ANNEX 2: Action Fiche for Tonga

ANNEX 2: Action Fiche for Tonga 1. IDENTIFICATION Title/Number Rehabilitation of the health sector in Niuatoputapu (CRIS 022-583) Total cost 1,495,000: 1,375,000 (B envelope National Indicative Programme) 90,000 World Health Organisation 30,000 - World Bank Aid method / Project approach Method of Partially Decentralised Management implementation DAC-code 12230 Sector Basic Health Infrastructure 2. RATIONALE 2.1. Sector context The Kingdom of Tonga consists of 169 islands, clustered into three main groups - Tongatapu, Ha'apai, and Vava'u - with a total population of 102,898. The total land area is 748 square kilometres with an Exclusive Economic Zone of 700,000 square kilometres. Niuatoputapu is one of two inhabited Islands in Tonga's Niua group, with an estimated floating population of 865 to 1000 people. On Wednesday, 30 September 2009, at 06:50, an earthquake of 8.3 magnitude centred slightly off Samoa, was felt in the island of Niuatoputapu, with turbulence lasting for 20 minutes. Five minutes after the long turbulence, three six-meter tsunami waves struck the islands at three minutes intervals, travelling 600 meters inland, causing major impacts in Niuatoputapu and some damages on the neighbouring island of Tafahi. An initial assessment report confirmed nine dead, four people seriously injured, 60% of housing destroyed and extensive damage to buildings and other infrastructure including the hospital and the Government administration building. The water and sanitation systems on Niuatoputapu were completely devastated by the tsunami, and the reef and lagoon left heavily silted. The priority long-term recovery activities for Niuatoputapu include an early warning system, reconstruction of residential houses and the school, solar electrification, reconstruction of the hospital, the harbour channels, and long-term Government buildings. Relocation to higher ground is a critical task and a priority in the current status of planning for reconstruction as this is the prerequisite for the majority of the recovery activities to take place. The Tsunami Emergency Recovery and Management Project (TERMP) has been put in place to assist the recovery of private and public infrastructure in the affected area. TERMP aims to coordinate all assistance for tsunami recovery from the Government of Tonga, development partners, and the residents of Niuatoputapu. TERMP oversight is carried out by the recently established Project Co-ordination Committee (PCC) and its overall management by a Project Management Unit (PMU). TERMP and the PMU have been established since February 2010. In the framework of an approach coordinated with other donors, the EU assistance focuses on supporting the rehabilitation of the health sector. The Tongan Ministry of Health provides for the health needs of almost 100% of the population in Niuatoputapu. Following the tsunami the hospital 1

of Niutapoutou have been moved to a new temporary location in a primary school, twelve staff are currently employed working on nursing, dental, public health, auxiliary and administrative support sections. Other health services, referring to both clinical and public health care are also coordinated by the hospital. In particular regular visits for clinic and consultation and village inspections to communities in the islands, the one monthly home visit to elderly people and patients that cannot be transferred to the hospital. More generally, health services also includes the care of any case that needs medical evacuation by air, to a tertiary health care facility, at either the main island of Tongatapu, where the Kingdom's capital is located or overseas; in these cases the initial management and stabilisation of the patient is carried out at the hospital of Niutapoutapou. Currently, an average of ten to fifteen patients receive general care as outpatients every day, while dental care is administered to an average five patients. About sixty patients are admitted and twentyeight childbirths are assisted per year. The range of pathologies cared for at the hospital (both prior to the tsunami and at the current temporary location) primarily includes respiratory and skin infections, injuries, asthma and non-communicable diseases, such as diabetes and hypertension. The provision of health care is organised in four areas: clinical care, reproductive health and immunisation, dentistry and non-medical function (i.e. administration and general services). As a rule, patients with more complex pathologies that cannot be treated at the local hospital are evacuated to base hospitals at Tongatapu and Vava'u. The same applies when specifically needed treatment equipment is out of order, which may last for a protracted time, due to the remoteness of the site. Evacuation itself, however, can sometimes be problematic, depending on weather conditions and the availability of adequate means of transport. This has been an issue particularly for cases requiring urgent treatment. The remoteness of the site has led to difficulties in recruiting staff (whose eventual professional isolation may in turn become a problem). Incentives have been provided through the provision of lodging and measures to improve the possibility to frequently communicate with consultants at other locations. The Tongan Ministry of Health is strongly committed to strengthening the provision of services in the outer islands, as one of the six key strategic areas of its corporate plan 2008/09-2011/12. With an ultimate target of reducing by 10% the number of cases from the outer islands transferred to the main referral hospital in the capital Nuku'alofa. Such strategy foresees strengthening of specialist visits, staff rotation and training, expansion of appropriate services provided, improved communication systems, and disaster management plans. The budget of the Ministry of Health includes specific provision for staff and maintenance costs of health structures in the outer islands. In general the health sector is characterised by a strong focus on staff development and capacity building. The main referral hospital in the kingdom has recently been upgraded, with the support of Japan. Non-communicable diseases, including diabetes, cardiovascular diseases, hypertension and obesity, are the main cause of death in the country. Tonga is ranked as one of the top ten countries for the prevalence of diabetes. The Ministry of Health has been allocated 13% of the total estimate budget for the financial year 2011/2012. The envisaged EU contribution is intended to cover the reconstruction of the hospital and one of the annexed staff houses, all to be located on higher and safer grounds. The intended new hospital has been designed to ensure the same level of health care services available at Niuatoputapu prior to the 2009 tsunami and its operation is therefore expected to require the same level of resources (though possibly lower than the present temporary structure), which are already accounted for in the estimate budget for the next financial year. 2

2.2. Lessons learnt Lesson learnt from the 9 th EDF intervention in the outer islands (i.e. Vava u social programme) in health and education infrastructure rehabilitation has shown that successful implementation can be achieved with participatory implementation mechanisms involving local communities and authorities. Past experience has also shown that sustainability is better achieved when capacity building components are developed for ensuring adequate infrastructure management and maintenance. The project will build on previous experiences such as the post cyclone Waka support in 2002 jointly funded by the World Bank, the European Union and AusAID. The Government and the World Bank have agreed to adopt the same organizational structure used for the Waka rehabilitation support. Relevant construction standards will be used in order to strengthen resilience of the infrastructure in facing future natural disasters. 2.3. Complementary actions The World Bank is the main contributor to the estimated US$10 million TERMP, providing approximately 50% of the overall required contribution. The World Bank support has been in place for quite some time and includes the costs of the PMU and the housing reconstruction. In this respect it has taken considerable time (over one year) to complete the legal land transfers necessary for the resettlement actions, with construction starting in 2012. Other contributors to the postrecovery include AusAID (US$1 million) for the early recovery operation, NZAid (US$725,000) for education, Japan (US$1.2 million) for water and energy, the World Health Organisation (WHO - US$260,000) for health equipments, the Secretariat of the Pacific Community Applied Geoscience and Technology Division (SOPAC - US$180,000) for water, the United Nations Food and Agriculture Organisation (US$275,000) for agriculture and fisheries, the United Nations Development Programme (US$60,000) for community hall and income generating activities and the Pacific Islands Forum Secretariat (US$50,000) for micro-lending. 2.4. Donor coordination The PMU has been established under the PCC to be responsible for the day-to-day management, coordination and monitoring of the post-recovery activities. The PMU comprises of a Project Manager/Procurement Officer, a Project Accountant, an Administrative Assistant and a Project Engineer, on a part-time basis. The PMU is responsible for project accounting and financial management in cooperation with the Treasury Department of the Ministry of Finance and provides a monitoring and management report on a quarterly basis. 3. DESCRIPTION 3.1. Objectives The overall objective is to support the rehabilitation of the health sector in Niuatoputapu following the September 2009 tsunami. The specific objective of this proposal is to contribute to the construction of new health care facilities to support the provision of good quality primary health care on the island. 3.2. Expected results and main activities Expected results include: 1) new hospital and health-care workers residential buildings on Niuatoputapu built in a safer location; 2) new hospital properly equipped and operational. 3

Activities include: i) the construction of the new hospital, equipped with electricity 1, water and sanitation infrastructure; ii) the construction of one three-bedroom residential building and two two-bedroom residential buildings for the health-care staff; iii) provision of essential equipment, furniture and supplies, for the hospital and the above residential buildings. The EU contribution will be aimed at the construction of the hospital building and the threebedroom residential building and be complemented by contributions from the World Bank and WHO that are intended to cover for hospital equipment. Project management costs (including work and safety supervision) will be partly funded from the EU contribution, complemented by the contribution from the World Bank (who has funded the PMU). In addition, the construction of the two two-bedroom residential buildings will be funded through the WB's envelop for the housing reconstruction. A detailed design of the new hospital building and the annexed residences has been made available, based on which a careful estimate of the budget requirements has been carried out. The technical specifications for the implementation of the project will refer to the above detailed design documentation, while the engineering design of the facility will be finalised as part of the relevant scope of works. The intended new infrastructure is designed to provide the same level of health care as the hospital destroyed by the 2009 tsunami, to the same population and in view of providing basic treatment for the same type of pathologies. During the design phase of the project, measures will be considered to minimise the (very moderate) amount of medical waste produced by the new hospital and determine appropriate routes for its responsible management 2. 3.3. Risks and assumptions The risks identified are as follows. i) Limited involvement of local communities and authorities: close consultation between Government and the communities has been maintained from the outset of the recovery plan. ii) iii) iv) Land tenure arrangements not finalised: with relocation set as a priority for the authorities, a lot of emphasis has been placed on the settlement of the land issues, which has been achieved in April 2011 through the services of a specialised lawyer. The final transfer of deed was finalised in September 2011. Logistic capacity to reach the island is constrained: the capacity of the existing inter-island shipping, given the substantial volumes of construction materials and equipment required will be a major constraint and could cause delays and consequent cost escalation. Coordination amongst different interventions will be key to mitigating this risk, hence the role of the PCC and PMU. Weak management capacity for implementation: project accounting and financial management will be centrally provided by the PMU, reporting directly to the Ministry of Finance. To avoid multiplication of development partner procedures to be used it was proposed that the EU contribution be jointly managed by the World Bank, however discussions between the National Authorising Offer and the World Bank concluded in 1 Only the electricity distribution infrastructure is part of the scope of the project. The power source will be provided under the WB's programme. 2 Prior to 2009, the small quantities of medical waste produced by the hospital were disposed of by incineration in open fires. This is obviously not acceptable for the future operation of the new hospital. Therefore, the provision of adequate structures for the treatment, processing and transport of such waste shall be part of the scope of the project. 4

December 2011 that the administration fee (under an EU Administrative Agreement) would not effectively cover the management costs of the project, due to the limited budget involved. Nonetheless the PMU staff supported by the World Bank will be made available to manage the EU project. v) Uncertainties on the adequacy of the budget to cover the estimated costs may derive primarily (given the advanced status of the detailed design) from possible changes in the Euro exchange rates; in addition, there are obvious concerns about the transport costs associated with the performance of works in a remote location: priority has been given to the construction of the hospital building (see section 4.2 below); however, should the EU contribution be insufficient to also fund the three-bedroom housing (an essential element in incentivising medical staff to accept working at a remote location), it has been agreed that the World Bank would take over its construction as part of its housing reconstruction programme. 3.4. Crosscutting Issues The health sector infrastructure destroyed by the tsunami was built close to the sea shore. The new area made available by the Government for the hospital infrastructure is situated on higher land (10-12 metres above the sea level) and 1 kilometre from the coastal line, which will reduce the risk of eventual infrastructural damages due to future tsunamis. The new construction will be designed to improve resilience to natural disasters. The design of the building will also take into account possible environmental impacts such as groundwater contamination (an appropriate sanitation system will be part of the design), medical waste treatment and will be energy efficient. Community consultations have been key to locating the most appropriate site for the hospital. This being the only health facility in the remote island of Niuatoputapu responsible for coordinating all clinical and public health care, it is likely to bear crucial social benefits for the local population. These include addressing gender issues, notably in terms of improved maternal health and birth health services in a country characterized by a high fertility rate (4.2) and by an upward trend in adolescent birth rate experienced since 2008(following a period of decline between 2000 and 2005). In Niuatoputapu, 48% out of the total population (864 individuals reported by Ministry of Health in 2010), is composed by female population while 42% of the total population is under 15 years old. The new hospital is expected to provide assistance to some thirty childbirths per year, based on the statistics available for the operation of the old hospital and the present temporary health infrastructure. The intended improved management of medical waste (in spite of the latter's very limited quantity) will contribute to the overall responsible waste management in Niuatoputapu. 3.5. Stakeholders The Ministry of Health is the main stakeholder and has formulated the project proposal. EU support to contribute to the cost of reconstructing the hospital and residential housing will allow the Ministry of Health to allocate its budget resources to meeting the operational costs of the health infrastructure in Niuatoputapu. The people of Niuatoputapu (all age and gender groups) are the direct beneficiaries of the project as they will be able to receive quality basic health care in a permanent and dedicated structure. The Ministry of Works is also an important partner and will provide expertise to supervise the construction. The Ministry of Finance embeds the TERMP and acts as a coordinator of development partners assistance in Tonga. The National Disaster Management Office, a Department of the Ministry of Works, will be particularly involved during the implementation of the project, through the very activities of the PMU and the overarching structure of the TERMP. The overall reconstruction activities have been explained in detail to all the communities on Niuatoputapu, during a series of consultation meetings with each of the three communities in April 2010. Clarifications were provided on various issues relating to the resettlement program. Overall, 5

the communities endorsed the program and urged its implementation to be expedited. Consultations and coordination with both other donors and the communities will be a continuing process throughout the implementation phase. 4. IMPLEMENTATION ISSUES 4.1. Method of implementation The method of implementation will be decentralised management through the signature of a Financing Agreement with the government of Tonga in accordance with Articles 21 to 24 of the Financial Regulation of the 10 th EDF. It is envisaged that a single call for tender be launched, comprising of two lots, for the works of the main hospital building (Lot 1) and the three-bedroom residential unit (Lot 2). This would allow the National Authorising Officer to attribute the higher priority to the works on the hospital building, in case received tenders for Lot 1 should exceed the relevant provisional budget allocation. In the latter case, coordination with other donors (World Bank) could allow the finalisation of a contract for Lot 2, according to the conclusions of the relevant evaluation procedure. The Commission controls ex ante all the procurement procedures except in cases where programme estimates are applied, under which the Commission applies ex ante control for procurement contracts > 50,000 EUR and may apply ex post for procurement contracts 50,000 EUR. The Commission controls ex ante the contracting procedures for all grant contracts. Payments are executed by the Commission except in cases where programmes estimates are applied, under which payments are executed by the beneficiary country for operating costs and contracts up to the ceilings indicated in the table below. The responsible Authorising Officer ensures that, by using the model of financing agreement for decentralised management, the segregation of duties between the authorising officer and the accounting officer or of the equivalent functions within the delegated entity will be effective, so that the decentralisation of the payments can be carried out for contracts up to the ceilings specified below. Works Supplies Services Grants < 300,000 EUR < 150,000 EUR < 200,000 EUR 100,000 EUR The change of management mode constitutes a substantial change except where the Commission "re-centralises" or reduces the level of tasks previously delegated to the beneficiary country, international organisation or delegate body under, respectively, decentralised, joint or indirect centralised management. 4.2. Procurement and grant award procedures / programme estimates All contracts implementing the action must be awarded and implemented in accordance with the procedures and standard documents laid down and published by the Commission for the implementation of external operations, in force at the time of the launch of the procedure in question. Participation in the award of contracts for the present action shall be open to all natural and legal persons covered by the Financial Regulation of the 10 th EDF. For the present action, it is expected that the beneficiary may submit a request for derogation to the rules of nationality and origin to extend participation Australia and New Zealand. Any such request for derogation shall be dealt with based on the relevant motivation and according to the applicable rules. Further extensions of this participation to other natural or legal persons by the concerned Authorising Officer shall be subject to the conditions provided for in article 20 of Annex IV of the Cotonou Agreement. 6

All programme estimates must respect the procedures and standard documents laid down by the Commission, in force at the time of the adoption of the programme estimates in question (i. e. the Practical Guide to procedures for programme estimates). The EDF financial contribution may cover the ordinary operating costs deriving from the programme-estimates. 4.3. Budget and calendar The EU contribution, under the present action, is to cover the scope of the works on the hospital building and one staff "three-bedroom" residential unit, according to the table below. A 60,000 inkind contribution of the Government of Tonga is foreseen that is accounted for additional project management and supervision of works. The implementation period of the present project is 24 months, starting from the date of the last signature of the Financing Agreement. It will be followed by a 24 months closure period. The procurement process for the works will be launched during the first quarter of the implementation period, and last approximately 4 months. The detailed design of the new hospital is already agreed with the authorities and the detailed tender dossier is being finalised. Following the finalisation of the engineering design, works are expected to last one year (including transport to the Niuas group of islands of materials that are not available locally). This duration takes into account the remoteness of Niuatoputapu and the challenges attached to its unique environment. The budget is as follows: Categories EU contribution ( ) World Bank/ WHO ( ) Total ( ) Construction of the new Hospital (works-lot 1) and Construction of staff housing (works-lot 2) 1,065,000 0 1,065,000 Hospital equipment 0 90,000 3 90,000 Project management works supervision 150,000 30,000 4 180,000 Communication/Visibility 5,000 0 5,000 Monitoring, External Evaluation and Audit 20,000 0 20,000 Contingencies 135,000 0 135,000 TOTAL 1,375,000 120,000 1, 495,000 4.4. Performance monitoring The indicator for the present project is a successful completion of the construction of the hospital and the staff housing, with the aim of having a fully operational hospital by the end of the project. Indicators related to a restored or improved quality, effective and sustainable provision of health services to the population of Niutapotapu will be considered in an ex-post evaluation exercise. 4.5. Evaluation and audit A final financial audit will be undertaken by an independent Audit Company contracted by the EU. Financial provisions shall be made under the Financing Agreement for this purpose. In addition, 3 Part of WHO allocation of US$ 260,000 : equipment already purchased for hospital 4 Part of WB allocation of US$400,000 to PMU 7

independent Result Oriented Monitoring (ROM) missions recruited by the EU will be carried out on an annual basis. 4.6. Communication and visibility Visibility of the EU intervention will be ensured, through inter alia the installation of permanent and visible signs on the hospital and health-care staff residential buildings acknowledging the EU assistance. The EU guidelines on visibility shall be applied. EU financial support will be highlighted in all activities, reports and media releases. The EU logo will be clearly displayed on all project deliverables and at project events. EU promotional material will also be produced and distributed during the project. Provisions have been made in the budget for this purpose 8