source/agency Entity following WHO the referrals, if needed, to the and will also verify with the patients. definition main hospitals. This indicator will Sampling will be used for verification when measure the outcomes of NCD necessary. management at the rural health facilities. Implementation The operation will support The National NCD Committee will report on completion rate capacity building and technical the progress and SBS will verify according to of annual assistance needed through the verification protocol and criteria capacity building formulation and execution of an specified in the annual capacity-building plan for NCD annual capacity-building plan for plan. For multiyear activities, the completion program the national NCD control will be accounted for the completion year. approved by the program. The annual plan needs 6 HPAC to be reviewed and approved by Y MOH SBS the Samoa HPAC. Progress will be measured based on percentage of capacity building activities in the annual capacity-building plan that have been completed according to the defined standard in the plan. Page 54 of 103 The World Bank Samoa Health System Strengthening Program (P164382) World Bank Disbursement Table Financing Is Minimum DLI Maximum DLI Allocatio Available For Value Value n to the Required to Expected to Deadline for Determination of Amount to Be Disbursed against # DLI DLI Trigger Be Achieved Prior Achievement Achieved and Verified DLIs (US$, Advance Disbursement for World Results millions) of World Bank Bank Finance Disbursement Achievement is calculated based on the total number of Percentage of school children ages 5–12 screened as overweight that children (5– have been managed by a health promotion program 12 years old), (numerator) and the total number of school children ages screened as 5–12 screened as overweight (denominator). overweight through the The total allocation is to be disbursed in portions based on School Nurse Upon the formula below, upon verification of achievement of 1 1.98 n.a. June 30, 2025 30% Yearly target Program, request the yearly target values. The maximum amount to be referred to disbursed every year is capped at yearly allocation. No and managed disbursement will be made if the minimum value of the under a DLI target (30%) to trigger disbursement is not met. health promotion Formula: Disbursement = Current year achievement × unit program price Unit price = US$ 6,000 per 1 percentage point Number of Achievement is calculated based on the number of districts with districts with PEN Fa’a Samoa screening rolled out PEN Fa’a according to the updated protocol. At least 70% of the Samoa citizens and at least 60% of men ages 20 and older in the screening district have to be screened for it to be qualified as n.a Upon 2 rolled out 1.68 June 30, 2025 3 districts 26 districts completed. request according to the updated The target of this indicator is cumulative, the protocol (at disbursements will be made based on the formula below, least 70% of upon verification of achievement of the yearly target citizens and values. Disbursement corresponding to the Page 55 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Financing Is Minimum DLI Maximum DLI Allocatio Available For Value Value n to the Required to Expected to Deadline for Determination of Amount to Be Disbursed against # DLI DLI Trigger Be Achieved Prior Achievement Achieved and Verified DLIs (US$, Advance Disbursement for World Results millions) of World Bank Bank Finance Disbursement at least 60% overachievement of the targets can be made, up to the of men aged maximum allocation of this DLI. Unutilized amount for 20 years old previous year could be carried forward to the following and older in year and be disbursed when the previous year’s target is the district met. No disbursement will be made if the minimum value screened) of DLI target (3 districts) to trigger disbursement is not met. Formula: Disbursement = (Current year achievement − baseline) × unit price − cumulative disbursed amount. Unit price = US$ 70,000 per an increase by 1 district. Achievement is calculated based on number of high-risk citizens, identified through PEN Fa’a Samoa screening, actually end up in the referred health facility to have a Percentage of diagnosis on whether they have an NCD or not high-risk (numerator) and the total number of high-risk citizens people, identified through PEN Fa’a Samoa screening identified (denominator). through PEN Fa’a Samoa n.a Upon The maximum amount to be disbursed every year is 3 1.5 June 30, 2025 40% Yearly targets screening, request capped at yearly allocation. No disbursement will be made diagnosed if the minimum value of DLI target (40%) to trigger within 60 disbursement is not met. The disbursements will be made days at based on the formula below, upon verification of designated achievement of the yearly target values. health facility Formula: Disbursement = Current year achievement × unit price Unit price = US$ 5,000 per 1 percentage point Page 56 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Financing Is Minimum DLI Maximum DLI Allocatio Available For Value Value n to the Required to Expected to Deadline for Determination of Amount to Be Disbursed against # DLI DLI Trigger Be Achieved Prior Achievement Achieved and Verified DLIs (US$, Advance Disbursement for World Results millions) of World Bank Bank Finance Disbursement Achievement is calculated based on the number of rural district hospitals with a multidisciplinary team in place. This target of this indicator is cumulative. The total allocation is to be disbursed in portions based on the formula below, upon verification of achievement of the Number of yearly target values. Disbursement corresponding to the rural district overachievement of the targets can be made, up to the hospitals Upon maximum value of this DLI. Unutilized amount for 4 with a 0.96 n.a June 30, 2025 1 hospital 8 hospitals request previous year can be carried forward to the following multidisciplin year. No disbursement will be made if the minimum value ary team in of DLI target (1 rural district hospital) to trigger place disbursement is not met. Formula: Disbursement = (Current year achievement – baseline) × unit price – cumulative disbursed amount Unit price = US$ 120,000 per an increase by 1 rural district hospital with a multidisciplinary team in place Achievement is calculated based on number of Percentage of hypertensive patients, managed by the rural district hypertensive hospitals, who have their blood pressure under control patients, managed by (numerator) and the total number of hypertensive patients managed by the rural district hospitals following rural health n.a Upon 5 1.70 June 30, 2025 19% Yearly values standardized disease management protocol facilities, request having their (denominator). condition The disbursements will be made based on the formula under control below, upon verification of achievement of the yearly following target values. The maximum amount to be disbursed Page 57 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Financing Is Minimum DLI Maximum DLI Allocatio Available For Value Value n to the Required to Expected to Deadline for Determination of Amount to Be Disbursed against # DLI DLI Trigger Be Achieved Prior Achievement Achieved and Verified DLIs (US$, Advance Disbursement for World Results millions) of World Bank Bank Finance Disbursement WHO every year is capped at yearly allocation. No disbursement definition will be made if the minimum value of DLI target (19%) to trigger the disbursement is not met. Formula: Disbursement = Current year achievement × unit price Unit price = US$ 8,292 per 1 percentage point Achievement is calculated based on the total number of capacity-building activities in the annual plan completed Implementati (numerator) and the total number of capacity-building on activities in the plan (denominator). completion The maximum amount to be disbursed every year is rate of capped at yearly allocation. Unutilized amount for annual Upon previous year could be carried forward to the following 6 capacity 0.68 n.a June 30, 2025 40% Yearly targets request year and be disbursed when the previous year’s activity is building plan completed. No disbursement will be made if the minimum for NCD value of DLI target (40%) to trigger disbursement is not program met. approved by the HPAC Formula: Disbursement = Current year achievement × unit price. Unit price = US$ 2,000 per 1 percentage point. Page 58 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 3. (SUMMARY) TECHNICAL ASSESSMENT COUNTRY : Samoa Samoa Health System Strengthening Program A. Strategic relevance and technical soundness of the proposed PforR 1. Samoa’s NCD policy is founded on the GoS’ priorities articulated in SDS 2016/17–2019/20. The SDS identifies health as a priority and highlights the priorities of the health sector with the vision of ‘Healthy Samoa’. This vision translates into the overarching goal for health sector development that calls for building an inclusive, people-centered health service with emphasis on prevention, protection, and compliance. Samoa’s new Health Sector Strategy (2019–2029) recognizes that the rapidly increasing levels of NCDs continue to pose a strategic challenge to Samoa and prioritizes improved prevention, control, and management of NCDs as one of its seven key strategic outcomes. The new HSP prioritizes the revival of Samoa’s public health system and defines the PEN Fa’a Samoa initiatives as the center of the sector plan. 2. The recently adopted National NCD Policy 2019–202331 is aligned to the strategic goals of the HSP 2019–2029. The new NCD policy is operationalized by an action plan that details five KSAs: (a) Governance, Leadership, and Partnership; (b) Health Promotion, Advocacy, and Risk Reduction; (c) Health System Strengthening to Address NCDs; (d) Surveillance and Monitoring and Evaluation (M&E); (e) Disaster Preparedness and NCDs. The proposed PforR will support a subset of the Government’s National NCD Policy and Action Plan 2019–2023 with the focus on scaling up the essential interventions of NCD control at the PHC and community setting. 3. The proposed health PforR operation builds on the World Bank’s previous analytical work on NCD control and costing in Samoa. The overall vision and the policy interventions listed are well aligned with government policy directives and, importantly, they build on lessons learned from past World Bank operations in Samoa as well as operations of other development partners. The design of the PforR operation draws on the findings and recommendations of international best practice and global knowledge for NCD control.32 In summary, the proposed operation is expected to significantly boost up the NCD control efforts in Samoa. B. Program Expenditure Framework 4. The expenditure framework assessment (EFA) is conducted based on the government health sector budget estimates for FY2019–20 and projections for the next four years FY2020–21 to FY2023–2433 and an assessment of historical budgets and public accounts for 2014–2018. The EFA includes the 31 The first National NCD Policy covered 2010–2015. 32 Such as Pacific NCD Road Map, Key Strategies Committed at the Inaugural Joint Forum Economic and Pacific Health Ministers Meeting in July 2014, WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020. 33 The MOF develops a three-year profile of estimated expenditure. Ministries and agencies are required to complete budget templates to submit information for the current budget and two subsequent years. The current year budget estimates form the ceiling for the subsequent year budget. Page 59 of 103 The World Bank Samoa Health System Strengthening Program (P164382) following dimensions: (a) program expenditure scope, (b) Program financing and fiscal sustainability, (c) budget allocation and execution, and (d) efficiency of Program financing. Program Expenditure Scope 5. The Samoa health sector budget has historically been structured by outputs reflecting the divisional structure of the MOH and the NHS. Before the institutional merger of the MOH and the NHS, separate budgets were produced for the two entities structured by outputs34 for the MOH and the NHS and outputs by third parties through grants and subsidies.35 Following the merger of the two entities in January 2019, there has been an integration of the MOH and NHS budgets effective from July 1, 2019, resulting in a consolidated health sector budget similarly structured by divisional outputs. This new consolidated budget includes 22 divisional outputs by the MOH and third-party outputs though grants and subsidies. 6. The expenditure framework of the Program is defined based on the workplans of the divisions implementing the NCD program, excluding the tertiary care divisions, and assessed based on the health sector budget allocated for these divisional outputs. Specifically, 10 divisions of the MOH implementing the government NCD program fall into the boundary (see Figure 3.1) with a combined estimated budget of US$ 64.64 million (SAT 167.43 million) over the next five years, including both NCD and non-NCD activities. As this is the first integrated health sector budget following the MOH and the NHS merger in 2019, the budget is based on indicative projections, and it is expected that the budgets for Savaii Health Services and Primary Health Care and Outreach Services will be increased following mid-year budget reviews36 with supplementary budgets expected for both outputs. 7. The existing financial system does not provide Program-specific information to, for instance, distinguish NCD and non-NCD expenses. The NCD-related expenses for these divisional outputs over the next five years were estimated based on the planned activities. The estimated total Program cost over the five years is US$ 40.54million (SAT 104.99 million), which includes support by a World Bank grant of US$ 9.30 million. The Program expenditure framework accounts for about 19 percent of the total health sector budget over the five-year period. Specific expenditure categories include recurrent salary expenditures, civil works, equipment, drugs and diagnostic supplies, payment for health promotion and screening campaigns, a patient tracking system, and payments for professional services. Table 3.1 shows the overall Program expenditure framework by results area and by expenditure category. 34 Samoa government budget is classified by outputs which represent functional divisions. 35 The whole NCD expenditures from the GoS were spread across five outputs delivered by the MOH: Health Protection and Enforcement Division; Health Services, Performance, and Quality for Medical, Dental and Allied Health Services; Health Information System and Information, Communication, and Technology; National Health Surveillance and International Health Regulations; and Health Sector Coordination, Resourcing, and Monitoring. Third-party outputs included Non-Communicable Diseases Clinic, Samoa National Kidney Foundation, and Samoa Cancer Society. Under the former NHS budget, NCD expenditures were spread across nine outputs: Clinical - TTM Hospital and Allied Services; Clinical - Laboratory Services; Clinical - Pharmaceutical Services; Clinical - MTII Hospital Services; Nursing Integrated and Community Services; Other Allied Health and Support Services; Infrastructure, Plant, and Non-Medical Equipment; Primary Health Care and Outreach Services; and Information Technology. 36 The GoS reviews the budgets mid-year to determine additional funding. See Table 3.3. Page 60 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Figure 3.1. Expenditure Scope of the Program (FY2020–25) Table 3.1. Program Expenditure Framework by Results Areas and Expenditure Category (US$, millions) Results Expenditure Budget Output FY2020/21 FY2021/22 FY2022/23 FY2023/24 FY2024/25 Total Areas Category RA 1 Output 4: Health Wage bill 1.65 1.01 1.16 1.16 0.86 5.84 Protection and Goods and Prevention Health Services RA 2 Output 20: Primary Wage bill 1.34 1.47 1.60 1.67 1.76 7.85 Health Care and Goods and Outreach Services Services RA 3 Output 5: Health Capital 4.24 4.38 4.65 4.75 4.96 22.98 Services costs Performances/Quality Wage bill Assurance for Goods and Medical, Dental, and Services Allied Services Output 12: Laboratory Services Output 15: Pharmaceutical Services Output 16: Savaii Health Services (PHC) and MTII Hospital Output 22: Pharmaceuticals and Consumables Page 61 of 103 The World Bank Samoa Health System Strengthening Program (P164382) RA 4 Output 8: Health Wage bill 1.65 0.85 0.52 0.52 0.52 4.07 Information System Goods and and ICT services Output 9: National Health Surveillance and International Health Regulation Output 10: Health Sector Coordination, Resourcing, and Monitoring Total PforR 8.88 7.71 7.94 8.11 8.10 40.54 Program Financing and Fiscal Sustainability 8. Financial sustainability and funding predictability do not pose a specific risk as the overall budget execution is centralized. The health sector, including the government NCD program, is mainly financed by the GoS health sector budget and supplemented by development partners financing for specific activities. The GoS has demonstrated its commitment to the health of Samoa’s residents through increases in budget allocations to the health sector in recent years. During 2014–2019, the government health budget increased by 25 percent in nominal terms from US$ 31.90 million (SAT 81.88 million) to US$ 39.97 million (SAT 102.59 million). Development partner contributions to the health sector, on the other hand, have fluctuated in the last five years increasing to US$ 5.34 million (SAT 13.70 million) in FY2019 (see Table 3.2). In both FY2018–19 and FY2019–20, the total health sector budget allocation increased by around 11 percent and similar increases in allocations are expected in the future years. Table 3.2. Trends in Health Sector Budget, FY2014 to FY2019 (US$, millions) FY2014/15 FY2015/16 FY2016/17 FY2017/18 FY2018/19 FY2019/20 MOH 3.41 3.67 3.93 7.47 7.17 39.97 NHS 28.48 27.80 29.90 27.00 31.22 n.a. Development partner 0.44 5.01 0.21 2.16* 2.15* 5.34 contributions Total health sector 32.34 36.48 34.04 36.63 40.54 45.30 budget Health sector budget — +12.80 −6.69 +7.60 +10.67 +11.74 increase/decrease (%) Note: * based on estimates from budget document as the public accounts were not available. Budget Allocation and Execution 9. Samoa has a well-developed Chart of Accounts (COA) and budget classification system and scores relatively well on budget credibility, comprehensiveness in classification, treasury operations including budget, payroll, and expenditure controls and in-year reporting. Overall, in the past five years, the health Page 62 of 103 The World Bank Samoa Health System Strengthening Program (P164382) budget has been fully implemented, with supplementary budget allocations balancing the overspending. The Public Expenditure and Financial Accountability (PEFA) 2018 report showed good quantitative data on budget allocation and outturns of the health sector compared to others. The actual health sector budget execution for the last three years (FY2014–17) with audited financial statements shows an average aggregate budget outturn of 3 percent of the originally approved budget, and there was no unexpected expenditure arising. Table 3.3 presents the budget outturns for the three most recent years with audited financial statements Table 3.3. Original Health Budget versus Actual Expenditures, 2014–2017 FY2014/15 FY2015/16 FY2016/17 Original budget (US$, millions) 31.90 30.89 33.83 Final budget (US$, millions) 32.90 33.01 34.41 Actual expenditure (US$, millions) 32.71 32.70 34.29 Budget outturn (%) 3 6 1 10. Financial management risks have been identified due to the lack of Program identification in the current health sector budgeting and financial reporting, which may result in uncertainty in the adequacy of the funds allocated to the NCD-specific activities. During FY2017/18, it is estimated that a total of US$ 18.25 million (SAT 46.76 million) of the total government health budget of US$ 34.51 (SAT 88.48 million) was spent on NCD activities representing around 53 percent of the estimated cost of the total government budget for the health sector. About US$ 0.55 million (SAT 1.41 million) out of the MOH budget of US$ 7.48 (SAT 19.17 million) was spent by the MOH for the fulfilment of its stewardship functions for the NCD program. Given that there are no program classifiers attached to the budget allocations, using a recent World Bank study37 which found that medical spending on NCDs accounts for about 55 percent of total medical spending and 40 percent of total health sector spending, it is estimated that US$ 14.87 million (SAT 38.12 million) of the total US$ 27.03 million (SAT 69.31 million) allocation for the NHS was spent on NCD management. Other expenditures for the NCD program were US$2.71 million (SAT 6.94 million) to the Samoa National Kidney Foundation; US$ 97,500 (SAT 250,000) to the Non-Communicable Diseases Clinic; and US$ 15,600 (SAT 40,000) to the Samoa Cancer Society. Development partner support particularly for PEN Fa’a Samoa activities (specifically from the WHO) have been estimated at US$ 200,000 (SAT 500,000). Similar contributions by the WHO are expected to continue in the medium term. 11. To mitigate any risks to budget allocation and execution resulting from a lack of NCD Program identification in the current health sector budgeting and financial reporting, it has been agreed that a new budget line item for Program identification will be assigned in the current COA. This will enable generation of Program-specific annual budget and Program expenditure reports and subsequently improve the efficiency of health sector budget planning and allocation, as well as facilitate close monitoring of budget execution. Efficiency of Program Financing 12. Government spending on health has increased over the past decade, both as a share of total government spending and GDP as well as in real per capita terms. However, spending for PHC and, 37Samoa National NCD Cost Analysis Study, World Bank 2017. Based on estimates from budget document as public accounts are not available. Page 63 of 103 The World Bank Samoa Health System Strengthening Program (P164382) particularly, for health promotion, immunization, and reproductive health in Samoa remains low (despite recent increases in preventive health spending) and significantly relies on development partner financing. Currently, only 15 percent of the health sector budget is allocated to health promotion and PHC. To improve the efficiency of the health sector spending, the GoS, through this PforR, aimed to shift resources gradually from specialized, tertiary curative care toward preventive health services and PHC. The World Bank will provide analysis of health sector expenditures and technical assistance to the Government to achieve efficiency improvement. C. Results Chain and the Logic Underlying DLI Selection 13. Figure 3.2 presents the results chain of the NCD Program. The result chain lays out the interventions/activities to be taken during the program implementation, the intermediate outputs and results, and outcomes by the results areas. The PforR focuses on four results areas targeting three core steps of the NCD control implementation cascade (Figure 3.2). There are six DLIs and seven monitoring indicators to measure the scaling-up of the major interventions addressing NCDs. The result chain table explains the logic of how the Program activities are expected to be translated into enhanced services which lead to the desired results. Page 64 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Figure 3.2. Theory of Change—the Result Chain for the Proposed Program Activities and Processes Outputs Intermediate Results Outcomes Results Area 1: Address behavioral risk factors through Establish a mechanism to monitor population-based health promotion the impact of NCD taxation policy Improved quality and  Enhancing the effectiveness of macro-policy and provide information for NCD taxation policies updated improved efficiency of interventions through impact assessment of NCD evidence-based decision making based on the result of the impact NCD prevention and taxation policies. assessment. control  Capacity building of the VWCs to undertake health Increase number of students promotion activities and conduct NCD risk assessments. whose BMI is monitored DLI 1: Percentage of children (5–  BMI monitoring among school children, that is, prospective 12 years old), screened as monitoring of child health indicators through the School Increase number of women at overweight through the School Reduced occurrence Nurse Programs with referrals for children identified at risk reproductive age participating in Nurse Program, referred to and of NCD risk factors in for NCDs to health education and physical activity programs. health promotions program managed under a health general population. promotion program This will include engaging NGOs to provide physical activity Percentage of primary schools Improved efficiency camps. identified in the previous year Increased percentage of resident (more services  School nutrition standards compliance enforcement inspection as noncompliant with in PEN Fa’a Samoa districts with provided by PHC  Provision of education by VWC on healthy eating and risk school nutrition standards improved knowledge and facilities) and quality factors for NCDs for children, parents, teachers, and school becoming compliant awareness of NCD risk factors, in health service committees. disaggregated by gender. delivery (following  Healthy lifestyle mass campaigns incorporating healthy Increase number of women of evidence-based lifestyle ambassadors and champions. reproductive age who are disease management). screened as overweight and provided healthy lifestyle Improved service intervention package capacity of rural district hospitals. Results Area 2: Increase screening, referral, and diagnosis of DLI 2: (Increased) Number of DLI 3: (Increased) Percentage of Increased percentage NCD high-risk groups and NCD patients districts with PEN Fa’a Samoa high-risk people, identified of hypertensive adults Accelerated expansion of PEN Fa’a Samoa to all villages rolled out according to the through PEN Fa’a Samoa whose blood pressure  Refining and updating PEN protocol for community- updated screening protocol (at screening, diagnosed within 60 is under control. based screening. least 70% of citizens and 60% of days at designated health facility men 20 years old and older in Reduced occurrence Page 65 of 103 The World Bank Samoa Health System Strengthening Program (P164382)  Having the district hospitals to perform the district screened) Percentage of non-NCDs patients of morbidity, screening, working together with the VWCs. The ages 20 and above, who presents premature mortality, quality assurance unit in the MOH will provide PEN Fa’a Samoa screening to a publicly funded health facility, and disability in NCD technical guidance, training, and supervision in the protocols updated. screened for NCD annually patients future. according to the screening  The district hospitals and community health centers Health facility NCD screening protocol Reduced occurrence will be responsible for ensuring that the high-risk protocols developed. of NCDs by focusing groups identified by the screening arrive in the on high-risk health facilities for diagnosis. Training on the updated protocols population provided to health workers management -Institutionalizing routine screening at the health facility level Referral and diagnosis Improved patient Results Area 3: Strengthen primary care and quality of NCD DLI 4: (Increased) number of rural Increased percentage of people satisfaction. management district hospitals with a identified as high-risk through multidisciplinary team in place screening, tracked and managed  Establishing a multidisciplinary team stationed at by rural health facilities following district hospitals. Community health centers are standardized protocols.  Need-based infrastructure and equipment updated and upgraded to rural investment district hospitals. Essential Increased percentage of patients  Developing evidence-based NCD management. equipment procured in hypertension and diabetes Pathway for all levels of the health system to guide registries tracked and managed by health workers through the clinical decision-making Training on standardized disease rural health facilities following process. management pathways provided. standardized disease management  Ensuring reliable, uninterrupted, and affordable protocols. essential drug supply. Reduction of stock-outs of all essential drugs in rural health DLI 5: (Increased) Percentage of facilities hypertensive patients, managed by rural health facilities, having their condition under control following WHO definition. Page 66 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Results Area 4: Strengthen multisectoral NCD program Formulation of annual capacity- DLI 6: Implementation completion stewardship and build institutional capacity building plan rate of annual capacity building  Strengthening Program stewardship and building plan for NCD program approved implementation capacity of the Government. Program M&E system established by the HPAC.  Building up Program M&E capacity. and reports on the progress of the  Health workforce development and training. result indicators  Establishing an essential patient tracking system Health workforce plan developed. Page 67 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Program Results Framework 14. The Program Results Framework will use five PDO level results indicators and eight intermediate results indicators to measure progress toward achieving the PDOs. Out of these indicators, six were selected as DLIs. Measurement and verification of these results will rely on the country’s data collection and reporting system. Monitoring and Evaluation 15. M&E capacity. Samoa’s health information system is predominantly paper based and, where automated, remains fragmented with a lack of connectivity between different information systems across health facilities. An e-Health information system is currently being designed under the ADB’s Samoa Submarine Cable Project approved in November 2015, which is severely delayed with further delay anticipated. The country’s weak M&E system poses substantial risk for the attainment of the PforR Program PDOs. Given the apparent delays in the e-Health project and the GoS’ intention to not trade design quality for speed given the envisaged substantial (US$ 14–15 million) investment, it was agreed with the GoS that the PPA will finance the design and development of a mobile phone-based application. The application would be compatible with the forthcoming e-Health system and serve as an interim solution for the patient tracking system, which is critical for NCD management, in general, and for the ability of the MOH to reliably measure and report on the tracking and management of hypertensive and diabetes patients by health facilities (DLI 3 and 5). The establishment and institutionalization of regular M&E mechanisms to monitor the overall implementation of NCD interventions and appropriate tools to generate the needed evidence will be included in the PAP. 16. Methodology. Under the PforR, it is proposed that SBS be selected as the IVA for all the DLIs. Several agencies, including the SAO, South Pacific Community headquartered in New Caledonia, the WHO, and SBS, were proposed to be the verification agency for DLIs. Discussions were held with the MOH and the MOF regarding these candidates against the following criteria: (a) absence of conflict of interest, (b) relevant technical expertise and experience, and (c) adequate capacity. In addition, the GoS emphasized the need to build domestic capacity and to save costs to the extent possible. Governance Structure and Institutional Arrangements 17. The existing institutional framework of the country was assessed to be adequate to implement the proposed Program. At the national level, the HPAC, currently chaired by the CEO of Ministry of Foreign Affairs and Trade, comprising representatives of relevant line ministries and key stakeholders, is in place to provide overall policy guidance, strategic direction, cross-sectoral coordination, and critical decision making. 38 The National NCD Committee provides technical leadership and implementation oversight functions for NCD control programs and related risk factors in the country. Chaired by the MOH, the 38More specifically, the HPAC’s existing advisory tasks include the following: provide overall policy and strategic guidance on Health Sector Program implementation and propose corrective action, if needed; approve Health Sector Program progress reports; endorse plan of works; ensure that priority programs, including the National NCD Policy, are sufficiently resourced; ensure that externally supported Health Sector Programs are in accordance with GoS’ policies, priorities, and plans; provide advice on way forward with regard to problematic concerns in the health system; and provide advice on technical assistance reports and recommendations. Page 68 of 103 The World Bank Samoa Health System Strengthening Program (P164382) National NCD Committee includes representatives of the Ministry of Women, Community, and Social Development; MESC; Ministry of Agriculture and Fisheries; National Council of Churches; Samoa Family Health Association; Samoa Red Cross and National Kidney Foundation. The Public Health Service Department of the MOH provides technical leadership and secretariat functions for the National NCD Committee. The MOH will implement the Program as the implementing agency of the GoS and engage health sector agencies and facilities at all levels, communities, schools, churches, youth groups, and civil society organizations in supporting Program implementation, as needed. 18. At the MOH level, the HSCRM Division is responsible for coordinating and managing development assistances that are channeled through the MOH for health sector development. This division works to pool the resources of the whole health sector, focusing on the coordination, distribution, and monitoring of resources and finances as well as the progress of the Health Sector Program. It also has the NCD coordination function through its Non-Communicable Disease Coordination, Programming, and Implementation Unit headed by the Principal NCD Officer. The primary function of the HSCRM Division will be to perform day-to-day program management by coordinating, planning, ensuring budget availability, addressing cross-divisional issues, managing the IVA, and overall monitoring of and reporting on the Program progress. The latter function will be performed in collaboration with the Strategic Planning Policy and Research Division, one of the core functions of which is to monitor the progress of the HSP and the implementation of Cabinet-endorsed policies, including the National NCD Control Policy. Apart from the MOH technical implementation/coordination role, the MOF Aid Coordination and Debt Management Division will be the direct borrower-level counterpart for the World Bank at the central level. It will be closely involved in overall Program coordination to ensure efficient coordination and communication among the key stakeholders involved. Economic Rationale 19. The proposed Program is intended to support the strengthening of PHC for the delivery of NCD services. Given the large NCD burden in Samoa, government intervention in the health sector at the primary care level is strongly justified for improving equitable distribution of health services for NCD control and management across populations. Evidence from other settings not only shows that PHC (in contrast to specialty care) is associated with a more equitable distribution of health in populations but also that a focus on primary care improves overall health and helps prevent morbidity and mortality. PHC benefits are derived from its characteristics of first-contact care, person-focused care over time, coordinated and comprehensive care, and its community orientation. 20. The Program will facilitate improvements in both allocative and implementation efficiency by supporting health promotion among school children, expanding screening for NCDs, establishing a multidisciplinary team to support the management and control of NCDs at the primary care level in line with achieving the Sustainable Development Goals targets by 2030. Specifically, the Program seeks to achieve allocative efficiency by supporting a combination of NCD response interventions that yield the highest impact through its focus on primary and secondary prevention of NCDs. Implementation efficiencies can also be achieved through the establishment of multidisciplinary teams to ensure that NCD services are delivered in a way that achieves maximum output with given resources. The investment in the harmonized package of NCD prevention, control, and treatment services will improve access to high- impact, cost-effective services and will be delivered using results-based financing mechanisms. Supply- Page 69 of 103 The World Bank Samoa Health System Strengthening Program (P164382) side interventions will strengthen basic health systems aimed at increasing the ability of the rural district hospitals in managing the NCD epidemic. 21. Measuring the PforR Benefits. The costs and benefits of the impacts of an intervention can be evaluated either in terms of public willingness to pay for them (benefits) or willingness to pay to avoid them (costs) or in terms of actual costs, if control efforts have been implemented. In this case, an investment case analysis approach is used to justify the use of resources intended to increase the stock of health. This analysis assumes that there are three interacting individual-level benefits that can be derived from interventions which enable good health, and these are increased (a) health-related quality of life due to the absence of ill health, (b) years of life due to the prevention of premature deaths, and (c) economic and social activity. Program Costs 22. The estimate of direct costs of the economic burden considered only government health expenditure and not patient-level costs. Incremental intervention costs were estimated for 2019–2030 using government estimates for planned expenditures on these actions in the national NCD action plan. The overall NCD program cost, which includes the planned government expenditure for the five-year period 2019–2023, is SAT 236.36 million (US$ 92.18 million), of which the World Bank’s contribution is US$ 9.3 million. Indirect costs due to losses in labor force productivity were estimated at US$ 35 million over the five-year period. Program Benefits 23. The benefits of investing in NCD prevention and management are well documented. A recent study by Bertram et al. (2018)39 concluded that scaling up even a limited set of effective and preventive interventions could avert up to 13 million incidents of stroke and 8 million incidents of ischemic heart disease within 15 years, in addition to moving countries toward the Sustainable Development Goal target of reducing premature NCD mortality. In addition, the study concluded that the number of labor force participants would increase directly as a result of averted mortality and productivity would increase as a result of avoided disabling side effects of NCDs. 24. By focusing on primary and secondary prevention of NCDs, the PforR will contribute to saving health care costs related to NCD treatment. Additional program benefits include the following: (a) Reduced incidence of NCDs. A deliberate focus on reducing exposure of the population to modifiable risk factors of major NCDs such as tobacco use, unhealthy diets, physical inactivity, and harmful use of alcohol contributes to reduction of the incidence of all four main NCDs. (b) Reduced NCD-related morbidity and mortality. An increase in the number of people screened and referred for secondary prevention would result in lower NCD-related 39Bertram, M. Y., K. Sweeny, J. A. Lauer, D. Chisholm, P. Sheehan, B. Rasmussen, S. R. Upreti, L. P. Dixit, K. George, and S.Deane. 2018. “Investing in Non-communicable Diseases: An Estimation of the Return on Investment for Prevention and Treatment Services.” The Lancet. Page 70 of 103 The World Bank Samoa Health System Strengthening Program (P164382) morbidity and premature deaths due to NCD-related causes as measured by life years gained. (c) Reduced overseas referrals for NCD treatment. An increase in the number of patients with controlled blood pressure and blood sugar would not only result in reduced NCD morbidity but also the need for overseas referrals for NCD comorbidities. Return on Investment Analysis 25. The return on investment analysis shows that the World Bank investment of US$ 9.3 million over the next five years to scale up a limited set of prevention and treatment activities for cardiovascular diseases would generate significant health and economic benefits with positive returns on investment. The impact of these investments at the end of the Sustainable Development Goal period indicates a return on investment of 1.7 (indicating that for every dollar invested in the limited NCD interventions, the expected return is US$ 1.7 over the PforR implementation period). Page 71 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 4. (SUMMARY) FIDUCIARY SYSTEMS ASSESSMENT COUNTRY : Samoa Samoa Health System Strengthening Program SECTION 1: CONCLUSION 1. Reasonable Assurance 1. In assessing the performance of the fiduciary systems under which the Program operates, the World Bank identified various issues which, once addressed, will result in Program fiduciary systems that provide reasonable assurance that the Program expenditures will be used appropriately to achieve their intended purpose with due attention to the principles of efficiency, effectiveness, transparency, and accountability. 2. The fiduciary systems assessment identifies risks and proposed mitigation measures. Before undertaking the mitigation measures, the Program fiduciary system risk was assessed as Substantial. During preparation, the World Bank assessed all the available options including dated covenants, capacity building, DLIs, and Program design revisions, to help mitigate these risks. The results of the assessment and recommendations are reflected in the technical assistance program and the integrated PAP. 1.1 Risk Assessment 3. Financial management risks have been identified for the lack of Program identification in the current health sector budgeting and financial reporting, which may result in (a) uncertainty in the adequacy of Program medium-term and annual budget allocation, which may adversely affect Program implementation and prevent timely achievement of Program results and (b) absence of a Program-specific audit report, which may lead to the lack of timely identification of errors/misrepresentation in Program expenditures for corrective action and no assurance on the financial statistics provided to Program management and oversight bodies. 4. Procurement-related risks include the following: (a) capacity challenges: with the NHS being recently merged back into the MOH, there will be potential delay of procurement because of capacity constraints and (b) procedural issues: (i) the procurement complaints-handling system has not been operationalized, (ii) thresholds for open tendering are low, and (iii) the review and approval for high-value contracts follow a lengthy process (in the context of Samoa, this is contracts in excess of SAT 50,000, which require open tendering and approval by the Government of Samoa Tenders Board). 5. To mitigate those risks in financial management, the following recommendations are made: (a) A new budget line item for the Program identification will be created under ‘Transactions on Behalf of the State’ Category of the MOH budget so that the country's financial information system can generate annual Program-specific budget and expenditure reports. Personnel expenditures and indirect costs will be allocated to the Program on the basis described in the POM. Page 72 of 103 The World Bank Samoa Health System Strengthening Program (P164382) (b) Program-specific financial statements, covering all Program sources of revenues and expenditures need to be developed, prepared, and submitted to the SAO for audit. Audit opinions on Program financial statements, Program’s effectiveness of internal control and compliance are to be provided by the SAO while enforcement of audit recommendations must be in place and be documented. (c) Performance audit is to be conducted by the SAO twice for the Program: once during the midterm review and the second time no later than six months before the Program closing date. 6. To mitigate those risks in procurement, the following recommendations are made, or actions are being undertaken: (a) A capacity-building plan has been approved under the PPA to assist with Program preparation and institutional capacity strengthening. In addition, DFAT is currently financing a Procurement Specialist within the MOH to, among other things, provide hands-on capacity building to Ministry staff. (b) The MOH will use the services of the Procurement Specialist hired to the CTSSU, which is financed by the World Bank under the SCRTP. (c) The MOH will develop a Program-specific complaint-handling procedure in the POM until the GoS complaints-handling procedure becomes effective (approved by the Tenders Board on May 8, 2018). (d) Procurement performance will be closely monitored through the Program’s semiannual progress reports, and any issue relating to low thresholds or lengthy review and approval processes will be identified and resolved. 1.2 Procurement Exclusions 7. There are no procurement activities that involve the procurement of works, goods, and services whose estimated value exceeds Operations Procurement Review Committee thresholds (high-value contracts). SECTION 2: SCOPE OF THE ASSESSMENT 2.1 Objectives of the Assessment 8. The assessment of Program fiduciary systems integrates findings in three areas: (a) the Program procurement systems were assessed to determine the degree to which the planning, bidding, evaluation, contract award, and contract administration arrangements and practices provide a reasonable assurance that the Program will achieve intended results through the Government’s procurement processes and procedures; (b) the financial management systems were assessed to determine the degree to which the relevant planning, budgeting, accounting, internal controls, funds flow, financial reporting, and auditing arrangements provide a reasonable assurance on the appropriate use of Program funds and safeguarding of its assets; and (c) the Program was also assessed on how its governance systems handle the risks of Page 73 of 103 The World Bank Samoa Health System Strengthening Program (P164382) fraud and corruption, including the use of complaint mechanisms, and how such risks are managed and mitigated considering the Government’s commitments under the Guidelines on Preventing and Combating Fraud and Corruption in Program-for-Results Financing (Anti-corruption Guidelines [ACGs]). 2.2 Implementing Agencies 9. The Fiduciary Systems Assessment has been prepared based on interviews and analysis at the national level—MOF, SBS, and SAO—and implementing agency level—MOH departments. SECTION 3: FIDUCIARY SYSTEMS ASSESSMENT 3.1 Planning and Budgeting 3.1.1 Adequacy of Budget Current Arrangements 10. The MOF develops a three-year plan of estimated expenditure. Ministries and agencies are required to complete the budget templates to submit information for the current budget and two forward years. Once the first forward year estimate is established it becomes the ceiling for the subsequent budget. The MOF publishes the estimates of revenue and appropriated expenditure for the budget year only. Each year, the Budget and Fiscal Policy Division, under the MOF, prepares a budget circular providing all agencies (a) guidance on the requirements for updating information on budget and forward estimates, (b) the requirement to complete a Procurement Plan template, and (c) the calendar with deadlines and milestones. Expenditure ceilings are provided to line ministries but are not endorsed by the Cabinet at any stage. Legislative scrutiny of the budget is systemic and timely, with the Legislative Assembly delegating to the Finance and Expenditure Committee the role of scrutinizing the budget and reporting back to it. The recent PEFA assessment 2018 showed good quantitative data on budget allocation and outturns of the health sector compared to others. The supplementary budget accounted for only 2 percent of the total budget allocation for the year, and there was no unexpected expenditure arising. 11. The COA used for the preparation, execution, and reporting of the budget is approved and administered by the MOF. The COA provides for (a) administrative classification (that is, the legal structure of the Government); (b) classification of outputs and suboutputs (as opposed to programs); and (c) economic type through the natural account. The budgeting process is effective at the ministerial level but does not necessarily ensure timely and adequate budget allocation for the proposed Program in terms of both annual budget and medium-term planning. The COA classification codes (and hence budget lines) are only assigned to outputs and suboutputs instead of programs, while there may be situations where activities of more than one program are required to achieve an output, or it takes more than one financial period to achieve an output. In both cases, the existing setting up of annual budget allocation is not effective and efficient for Program implementation and reporting. For the proposed PforR, a separate budget line item for Program identification should be assigned to Program activities in the current COA so that the system can generate Program annual budget and Program expenditure reports. Page 74 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 3.1.2 Procurement Planning 12. Procurement planning - The Treasury Instruction - Section 6. Procurement and contracting (Part K Amended in 2016) requires procuring entities to prepare and submit an Annual Procurement Plan for each financial year, in accordance with prevailing government policies, and that these plans be integrated with applicable budget processes. In practice, the MOH follows this requirement, but the plan is not publicly disclosed on the MOF’s website40. The MOF has agreed that the portion of the MOH Annual Procurement Plan that falls within the Program boundary will be published on their website. The MOH has also confirmed that once the MOH’s website is operational, the same information will also be published on the MOH’s website. Under the PforR, the MOH will be required to provide the World Bank with a copy of its Annual Procurement Plan, as part of the annual workplan, which clearly indicates the planned procurement activities that fall within the Program boundary, especially the procurement activities that are essential to the successful achievement of the Program indicators such as the construction of rural district hospitals and physician housing, procurement of diagnostic equipment, and development of various programs and policies. 3.1.3 Procurement Profile of the Program 13. From the expenditure framework analysis, it is noted that a significant proportion of the Program funds will be used for recurrent or operation costs, which are not subject to procurement. The planned procurement activities that are within the Program boundary (that is, about 10 percent of the total program expenditure boundary) include the procurement of consulting services (policy development and training), construction (rural district hospitals and physician housing), and goods (diagnostic equipment and supplies). 3.2 Budget Execution 3.2.1 Treasury Management and Fund Flow 14. Institutional arrangements in Samoa for the management of budget resources are quite centralized in the MOF and the overarching regulatory framework is set centrally and applied across the Government. Funds for NCD activities flow from the MOF to the ultimate service delivery units including hospitals, clinics, PHC facilities, MOH payrolls, and so on through the Treasury system, of which the accounts are held within the Treasury General Fund with transfers from the designated special accounts at Central Bank of Samoa for the PforR. Based on the approved budget plan, the implementing units will conduct NCD activities. Fund flow for the Program in the Government’s current system is illustrated in Figure 4.1. 40 https://www.mof.gov.ws/Services/Procurement/tabid/5587/Default.aspx Page 75 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Figure 4.1. Fund Flow MOF budget proposal MOH funds transfer MOH divisions Contractors/ Health facilities, communities, schools, suppliers/payroll churches, and other primary health care units 15. The risk of misuse of funds is low as the SAO is involved significantly in the ongoing transaction processing. Every payment from the government budget has a preaudit check undertaken by the SAO. With the proposed PforR, NCD Program funds will be ring-fenced with a separate budget line item under the ‘Transactions on Behalf of the State’ budget category in the MOH Budget for both budget proposal and budget execution reporting to better manage budgetary allocations, execution, and reporting of NCD activities and results. Funds allocated and transferred from the MOF to MOH are to be performance based. The amount allocated by the MOF to the MOH annually for this Program should reflect the amount needed by the MOH to achieve the planned results and DLIs. Funds transferred from the MOH’s account to implementing agencies’ accounts are to follow the same principles. 3.2.2 Accounting and Financial Reporting 16. The MOF centralizes the capture and processing of ministries’ transaction data. It produces whole- of-government (Budgetary Central Government) consolidated reports and distributes budgetary unit- specific reports, including the MOH’s expenditures. Its Operating Manual on Monitoring and Review Procedures defines policies and procedures pertaining to regular monitoring, review, and reporting of financial data. The annual financial statements are prepared under International Public Sector Accounting Standards cash reporting standards and are to meet the Public Financial Management Act (PFMA) requirements. The annual financial statements report on budgetary central government are directly comparable to the approved budget. In addition, like the budget classification system, the NHS financial reporting system, before the merger in January 2019, did not assign identification for NCD activities, but only generated reports on the NHS. 17. For the proposed PforR, separate boundary reporting for Program expenditures is required for Program financial statements and Program audit. Assigning a separate budget line item for the NCD Program under the ‘Transactions on Behalf of the State’ budget category will ensure the system can generate Program annual budget and expenditures reports. Program financial statements, covering all Program sources of revenues and expenditures, must be prepared and submitted to the SAO for audit. Page 76 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 3.2.3 Procurement Process and Procedures 18. Public procurement in Samoa is based on clear, mandatory, and enforceable rules that are freely accessible to the public (refer to this link to the MOF website: https://www.mof.gov.ws/Services/Procurement/ProcurementLegalFramework/tabid/8807/Default.aspx ). Public procurement is governed by the requirements detailed in the relevant sections of Public Finance Management Act 2001 (Section XII Procurement and Contracts); Treasury Instructions - Section 6: Procurement and Contracting (Part K Amended 2016); Procurement Guidelines: Goods, Works, and General Services (Amended 2016); Procurement Guidelines: Consulting Services (2014); and the B4 Schedule: Thresholds and Approvals. 19. The MOH has experience financing and undertaking procurement of activities of a similar nature envisaged under the PforR-supported Program. However, there are still some issues which may affect procurement implementation of this program. (a) Thresholds 20. The B4 Schedule issued by the Government of Samoa Tenders Board specifies low thresholds for open tendering processes which results in most procurement activities having to go through a formal tendering process. The Treasury Instructions require competitive tendering for activities with an estimate exceeding SAT 150,000 (about US$ 57,000 equivalent). However, in practice, the line ministries apply this to all activities with an estimate exceeding SAT 50,000 (US$ 19,000 equivalent) according to the requirements of the Government of Samoa Tenders Board. This requirement and its application may result in lengthy processes and unnecessary and complex procurement documentation as well as a greater administrative burden. (b) Complaints Handling 21. The Government of Samoa Tenders Board approved a complaint-handling procedure on May 8, 2018. The procedure was issued to line ministries on August 6, 2018, through the Tenders Board Calendar of Meetings 2018/19 Circular Memorandum. The Procurement Division has identified a primary adjudicator and two alternates. The Government of Samoa Tenders Board has now approved the appointment of the primary adjudicator and two alternate adjudicators who will also be contracted (in case of conflict of interest or issue with unavailability of the primary adjudicator). The Samoa Consultancy Remuneration Framework is being used as the basis for negotiation rates. Once agreed, the adjudicators are expected to be contracted by the end of October 2019, at which point the complaints-handling procedure will become operational. 3.2.4 Contract Administration 22. The Methodology for Assessing Procurement Systems assessment looked at norms for the safekeeping of records and documents related to transactions and contract management. It determined that the legal/regulatory framework establishes a list of the procurement records that must be kept at the operational level, and what is available for public inspection, as well as conditions for access. No specific contractual management issues were flagged in the Implementation Completion and Results Report for the SWAp other than the identification of various variations to key contracts. However, as a Page 77 of 103 The World Bank Samoa Health System Strengthening Program (P164382) newly re-amalgamated ministry, the MOH should ensure that staff are identified and assigned responsibility for management of contracts, specific training is provided for these individual(s), and training forms part of the MOH procurement capacity-building plan to enhance staff technical capacity to manage resulting contracts. In addition, the DFAT and CTSSU Procurement Specialists can assist the MOH develop contract management plan templates and contract registers, as well as to provide training and mentoring to ensure that good practices are established and/or maintained. 23. Administrative procedures for contract variations. The GoS Guidelines require review and approval of all contract variations/modifications (regardless of value) by the Tenders Board (Guideline Goods, Works, and General Services, paragraph B.15 3.40) and for substantial modifications to consulting contracts (Guideline for Consulting Services paragraph R.4.33). The lack of delegation of authority to project managers and line ministries for the management of minor contract variations has in the past caused significant delays (DFAT Assessment of National Systems 2018). This has been highlighted as a risk that would likely contribute to delays during implementation of contracts. The proposed PAP includes the development of technical specifications/terms of reference and detailed cost estimates to avoid unnecessary variations/modifications. 3.3 Internal Controls 3.3.1 Internal Controls 24. The control environment for public financial management (PFM) in Samoa has been established through the Constitution and legislation enacted by the Legislative Assembly. The Constitution and the PFMA are the key documents for the financial activities of the Government. The coverage of the PFMA includes (a) responsibility for financial management; (b) fiscal responsibility; (c) economic, financial, and fiscal policy; (d) budget and appropriations; (e) public money and the General Revenue Fund; (f) special purpose funds; and (g) trust funds. 25. The risk assessment component is provided in the Treasury Instructions, which covers risk assessment in general and specific areas, including receipt of public money, accounting forms, electronic payments, and financial derivatives which have risk components. Additional mention is made, throughout the Treasury Instructions, of procurement and stores (inventory). Other requirements addressing risk include monitoring and internal audit activities and the compliance function performed by the staff at the SAO, coupled with other similar activities within the ministries. The information and communication component are established throughout the Government, including within legislation issued by the Legislative Assembly and intergovernmental communications, while documentation is established by the MOF officials and interdepartmental communications are issued by the Government. 26. Monitoring activities are to be carried out continually by ministries’ staff within their requirement to establish procedures to review adequacy and compliance with internal control system. The Controller and the SAO may require any payment to be submitted for examination and approval before the payment is made. In Samoa, the Controller and Auditor General has elected to review 100 percent of the payments. Given the acceptable level of internal controls in Samoa, this fiduciary assessment does not recommend 100 percent transaction review but shifting the audit approach to be more risked based and result oriented. Although the risk of misuse of funds is low as the SAO is involved significantly in the ongoing transaction processing, every payment from the government budget has a preaudit check undertaken by Page 78 of 103 The World Bank Samoa Health System Strengthening Program (P164382) the SAO. Oversight on the performance, effectiveness, and efficiency of government agencies spending is not yet highlighted in Samoa. This performance management is essential for result-based financing programs such as PforR. 3.3.2 Internal Audit 27. Internal Audit units in Samoa operate in all 9 large ministries and 17 public entities. The NHS activities, before the merger in 2019, were subject to the internal audit of the MOH. Annual work plans for 2017/18 and 2018/19 of the MOH are properly documented, based on the risks identified, but there is lack of evidence of approval by the audit division. The internal audit activities are mostly focused on financial compliance. While spot checks and investigative work performed may be based on risk, the risk appears related to financial activities and areas of noncompliance. Recommendations are mostly for corrective activity and not on actions to improve business processes (other than to identify what procedures should be complied with). Internal audit of the MOH is ahead of other ministries in terms of evaluating the adequacy and/or effectiveness of internal controls with recommendations on improving processes. 28. Documentation and the PEFA assessment 2018 show that internal audit of the MOH is rated higher than other ministries in terms of evaluating the adequacy and/or effectiveness of internal controls with recommendations on improving processes. However, follow-up on actual implementation is not tracked through the process. No validation of the response was noted in any report. The lack of written evidence for implementation of audit recommendations reduces the enforcement effectiveness of the internal audit function and the efficiency of the later audit when the auditors must review the entire process again instead of following up with the documented evidence. 29. Capacity building for the internal audit function will be done through the Program implementation support to improve audit documentation and follow up of audit recommendations. As the SAO already checks all payments, it is not necessary to include an action plan on internal audit in the PAP. 3.3.3 Governance and Anti-corruption 30. Fraud and corruption. The GoS is required to take all appropriate measures to ensure that the Program is carried out in accordance with the ‘World Bank Guidelines on Preventing and Combating Fraud and Corruption in Program-for-Results Financing July 10, 2015’ (ACG). In this regard, it is noted that the GoS has established anti-fraud and anti-corruption systems and processes, which are also reported on. Discussions took place with the GoS concerning the World Bank’s ACG and that the World Bank may make ‘administrative inquiries’ to determine compliance with the World Bank’s ACG policies, directives, and procedures. Inquiries include the review of relevant accounts, records, and other documents, as well as interviews with relevant persons. The GoS has indicated that it is prepared to agree to report, regularly (yearly, at a minimum) to the World Bank, any credible and material allegations relating to the PforR- supported Program. The GoS has also indicated that it agrees to apply the World Bank’s debarment and suspension lists to the PforR-supported Program to ensure that any person or entity debarred or suspended by the World Bank is not awarded a contract under or, otherwise, allowed to participate in the Program during the period of such debarment or suspension. Page 79 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 31. Debarred and suspended firms. During the procurement and contracting processes, the GoS will need to check the World Bank’s debarment and suspension list before awarding a contract to ensure that a contract is not awarded to an individual or entity debarred or suspended (see enclosed link http://www.worldbank.org/en/projects-operations/procurement/debarred-firms). This requirement will need to be procedurally specified in the POM to ensure adherence to the requirement. 3.4 Auditing 32. The Audit Act is the major statute providing for the role of the SAO within the public sector. It outlines the functions, powers, immunities, and independence of the Controller and Auditor General and provides for the independent audit of the public sector and related entities. The SAO carried out the audit of the public accounts and financial statements for nine extra budgetary units (EBUs), including the NHS and National Kidney Foundation, for the past three years (2014/15, 2015/16, and 2016/17). Some of these audits were outsourced to the private sector as permitted by the Audit Act but remained under the direction of the Controller and Auditor General. 33. The audit opinions for public accounts and the financial statements for all EBUs were unqualified. However, there were some significant issues which required subsequent consideration and appropriate action by the agencies being audited. The health sector, however, had no significant issue reported except for the need to improve fixed asset register management. The reported auditing standard used to conduct the external audits was the International Standards on Auditing. While the audit coverage on Government Public Accounts is high (that is, more than 80 percent), the coverage on EBUs is very limited: 1 percent for National Kidney Foundation and 11 percent for the NHS. Low coverage of audit in the NHS (11 percent) may lead to the risk that the Program expenditures are not adequately audited by the SAO. 34. Almost all the central government agencies submitted their financial statements to the external auditors within six months of the end of the financial year for the past three years; and the external auditors had completed auditing within six months after the receipt of the financial statements. Copies of these financial statements were made available on hand. The SAO took only two months to audit the National Kidney Foundation, and six months to audit the NHS for 2016/17. The MOH’s expenditures are consolidated in the Government Public Accounts, which took the SAO four months to audit. SAO’s management letters on the outcome of the auditing of the government public accounts for 2014/15 to 2016/17 were received together with the written responses from the MOF. There were no other audit management letters and responses to them from the other agencies of the central government obtained. 35. The appointment and removal of the Controller and Auditor General is contingent on the advice of the Prime Minister to Parliament. The resources required for conducting its annual operations are still subject to the budget consideration of the MOF. Advice from the Prime Minister on the appointment and removal of the Controller and Auditor General and the budget consideration of the MOF to the SAO for conducting its annual operations reduce the independence of the SAO from the Government executive function. 36. For the proposed PforR, there should be the SAO’s audit opinion on the full scope of the Program- specific financial statements. As the Program disbursements will be based on achieved and verified results, SAO’s role should be extended from financial compliance checking to supporting the Program Page 80 of 103 The World Bank Samoa Health System Strengthening Program (P164382) results achievement. The PAP proposes two performance audits to be performed by the SAO: one at the Program midterm review and another at six months before Program closing date. 3.5 Procurement and Financial Management Capacity 37. The lead role in PFM is assigned to the MOF. The Government sectoral policy and regulations is the responsibility of sixteen line-ministries led by CEOs, who are accountable to the Cabinet through portfolio ministers. Policies are implemented, and public services are delivered by ministries and agencies. Line ministries have functional responsibilities with some being responsible for the maintenance of internal controls within their ministries. Line ministries originate the ministry budget proposals, execute the approved budget, incur expenditure, procure goods and services, and report on their performance to the MOF. The existence and powers of the Controller and Auditor General are stipulated in the Audit Act 2013. 38. The financial management function in the MOH is under the Corporate Services Division, which is headed by an Assistant CEO of the ministry. The function is performed by five tiers of personnel (a) principal accountant officer, (b) senior accountant and senior asset management officer, (c) accounting officer, (d) senior accounts receivable/payable, and (e) office assistants - accounts. All people in the highest four levels possess a Bachelor of Commerce degree with more than five years of working experience. The principal accountant officer and senior accountant also possess an accounting diploma. Financial management capacity of the MOF, as well as the MOH and its departments and PHC units is adequate for Program implementation. 39. Within the MOH, the Procurement Unit is designated for procurement. The MOH has identified eight staff for this unit. One of these staff has a diploma in procurement from Italy and others have a Bachelor of Commerce degree or secondary school certificates. Most of the staff have been in service for more than 10 years. In addition, a consolidated capacity assessment was carried out by the DFAT-financed Procurement Specialist, which provided relevant details about staff from the following areas: MOH, procurement, pharmacy warehouse, and biomedical. It included an assessment of their current experience (years of service), academic qualifications, and procurement training to date. The main capacity gap is the lack of technical expertise and experience in procurement. This capacity gap has been addressed in the MOH procurement capacity-building plan (which has been financed in part by the World Bank under the PPA and will continue to be financed under the PforR-supported Program) and the remaining training and capacity-building activities are being financed by DFAT. SECTION 4: PROGRAM SYSTEMS AND CAPACITY IMPROVEMENTS 40. In assessing the performance of the fiduciary systems under which the Program operates, the World Bank identified various weaknesses and gaps which will be addressed during implementation of the Program through the legal covenants, the PAP, the POM, and the World Bank’s technical assistance and implementation support. This is expected to enhance the Program fiduciary systems to ensure that they provide reasonable assurance that the Program expenditures will be used appropriately to achieve their intended purposes (Table 4.1). Page 81 of 103 The World Bank Samoa Health System Strengthening Program (P164382) SECTION 5: PROGRAM IMPLEMENTATION SUPPORT 41. The Implementation Support Plan has been prepared in line with the PforR operational guidelines. 42. The borrower is responsible for the implementation of all Program activities in support of the achievement of the agreed DLIs and the PAP. The World Bank team will conduct regular implementation support missions based on the Implementation Support Plan, whose focus will be on timely implementation of the agreed PAP, provision of necessary technical support, conducting fiduciary reviews, and verification of results, where appropriate. Focus of the fiduciary team will be placed on reviewing and ensuring the Program-based budgeting and financial reporting process and reviewing SAO’s financial audit report, performance audit report, management letter, and the evidences of enforcement of these audit recommendations. Page 82 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Table 4.1. Integrated Fiduciary Risk Mitigations and Fiduciary Action Plan Risks Mitigation Actions Fiduciary Timing Type of Action Area Funds for the Program may not be A new budget line item for the Program identification Financial Throughout PAP, POM, adequately allocated or supplemented on will be created under ‘Transactions on Behalf of the management Program technical time for Program activities due to lack of State’ category of the MOH’s budget, so that the implementation assistance Program identification in the budgeting country's financial information system can generate process, which may affect the program annual Program budget and expenditure reports. implementation. Personnel expenditures and indirect costs will be allocated to the Program on the basis described in the Without the Program identification in the POM. current COA, there is no accurate boundary to report on budget execution at the Program level for audit and performance assessment purposes. Low coverage of SAO’s audit in THE in Audit opinion on the full scope of the Program Financial Financial Annually PAP previous financial years (11%) may lead to Statements, which will be generated after the budget management the risk that Program expenditures are not line item for Program identification has been created in adequately audited by the SAO. the Financial Management Information System. Oversight on the performance, Two performance audits to be performed by the SAO Financial Midterm and 6 PAP effectiveness, and efficiency of government for the Program: one at the Program midterm review management months before agencies spending is not formally stipulated and another at 6 months before the Program closing closing in Samoa, while this performance date management is essential for result-based financing programs such as the PforR. Lack of written evidences for Capacity building for internal audit function to improve Financial Throughout DLI 6 - Program implementation of internal audit audit documentation and follow-up of audit management Program capacity- recommendations reduces the enforcement recommendations. implementation building plan effectiveness of the internal audit function Lack of clarity about organizational The MOH will complete, issue, and adopt its updated Procurement No later than PAP structure for procurement functions in the organizational structure, which includes at least one three months Implementation health sector following the merger of the functional unit, to be responsible for procurement, with after the support NHS and the MOH a mandate, composition, and resources. effective date Page 83 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Risks Mitigation Actions Fiduciary Timing Type of Action Area Lack of procurement capacity within the A detailed capacity-building program should be Procurement Throughout DLI 6 - Program MOH included and implemented under the Program that Program capacity- would build on the capacity building supported under implementation building plan the PPA, DFAT, and DLI 6 Number of MOH staff completing formal procurement PAP training (online, face to face). CTSSU Procurement Specialists (when hired) can provide training to the MOH staff Lack of technical procurement expertise for The newly established CTSSU financed by the World Procurement Throughout PAP, procurement implementation Bank under SCRTP (P165782) can be a source of Program implementation fiduciary support to the MOH. implementation support In addition, there is a DFAT-financed Procurement Specialist working in the MOH who is providing technical assistance. Poor quality of procurement and contract Procurement documents should undergo quality Procurement Throughout Implementation documentation leads to suboptimal assurance to avoid contract variations as part of the Program support outcomes (in conjunction with a lack of internal procedures. Assistance from the CTSSU or implementation delegation of authority to manage contracts DFAT-financed procurement consultant may be given to line ministries and project needed. managers) Tracking the number of contracts for which variations are processed and the time associated with such approvals To ensure that NCD medicines are readily A Pharmaceutical Logistics Management Information Procurement June 30, 2020 PAP available in Samoa to support the System which includes NCD medicines is procured and achievement of Program results operationalized. Delayed implementation of procurement The implementation of activity open tenders should be Procurement Throughout Implementation activities for which Program results are closely monitored, and efficiency should be improved. Program support linked Establishing a time line for procurements subject to implementation Request for Quotations and adherence to or improving that timeline. Establishing a time line for procurements subject to Request for Bids and adherence to or improving that time line. Page 84 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 5. SUMMARY ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT COUNTRY : Samoa Samoa Health System Strengthening Program 1. This annex summarizes the findings of the ESSA dated September 17, 2019. The ESSA involved consideration of potential environmental and social risks from Program activities; assessment of the Samoan system for environment, social, and health and safety (ESHS) risk management; a review of the effectiveness of the country system in addressing the ESHS risks associated with the Program; and an evaluation of the institutional capacity of the implementation agency, MOH. Environmental and Social Risks 2. The Program activities are not expected to significantly increase environmental hazards. The activities under the Program with potential environmental risks—minor increase in HCW volumes and building construction activities—are not unprecedented and are currently managed under existing Samoan Government systems. Results Area 2 seeks to increase screening for NCDs among the Samoan population through the PEN Fa’a Samoa program. Screening involves generation of hazardous waste (for example, syringes from blood testing) and this—and subsequent medical treatment for those diagnosed —will result in a marginal increase in the volume of HCW generated by the Samoan public health sector in the short term. HCW will also be generated at the two new district hospitals; however, this can be managed under the existing systems which will not be overburdened. By itself, the additional HCW does not significantly increase the environmental risk as the waste types are similar to those already being managed under the HCWM system. NCD treatment in Samoa does not involve the use of cytotoxic medicines and no radiotherapy is available in the country. 3. There is minor risk to the environment associated with the current HCWM regime on Savaii. HCW is collected from the MTII hospital and health centers and transported to Vaiaata landfill for disposal. A recent assessment concluded that Vaiaata landfill is not suitable for HCW disposal due to the lack of cover material available following disposal of waste and the potential for groundwater pollution. There is also a minor risk of water pollution associated with cleaning of HCW bins at MTII hospital. HCW treatment at Vaiaata landfill is inadequate as the incinerator is dysfunctional and waste is burned in situ at the landfill. This is considered to be more of a health and safety issue, as described below. 4. HCW includes all the waste generated within health care facilities, research centers, and laboratories for medical procedures. It also includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices, and radioactive materials. Portions of this waste carry greater potential for causing infection and injury than other types of domestic waste due to its contamination state and this necessitates proper handling and management. 5. Handling, storage, and treatment of hazardous HCW is often substandard in the Samoan context posing a risk to clinical and non-clinical MOH employees from, for example, needle-stick injuries and contracting diseases such as hepatitis and tetanus. The HCWM chain of custody requires improvement to ensure that safety of all employees is adequately protected. Waste handling infrastructure, personal protective equipment, and lack of prophylaxis for transmissible diseases poses an elevated risk to MOH employees, particularly waste management staff. Page 85 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 6. The adopted HCW treatment method in Samoa is incineration. Two incinerator facilities have been established: at Tafaigata landfill on Upolu and Vaiaata landfill on Savaii. The Upolu facility is functioning and satisfactorily maintained; however, HCW is often combusted at less than the required temperature resulting in potentially hazardous air emissions. The HCW incinerators at the Vaiaata landfill on Savaii island are dysfunctional and HCW is being burned in situ at the landfill. This practice results in the generation of hazardous air emissions including persistent organic pollutants that pose a risk to human health. Given the remote location of the incinerators on Upolu and Savaii those at most risk from these emissions are the HCWM and landfill staff with the risk to the broader community being considered very low with no residential or community receivers near the landfill. Notwithstanding, the accumulation of persistent organic pollutants in the environment (even in small quantities) should be avoided. 7. Construction of rural district hospitals and housing for doctors is included within the Program boundary. Sites have been identified for planned activities and lease arrangements are in place already, but it is possible that land needs may evolve over the life of the project, which has the potential to affect land. Sites have been identified for planned activities and land requirements are limited, but this may evolve over the life of the project. Typical risks associated with land acquisition include a lack of consultation, inadequate compensation amounts and arrangements, limited recognition of informal rights, and lack of a grievance system. In practice, the risks are considered limited due to existing social practices and legislative requirements and practice. In summary, impacts to land are possible but considered unlikely. 8. Without adequate planning, there is a potential risk that vulnerable groups will be less able to participate in Program benefits than others, limiting the effectiveness of the Program. However, the likelihood of this risk materializing is low given the program design and scope. The four Program components are designed to benefit all residents of Samoa through improving access to health care for the diagnosis and treatment of NCDs. For example, the Program will introduce improved NCD screening in all health care facilities, and BMI will be checked for all school children. These activities will benefit a range of age groups across the community including youth, adults, and the elderly, as well as other potentially vulnerable groups such as women or those with disabilities. 9. The environmental and social risks associated with the Program are summarized in Table 5.1. Table 5.1. Environmental and Social Risks Project Activity Environmental and Social Issues Results Area 1: Address behavioral risk factors through population-based health promotion Enhancing the effectiveness of No anticipated negative environmental or social impacts. macro-policy interventions through impact assessment of NCD taxation policies, including implementation monitoring mechanism. Promoting healthy lifestyles through No anticipated negative environmental or social impacts from community engagement and school- promoting health lifestyles. based interventions. This includes Positive impacts are likely to include improved health outcomes and building capacity of VWCs, BMI monitoring due to increased awareness and access to treatment and monitoring as part of the School prevention. Capacity-building activities are also likely to be positive. Nurse Program, school nutrition Page 86 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Project Activity Environmental and Social Issues standards compliance enforcement, and healthy lifestyle mass campaigns. Results Area 2: Increase screening, referral and diagnosis of NCD high-risk group and NCD patients Accelerated expansion of PEN Fa’a Potential environmental impacts related to (small) increase in medical Samoa screening to rural districts, waste within villages. There will be a need for clear communication and which involves screening for NCD risk stakeholder engagement to encourage participation. factors including BMI, blood pressure, The pilot program indicates that implementation of the PEN Fa ’a and blood glucose. Samoa in chosen villages will lead to positive health impacts. All individuals over age 20 years will be encouraged to participate, with specific training provided to local implementers (VWCs) to support those who are considered vulnerable to participate. Integration of routine NCD screening Potential (small) increase in medical waste within health care facilities for those over age 20 years at health due to higher patient numbers and nature of diagnostic testing for facilities. NCDs. Health outcomes are likely to be positive for those who participate, including those who are considered vulnerable. Results Area 3: Strengthen primary care and quality of NCD management Establish multidisciplinary team at No anticipated negative environmental or social impacts. each district hospital. Positive impacts are likely to include improved health outcomes due to improved access to medical treatment. Need-based infrastructure and Typical environmental and social impacts associated with construction equipment investments including include noise, dust, increased traffic, construction waste, restricted accommodation quarters and access, occupational health and safety, and presence of construction construction of rural district hospital workers. Impacts can be managed through good site management and on MOH/GoS leased land. good practice construction processes. Careful consideration of the construction risks to patients will be required if works take place on existing health care facilities, particularly in relation to patient safety and continuity of health care services. New facilities may result in the need for land acquisition. Preference will be given to voluntary land donations secured through engagement with land owners and local community. Involuntary land acquisition is considered unlikely. Development of NCD management No anticipated negative environmental or social impacts. pathways for all levels of the health Positive impacts are likely to include improved health outcomes due to system including clinical guidelines increased awareness and access to treatment and prevention. and training. Ensuring reliable, uninterrupted, and No anticipated negative environmental or social impacts. affordable essential drug supply. Improved drug supply planning should decrease disposal of out of date medicines, potentially reducing environmental impacts. Results Area 4: Strengthen multisectoral NCD program stewardship and build institutional capacity Strengthen Program stewardship and No anticipated negative environmental or social impacts. build implementation capacity Positive impacts are likely to include improved capacity to manage NCD through formulation and execution of in the community and improved awareness of NCD management. an annual capacity-building plan for the national NCD control program. Build Program M&E capacity No anticipated negative environmental or social impacts. including building a routine data reporting and collection system for Page 87 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Project Activity Environmental and Social Issues the implementation of the NCD control program. Establishment of a patient tracking No anticipated negative environmental or social impacts. system (for example, mobile app) to Positive impacts are likely to include improved health outcomes due to monitor screening to treatment increased monitoring of NCD illnesses and tracking of follow-up care. pathways. Health workforce development and No anticipated negative environmental or social impacts. training including health workforce Positive impacts are likely to include improved waste handling planning mechanism. procedures and occupational health and safety management. 10. Based on the ESSA findings and draft mitigation and improvement measures the combined environmental and social risk is Moderate. The environmental risks associated with the Program are considered moderate and relate to the HCWM regime and the potential hazards to worker and community health and safety. This is largely an administrative issue that can be remedied through capacity development, development of implementation plans, and management intervention. The social risks associated with the Program are low. Overall, the Program is likely to result in substantial social benefits through improved access and treatment of NCDs. Despite inclusion of some actions to address vulnerable groups and land access, should particular activities be realized, the impacts of activities are limited and manageable with the implementation of standard mitigation measures. 11. OP/BP 7.50 Projects on International Waterways and OP/BP 7.60 Projects in Disputed Territories are not applicable to the Program. Legal and Institutional Framework 12. An assessment of the Samoa Government legal and institutional framework—as it relates to the Program risks—was undertaken in accordance with relevant core principles and planning elements under OP/BP 9.00 Program-for-Results Financing. Core Principles 1 (Assessment and Management), 3 (Public and Worker Safety), 4 (Land Acquisition and Access to Natural Resources), and 5 (Indigenous People and Vulnerable Groups) are relevant to the Program. Core Principles 2 (Natural Habitats and Physical Cultural Resources) and 6 (Social Conflict) are not relevant to the Program. 13. The legal and institutional framework in Samoa for assessment and management of environmental and social risks is adequate to manage Program activities. The existing legislation requires the assessment of environmental and social impacts and associated implementation of agreed mitigation measures; this is consistent with the mitigation hierarchy where impacts are avoided where possible. Engagement with stakeholders is required before the development of physical works. The existing legislative processes are generally in line with the World Bank’s requirements in relation to timing and approach which enables people to comment on, and contribute to, decision making. In practice, the Program will involve a range of methods of sharing information with specific groups, for example, youth in school program and women through involvement of VWC. 14. The legal and institutional framework in Samoa for public and worker safety is adequate to manage Program risks. There are, however, some existing challenges in implementation of the framework and these will be addressed through the PAP. Page 88 of 103 The World Bank Samoa Health System Strengthening Program (P164382) 15. The legal and institutional framework in Samoa for land acquisition and voluntary land donation is generally adequate for the purpose of this Program. Cultural norms are such that voluntary land donation is common for public services such as health facilities, and existing land use agreements are in place for all proposed construction sites. Land acquisition is not anticipated though it is possible the Program will evolve and therefore additional land or access may become necessary. A number of small gaps have been identified between the World Bank requirements and Samoa legislation, and Program actions are required to demonstrate these risks are adequately managed. These include the need for (a) brief assessment of impacts for sites proposed to be leased and exclusion of sites where a primary residence is affected, or land acquisition would result in significant impacts; (b) provision for enhanced consultation with landowners; and (c) establishment of a grievance process. 16. An assessment of the application of the World Bank’s policies on Indigenous Peoples in Pacific Islands determined that these policies are not typically triggered in the culturally homogeneous island nation of Samoa. Hence indigenous peoples are not relevant to the Program. While there is no universal definition of vulnerability in Samoa, the MOH has extensive experience planning and implementing programs that incorporate the needs of all groups within the community. Health care facilities are generally designed to accommodate the needs of all users, and the health care service provides support across the spectrum of health issues, socioeconomic status, age, and gender. The Program is designed to encourage all Samoans to participate and training will be provided to implementation groups (particularly the VWCs) to encourage involvement of those considered vulnerable. The legal and institutional framework in Samoa for vulnerable groups is adequate to manage Program risks. Capacity and Track Record 17. The MOH will need to work closely with a number of departments in the implementation of the Program; some existing relationships and institutional arrangements are already in place. For example, the implementation of the Program requires close working relationships between the MOH and Ministry of Natural Resources and Environment in relation to environmental and social assessments, HCW, development permits, and land lease registration. The two agencies have an existing working relationship based on the MOH portfolio; for the purposes of the Program, the focus on the NCD issues is unlikely to cause significant changes in current working arrangements. Similarly, the MOH already works closely with the Ministry of Women, Community and Social Development in relation to coordination of activities with the VWCs under the pilot PEN Fa’a Samoa program. Consultation with stakeholders did not reveal any existing issues that would impede the expansion of the Program. 18. The MOH’s relationship with the Ministry of Education is in the early phase of development and does not yet benefit from strong institutional ties though initial consultation indicates that issues are not anticipated. In addition, the environmental and social issues associated with activities to be undertaken in schools is assessed to be very limited. 19. The MOH has previously worked with the World Bank on the SWAp project (P086313), which was completed in 2016. At completion, the overall safeguard rating for the project was deemed to be Moderately Unsatisfactory due to poor waste management planning; poor waste segregation/separation, handling, and implementation; and late assessment of environmental impacts (and no assessment of social risks). The proposed PAP will address these risks and aim to strengthen the country system on HCWM. Page 89 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Consultative Process 20. The ESSA team visited a number of health care facilities in Samoa including rural district hospitals and village health posts. Observation and discussions during these visits provided a greater understanding of the potential environment and social impacts associated with these types of activities and capacity and procedure of government departments in dealing such impacts, including relevant measures currently adopted in accordance with relevant laws and regulations. Multiple meetings were held with the MOH staff in Apia and at health care facilities around the country. Meetings were also held with supporting implementing agencies including the Ministry of Natural Resources and Environment; Ministry of Women, Community, and Social Development; and the MESC. Improvements under the PAP 21. A number of actions to address environmental and social issues have been included in the PAP. These are described in Annex 6 and can be summarized as follows:  Improvement in management of HCW through development and implementation of a HCWM Policy, installation of HCW infrastructure, and development of human resources through training and field support.  Implementation of grievance procedures including an annual report,  Improved capacity in VWC under PEN Fa’a Samoa program, to increase participation of vulnerable groups.  Additional procedures in the (unlikely) event that additional land is required for the construction of medical facilities including screening for impacts, exclusion of activities affecting houses or causing significant impacts, consultation with the land owner, and evidence of agreement including payment of compensation (as necessary). Page 90 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 6. PROGRAM ACTION PLAN . Responsible Action Description Frequency Due Date Completion Measurement Party Technical 1. Develop a systematic MOH Recurrent The framework The draft M&E framework M&E framework for (yearly) to be adopted to be submitted to the NCD control program no later than Association for review no and implement three months later than one month after throughout the Program after the the effective date implementation effective date Year 2–5: include annual and M&E workplan in the implemented Program annual workplan accordingly and annual capacity- thereafter building plan. Provide a summary in the semiannual progress report of the progress made on strengthening the M&E system according to the annual workplan 2. Complete, issue, and MOH — Updated Submit to the Association adopt the updated organizational the updated organizational organizational structure structure of the structure of the MOH for of the MOH, which MOH to be information includes at least one adopted no functional unit, to be later than three responsible for months after procurement, with the effective mandate, composition, date and resources Fiduciary 3. Create a new budget MOH and Recurrent — The system and the COA are line item for Program MOF (yearly) updated by May 31, 2020, identification under the and are being used to ‘Transactions on Behalf generate the Program- of the State’ category of specific annual budget and the MOH’s budget, so expenditure reports that the country's thereafter financial information system can generate annual Program budget and expenditure reports. Personnel expenditures and indirect costs will be allocated to the Program in accordance Page 91 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Responsible Action Description Frequency Due Date Completion Measurement Party with the POM 4. Ensure two MOF and Two audits Midterm and 6 Audit report to be performance audits for MOH during the months before submitted to the the Program are implementation closing date Association three months provided: one at the after the audit is completed Program midterm review and another by no later than six months before Program closing date 5. Ensure an audit MOF and Recurrent Yearly As demonstrated in the opinion on the full MOH (maximum nine audited financial statement scope of the Program months after of the Program financial statements is the end of the provided financial year) 6. Include and MOH Recurrent Yearly Provide a summary in the implement detailed semiannual progress report procurement capacity on procurement training building program under provided or received, DLI 6 including number of MOH staff completing formal procurement training (online, face to face) and assistance received from the newly established CTSSU financed by the Association under SCRTP (including capacity building) 7. Ensure transparency MOH and Recurrent Yearly Publication of Program of procurement-related MOF Annual Procurement Plan actions by (a) publishing on both the MOF and MOH Program Annual websites. Procurement Plan on Contracts awarded under both the MOF and MOH the Program published on websites and the MOF website including (b) publishing on the the availability of historical MOF website the contract award information contracts awarded (previous financial years) under the Program 8. Implement and MOH and June 30, 2020 The World Bank will ensure the operation of MOF conduct site investigation, the Pharmaceutical upon confirmation from the Logistics Management MOH, of the system Information System, operationalization which will be used to procure the NCD drugs. Page 92 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Responsible Action Description Frequency Due Date Completion Measurement Party ESSA 9. Procure and MOH By December Waste commission waste 31, 2020 management/treatment management/treatment infrastructure infrastructure as commissioned and recommended by the operational, as evidenced HCWM review by satisfactory HCWM audit findings 10. Develop/update and MOH Recurrent The National By March 31, 2020: implement the Policy and Implementation Plan for Implementation Plan of Implementation HCWM Strategy for both HCWM Policy and Plan to be Upolu and Savaii are HCWM Strategy formulated by submitted to the end of 2019 Association for review and and clearance. implemented Year 2–5: Measures to accordingly address any issues thereafter identified in the external audit report are formulated and implemented as proven by the audit report in the following year. The TOR of the external auditing to be submitted to the Association for review no later than May 31, 2020. 11. HCWM Staff receive MOH Recurrent Yearly Report in the semiannual training on HCWM, progress report the OSH, and environmental HCWM/environment health health as part of the training received including HPAC-approved annual number of MOH staff capacity-building plan completing training (online, (DLI 6) face to face, and so on). 12. Manage social MOH Recurrent Yearly when Submission to the impacts by applicable Association in the semi- (a) implementing the annual progress report grievance process and (a) evidence of (b) considering implementation of vulnerable groups grievance process, including report on the number of grievances received and timeliness of resolutions; (b) evidence that all capacity building and training for the PEN Fa’a Samoa program include consideration of vulnerable Page 93 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Responsible Action Description Frequency Due Date Completion Measurement Party groups. 13. Land access. For any MOH/MNRE Recurrent Report where Land access information (if proposed site where there is land any) to be reported in the land leases are required acquisition semiannual program which has not progress report, including previously been in the lease agreement letters control of MOH signed by land owners, (a) undertake screening compensation agreement for impacts including and payment, and records brief assessment of of impact screening. The physical and livelihood Association will review the impacts. If significant records and may conduct impacts are identified, on-site review during the or primary residence implementation support must be relocated, the missions. site shall be excluded from the PforR; (b) require and document consultation with the land owners; (c) collect evidence of compensation arrangements including assessment of value, payment of compensation, and consultation with affected land/asset owners. Page 94 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 7. IMPLEMENTATION SUPPORT PLAN COUNTRY : Samoa Samoa Health System Strengthening Program 1. A strong momentum, fueled by high political commitment, currently exists in Samoa for effectively tackling the rising NCD epidemic. Fulfilling this objective requires an effective institutional framework to ensure evidence-based policy making, coordination and enforcement of policies, multisectoral stakeholder buy-in and support, building of adequate technical capacity, a robust M&E system, and effective change management, including tailored communications to raise awareness of the targeted beneficiaries about the NCD risk factors and ensuring their adequate engagement. 2. The World Bank’s assessments have identified capacity gaps in a few areas including procurement, financial management, M&E, and HCWM. Specifically, in technical areas, the identified capacity gaps relate to ensuring that effective NCD initiatives, such as School Nurse Programs, are appropriately evaluated and successfully scaled up; enhancing the screening, referral, and diagnosis practices; developing evidence-based disease management pathways; creating effective drug management and supply planning; building a routine data collection and an interim patient management system for the implementation of the NCD control program; strengthening human resources for health; establishing and institutionalizing mechanisms to monitor the overall implementation of NCD interventions and developing the appropriate tools to generate the needed evidence; building the capacity of national staff and local entities through the annual capacity-building plan for the national NCD control program to ensure adequate manpower to implement all those initiatives and make them sustainable. The World Bank will work closely with the Government and provide technical assistance to the extent possible. 3. Given the comprehensiveness of the proposed service delivery reform under the National NCD Control Policy and the novelty of the PforR in Samoa, it is envisaged that substantial domestic, regional, and international technical assistance will be required to ensure its successful design and implementation on the two major islands. Thus, technical and reform implementation engagement by the World Bank throughout the Program implementation would be important. The World Bank team will also work closely with the multisectoral members of the HPAC and the National NCD Committee to support them with technical and policy advice, as needed, along the critical reform themes, such as the integrated NCD disease management with patient tracking system, essential drug supply, health workforce development, and M&E. The World Bank experts will provide technical assistance, implementation support, and supervision in respective focus areas. The World Bank team will support the Government in developing the implementation road map and will review the POM at the outset of the operation and annual workplans thereafter. 4. From a technical perspective, the World Bank will be focusing on compliance with DLI disbursement requirements and providing continuous technical assistance. For each DLI, the Government will be requested to produce annual action plans, explaining the steps already taken and those planned for the coming year to ensure that targets are met. The plan is required to be formulated in November of the previous year for the following year, and the World Bank team will review and suggest adjustments as necessary before the plan is submitted to the HPAC for endorsement. In particular, the World Bank team will bring in international and domestic expertise to cover the following specific areas: Page 95 of 103 The World Bank Samoa Health System Strengthening Program (P164382) (a) Engagement with the GoS on the technical design and implementation of the NCD taxation policy assessment, health promotion program, integrated NCD disease management system, patient tracking system, essential drug supply, health workforce development, and corresponding training programs. (b) Support the strengthening of the government policy development, stewardship, and M&E system and processes to enhance the capacity at the central and district levels as well as in health facilities in monitoring and reporting on performance and related indicators. Emphasis will be placed on the Program results areas and indicators, monitoring compliance with Legal Agreements, ensuring that the reported data are verified properly and that the results of the continuously evolving reform measures are captured effectively. 5. The Implementation Support Plan has been prepared in line with the PforR operational guidelines. The recipient country is in charge of the implementation of all Program activities in support of achievement of the agreed DLIs as well as the PAP. The World Bank team will conduct regular implementation support missions based on the Implementation Support Plan, whose focus would be on timely implementation of the agreed PAP, provision of necessary technical support, conducting of fiduciary reviews, and verification of results, where appropriate. Key members of the World Bank's implementation support team on fiduciary, governance, and social and environment safeguards systems are based in the World Bank’s Sydney and Fiji Hub Office for the Pacific Region, which will help ensure timely, efficient, and effective support to Program implementation and monitoring. The World Bank team will tailor implementation support to address the capacity issues identified in the technical, fiduciary, and safeguards assessments as follows: (a) Provide technical advice to the implementation of PAP and the achievement of DLIs and address other social, environmental, fiduciary, or governance-related bottlenecks relevant to the Program. (b) Review the progress of Program implementation including achievement of DLIs and review Program Progress Reports, audit reports, and other relevant information. (c) Monitor health system performance with emphasis on the Program results areas and monitoring compliance with Legal Agreements, keep record of risks and propose remedial actions to improve Program performance, as and when needed. (d) Provide support to resolving any operational issues pertaining to the Program. Page 96 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Table 7.1. Main Focus of Implementation Support Time Focus Skills Needed Resource Estimate Partner41 Role First 12 Implementation capacity Technical expertise on 50 staff weeks and 2 Partners will months strengthening including integrated NCD disease missions to (a) launch be invited to budget planning, management system, the Program and help join the financial statement, patient tracking system, start the technical missions and auditing, social and essential drug supply, assistance under the provide environment safeguard, health workforce PAP and (b) supervise technical and monitoring and development, M&E, health and provide assistance and verification of the DLIs promotion program design, implementation training as and results. fiduciary, and social and support appropriate. environment safeguards. 12–48 Timely implementation Technical expertise on 40 staff weeks per Partners will months of PAP, monitoring and integrated NCD disease year and regular be invited to verification of the DLIs management system, implementation join the and results, and health promotion program support missions missions. technical support on key evaluation, essential drug every six months health reforms. supply, health workforce development, M&E, fiduciary, and social and environment safeguards. 49–60 Timely implementation Technical expertise on 40 staff weeks per Partners will months of PAP, monitoring and fiduciary, social and year and regular be invited to verification of the environment safeguards, missions every six join the results remaining DLIs and and M&E, in particular on months, desk dissemination results, summarizing evaluation. technical review, activities. lessons learned and training and dissemination of participation/ knowledge generated. presentation in results dissemination conferences with government teams. 6. External development assistance in the form of government bilateral aid, grants, credit, and in- kind support constitutes an important part of total health sector spending in Samoa. DFAT and NZ-MFAT are the two major, long-standing donors providing substantial development support to Samoa. DFAT’s support to the health sector currently include supporting a partnership between Queensland's Department of Health and Samoa’s MOH focused on improving governance and leadership, public health, and health information; procurement capacity building for the MOH; and the development of a Pharmaceutical Logistics Information Management System. The NZ-MFAT support in the health sector continues to focus on providing support to the overseas medical treatment scheme and a scholarship program for allied health workers. Both DFAT and NZ-MFAT have indicated that addressing the NCD crisis 41Partners are the entities who will work with the World Bank team to support the technical assistance and implementation support. Page 97 of 103 The World Bank Samoa Health System Strengthening Program (P164382) and developing PHC are the priorities for their bilateral aid to Samoa and are currently in discussion with the GoS to agree on the key priorities of its bilateral aid program in the health sector. 7. In recent years, China has become another significant partner through funding construction of the national hospital and MOH headquarters, providing medical equipment and devices, and dispatching physicians to work in Samoa. The ADB is providing US$6 million to support the e-Health project. The WHO provides technical assistance to the GoS in supporting various programs, including PEN Fa’a Samoa. In addition, the United States Agency for International Development and various United Nations agencies (United Nations Population Fund and United Nations Children's Fund) also support the GoS in implementing various programs. The World Bank team is engaged closely with development partners, in particular, DFAT and NZ-MFAT, to explore possible synergies with the proposed operation, including cofinancing of the program as well as financing of the international technical assistance and capacity building when implementation begins. Table 7.2. Role of Partners in Program Implementation Name Institution/Country Role DFAT Australia Through its bilateral aid program, DFAT support will also target health programs such as PEN Fa’a Samoa and strengthen PHC through its support to the partnership arrangements for the MOH and the Queensland Health Authority. There is high potential to find synergy in supporting the Government’s program. DFAT is keen to support capacity building for program implementation and provide Trust Fund resources to support the World Bank team’s technical assistance and implementation support. NZ-MFAT New Zealand Through its bilateral aid program, NZ-MFAT is also focused on strengthening primary health services including providing support for infrastructure investments and technical assistance for capacity building. WHO Specialized United Provide financial and technical assistance to the Nations agency Government particularly for the PEN Fa’a Samoa program and partner with the World Bank to provide implementation support. ADB Regional development Provide financial support for the e-Health project institution Page 98 of 103 The World Bank Samoa Health System Strengthening Program (P164382) ANNEX 8. CLIMATE AND DISASTER RISK CONSIDERATIONS COUNTRY : Samoa Samoa Health System Strengthening Program 1. The geographic location and physical environment of Samoa makes the country prone to a number of natural and human-induced hazards. The major climate risks and natural hazards that are likely to affect the country’s sustainability are tsunamis, tropical cyclones/strong winds, prolonged periods of droughts, heavy rainfalls/flooding, and sea level rise. The combined effects from disasters in Samoa have in the past led to significant damages and serious disruptions to the functioning of society, including loss of human lives and disruption to the socioeconomic development of the country. Samoa borders the Pacific ‘Ring of Fire’ and has an increased risk from tsunami impacts. Samoa is susceptible to high tectonic activity and has experienced 115 tsunamis since 1900, 22 of which led to significant damage. A powerful 8.0 magnitude earthquake struck the main Samoan Island chain in September 2009 with its epicenter 190 km south of Apia, followed by two tsunami waves. An estimated 5,274 (about 1 out of 50) Samoans have been affected, mainly on Upolu Island. The total loss caused by the tsunami is estimated at US$ 124.04 million (22 percent of GDP of Samoa). The number of category 4 and 5 tropical cyclones in the Pacific region has more than doubled between 1975 and 2004. The worst tropical cyclones to hit Samoa were Ofa in 1990 and Val in 1991, which were 50- and 100-year events and caused US$ 440 million of damages and 23 fatalities. During 2005, there were five tropical cyclones, with two of them classified as category 5. In 1966, 1990, 1991, and 2009, each of the tropical cyclones affected 5,585 to 195,000 Samoan people. The destructive Cyclone Evan in 2012 destroyed three of the five hydropower plants. Samoa’s land, livelihoods, culture, and ecosystems are also threatened by sea level rise. Vulnerabilities are compounded by the fact that 70 percent of Samoa’s population and infrastructure are located in low-lying coastal areas, and sea level rise increases seawater intrusion into underground water aquifers in coastal communities. Observed trends include sea level rise of 5.2 mm a year and maximum hourly sea level increasing at a rate of 8.2 mm a year. The frequency and magnitude of emergencies and disasters have increased as the impact of climate change continues to unfold. 2. Samoa is already grappling with the impact on health from the triple burden of communicable diseases, NCDs, and climate change, and, therefore, disaster risk management is of special importance for the health of the residents in Samoa.42 Besides traumatic injuries and deaths that occur during extreme climate and weather events, communicable diseases, which the people of Samoa are vulnerable to and seriously affected by, include many climate-sensitive zoonotic, vector-borne, water-borne, and food- borne diseases such as dengue fever, chikungunya and zika viruses, typhoid fever, diarrhea, leptospirosis, and lymphatic filariasis. Some of these are endemic (but often underdetected) in Samoa and may have actually caused large-scale outbreaks in the past when enabling risk factors (flooding and hot and/or humid conditions) are in place. Existing evidence shows a link between the number of cases of communicable diseases reported and monthly climate reports in Samoa. For example, diarrheal cases are reported to have reached a peak during the early months of the year which coincides with the cyclone season of Samoa, whereas periods of heavy rainfall and flooding compromise the quality of water supplied to the public and can indirectly affect the crops and food supply.43 Climate change also has direct or indirect impacts on NCDs. For example, climate change may increase the risk of cardiovascular disease through three main exposure pathways: directly through air pollution and extreme temperatures and 42 The Health Sector Disaster Risk Management Strategy, 2017. 43 Health vulnerabilities to climate change, draft update of Samoa’s Climate Adaptation Strategy for Health, 2019–2020. Page 99 of 103 The World Bank Samoa Health System Strengthening Program (P164382) indirectly through changes to dietary options. The latter pathway affects NCDs mainly through overnutrition—when local supply of nutritious food, fruits, and vegetables may be affected in climatic events, more reliance will be placed on imported, overly energy-dense foods, which may not necessarily meet healthy dietary guidelines which could lead to the increase of NCDs in Samoa. Also, increasing frequency and intensity of extreme temperatures and weather events and increased competition for scarce natural resources are likely to affect interpersonal and intergroup behavior and may result in increased stress and anxiety. Heat-related morbidity and mortality may become an increasing concern in Samoa, especially with Samoa’s high prevalence of chronic diseases. To address these challenges, Samoa’s health care system needs to be strengthened as part of the country’s strategy to respond to climate change and related health issues. 3. The proposed operation is consistent with the World Bank’s Health, Nutrition and Population Global Practice’s overarching objective of ending preventable deaths and disability through universal health coverage and the World Bank Group Approach and Action Plan for Climate Change and Health, which aims to improve the climate resilience of the health sector. In addition, the Program will support the GoS’ climate policy goal of ‘a climate and disaster resilient Samoa’,44 with respective planning and implementation actions to be integrated into all sector plans and implementing agency corporate plans and with the health sector being among the nine highly vulnerable sectors prioritized in the National Adaptation Programme of Action. The proposed operation will also contribute to Samoa’s National Climate Adaptation Strategy for Health,45 which aims to move toward the health of all people in Samoa being resilient to climate change. 4. The Program has been screened for short- and long-term climate change and disaster risks and the overall risk rating is High. The Program mainly targets NCDs that are not as directly and substantially subject to climate change-induced risks as communicable diseases (for example, zoonotic, water-borne, vector-borne, and food-borne diseases, which may break out in extreme weather events, such as flooding). Along with that, the Program aims at an overall strengthening of Samoa’s health care system, especially preventive capabilities of the PHC, thereby increasing its adaptive capacity to be better prepared for existing and new climate-induced health risks and reducing vulnerability of the populations it serves. While trying to improve the quality and efficiency of the service delivery for tackling the rising NCDs, the Program will also closely and directly engage communities, including the most vulnerable, which will, in turn, increase the overall disaster and climate change resilience of those communities. At the community level and primary and secondary care levels, the population will not only receive critical essential health care services but also climate-relevant health knowledge. Health worker training will include topics on impacts of climate change and disaster events on human health, and the multisectoral NCD Committee will discuss climate-related health issues in its quarterly meetings. The climate and disaster risks have been addressed in the Program design through both mitigation and adaptation measures under the four complementary results areas as described in the following paragraphs. 5. Under Results Area 1, the community- and school-based disease prevention and health promotion activities will raise broad awareness—through VWCs, school nurses, healthy lifestyle ambassadors and champions, and media—on health impacts of climate change. These activities will also build capacity of communities for implementing practices that contribute to improving their health, well- 44 Key Outcome 14: Climate and Disaster Resilience; Strategy for the Development of Samoa 2017–2020. 45 Update of Samoa’s National Climate Adaptation Strategy for Health is currently in draft status. Page 100 of 103 The World Bank Samoa Health System Strengthening Program (P164382) being, and resilience to disasters and extreme climate events as well as reducing carbon emissions/air pollution, such as use of locally and sustainably produced healthy food, climate-friendly and energy- efficient home/cooking appliances, active transport (bicycles and so on), friendly physical and social environment (no plastic), and natural ventilation and lighting in homes, schools, and health facilities. 6. Under Results Area 2, NCD screening protocols and related training for community-based and health facility-based screenings will be updated to build, among other things, awareness and skills of VWC and health facility staff for preventing, recognizing, and addressing or appropriately referring climate- related health issues. 7. Under Results Area 3, climate adaptation and mitigations measures will include the following: (a) Services from well-qualified multidisciplinary teams at rural district hospitals close to local communities with enhanced capacities for proactive health promotion, disease prevention/management, and community outreach in their catchment areas will expand access of climate-sensitive populations to quality health care, thus reducing their vulnerability to and impacts from diseases caused/aggravated by extreme climatic events and disasters as well as health care- related travel for care at tertiary hospitals and related carbon emissions. (b) The evidence-based standardized clinical protocols and disease management pathways to be developed and intensified systematic training to be provided to health care workers will emphasize appropriate prevention and management of climate-related health issues and risk factors. (c) The following climate-resilient measures will be integrated in infrastructure and equipment investments: (i) The envisioned construction, including upgrade of the Sa’anapu community health center into a rural district hospital, construction of a new Falelatai rural district hospital to replace the previous CHC totally destroyed by Cyclone Evan in 2012, and building of accommodation quarters for health workers at rural district hospitals, will be undertaken in accordance with climate resilience/disaster management-compliant Samoa Building Code, adopted largely from that of Australia and New Zealand. In addition, the Falelatai rural district hospital and accommodation quarters will be built inland to ensure the new buildings are resilient to extreme weather events, with accommodation quarters planned to be easily accessible and have larger spaces to accommodate physicians’ families and patients in cases of natural disasters. Energy efficiency considerations will also be incorporated by having on-site renewable energy generation facilities (for example, solar panels) and equipping the facilities with energy- and water-efficient building management systems. (ii) Local materials will be used for construction to the extent possible, which would reduce the energy consumed for their transportation and related carbon emissions. (iii) Natural environment and vegetation will be preserved and enhanced to ensure more shade and improved rainwater management. (iv) Attention will be paid to using natural ventilation and natural lighting in the newly constructed/upgraded facilities to reduce energy demands and resulting greenhouse gas emissions, improve reliability and resilience of health facilities, and improve health outcomes by preventing infections. Page 101 of 103 The World Bank Samoa Health System Strengthening Program (P164382) (d) The measures to ensure reliable, uninterrupted, and affordable essential drug supply will aim for a reduced procurement carbon footprint by better planning and managing procurement of pharmaceuticals and other facility inputs, which would result in reduced energy footprint in production and transportation of unused pharmaceuticals and products, resource savings on unused/wasted products, and reduced risks from use of outdated/expired products. 8. Under Results Area 4, as part of strengthening stewardship and building institutional capacity for implementing the NCD program, attention will also be paid to enhancing strategic planning in the health sector to prepare for, mitigate, adapt, and respond to the impacts of climate change and disasters on the health and well-being of the Samoan population. Such enhanced capacities will contribute to the health system being more effective, agile, and climate resilient, resulting in more people, including climate- vulnerable groups, being effectively served. In particular, the efforts to build capacity for monitoring NCD risk factors and a routine data reporting and collection system for the implementation of the NCD control program will include the use of early warning systems for prediction, preparedness, and prevention of both climatic hazards and related disease burden. The PPA for this operation has also supported technical assistance to recommend improvements to existing HCWM practices and prepare technical specifications for most appropriate HCWM technology for Samoa. Specifically, the recommendations that will be implemented under the Program include waste minimization and waste segregation to ensure that only hazardous waste receives special treatment as required while other wastes can be recycled/reprocessed. Finally, capacity-building activities for the NCD Control Committee under the annual capacity-building plan will include climate and disaster adaptation and resilience as a relevant issue for data-driven health planning (with a dedicated DLI 6 worth US$ 0.68 million to support it). Figure 8.1. Conceptual Model Summarizing the Pathways between Climate Change and NCDs 46 Note: Broken arrows represent hypothetical links. 46Adopted from “Health Impacts of Climate Change in Pacific Island Countries: A Regional Assessment of Vulnerabilities and Adaptation Priorities.” Environment Health Prospect 2016 124 (11): 1707–1714. doi: 10.1289/ehp.1509756. Page 102 of 103 The World Bank Samoa Health System Strengthening Program (P164382) Map 1 Health Facilities in Samoa Map 2 Samoa Page 103 of 103