Philippines - Second Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 9380 PROJECT PERFORMANCE AUDIT REPORT AND PROJECT COMPLETION REPORT PHILIPPINES SECOND POPULATION PROJECT (CREDIT 923-PH) FEBRUARY 15, 1991 Operations Evaluation Department This document has a restricted distribution and may be used by reciplents only in the performance of their offici*al duties. Its ctontents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Currency Unit - Philippines Peso (P) US$1 P7.40 (May 1979) P21.0 (June 1988) ABBREVIATIONS AND ACRONYMS BHS - Barangay Health Station BHS-MW - Barangay Health Station Midwife BHW - Barangay Health Worker BSB - Botica sa Barangay BSPO - Barangay Service Point Ifficers CMC - Construction Management Consultant DBM - Department of Budget and Management DOF - Department of Finance DOH - Department of Health, formerly Ministry of Health EA - Executive Architect EPI - Expanded Program for Immunization FP - Family Planning GOP - Government of the Philippines HPP - Herbal Processing Plant IAMCC - Inter-Agency Monitoring and Coordinating Committee IDA - International Development Association IEC - Information, Education and Communication IPHO - Integrated Provincial Health Office JICA - Japan International Cooperation Agency MCH - Maternal and Child Health MHC - Main Health Center (now RHU) MIS - Management Information System NCR - National Capital Region NGO - Non-Governmental Organization NEDA - National Economic Development Authority OED - Operations Evaluation Department PCR - Project Completion Report PHC - Primary Health Care POPCOM - Population Commission (formerly Commission on Population PPAR - Project Performance Audit Report RHCDS - Restructured Health Care Delivery System RHU - Rural Health Unit RPO - Regional Population Office SAR - Staff Appraisal Report UNFPA - United Nations Fund for Population Activities UPPI - University of the Philippines Population Institute USAID - United States Agency for International Development WHO - World Health Organization FISCAL YEAR January 1 - December 31 FOR OFFICIAL USE ONLY THE WORLD BANK Washington, D.C. 20433 U.S.A. office of Drector-Ceral OperatMns Evaliatin February 15, 1991 MEMORANDUM TO THE EXECUTIVE DIRECTORS AND THE PRESIDENT SUBJECTs Project Performance Audit Report and Project Completion Report on Philippines - Second Population Project (Credit 923-PH) Attached, for information, is a copy of a report entitled "Project Performance Audit Report and Project Completion Report on Philippines - Second Population Project (Credit 923-PH)" prepared by the Operations Evaluation Department and the Asia Regional Office. Attachment 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. FOR OFFICIAL USE ONLY PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES SECOND POPULATION PROJECT (CREDIT 923-PH) Table of Contents Pale No. Preface . .t . . . . . . . . . . . . . . . . . . . . . . . Basic Data Sheet . . . . . . . . . . . . . . . . . . . . . . . . i Evaluation Summary . . . . ..... ... ...... . vi PROJECT PERFORMANCE AUDIT REPORT I. Background and History . . . . . . . . . . . . . . . . . . 1 II. Main leaues . . . . . . . . . . . . . . . . . . . . 3 A. Availability of Information about This Project . . . . 3 B. Project Design . . . . . . . . . . . . . . . . . . . . 5 C. Changes in Direction . . . . . . . . . . . . . . . . . 6 D. Output and Impact . . . . . . . . . . . . . . . . . .8 E. The Weakening of POPCOM . . . . . . . . . . . . . . . . 11 F. Sustainability . . . . .. . . . . . . . . . . . . . . 12 III. Conclusions and Lessons . . . . . . . . . . . . . . . . 13 PROJECT COMPLETION REPORT. . . . . . . . . . . . . . . . 15 1. Summary and Conclusions . . .. . . . . . . . . . . . . . . . 17 2. Background . . . . . ... . . . . . . . . . . . . 20 3. Project objectives and Description . . . . . . . . . . . . . 21 4. Project Design and Organization . . . . . . . . . . . . . 22 5. Implementation . . . . . . . . . . . . . . . . . . . . . . . 22 6. Impan . . . . . . . .. ........ . . . o... . . . . 27 7. Project Sustainability . . . . . . . . . . .. . . 29 8. Association and Borrower Performance . . . . . . . . . . . . 30 9. Lessons Learned and Recommendations . . . . . . . . . . 30 TAOLES . .. . . .. . .. .. ... . ... .. . .. . 32 1. Related Bank Loans and/or Credits . . . . . . . . . . . . . . 32 2. Project Financing and Costs . . . . . . .. . . . . . . . . 33 A. Project Financing . . . . . . . . . . . . . . ... . . . . 33 B. Project Costs . . . . . . . . . . . . . . . . 34 3. Status of Covenants . . . . . . . . . . . . . . . . . . . . . 35 .G... .................. .... 38 This document has a restricted distribution and m4y be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Table of Contents (contd.) Page No. ANNEX BORROWER'S PROJECT COMPLETION REPORT . . . . . . . . . . . . . . 39 Summary and Conclusions . . . ...... . . . . . . . . . . . 41 1. Proj,ct Review . . . . . . . . . . . . . . . . . . . . 48 2. Institutional Development . . . . . . . . . . . . . . . 61 TABLES 1. Loan Allocations by Category and Year of Reprogramming . . . 65 2. Credit Disbursement . . . . . . . . . . . . . . . . . *. . . . 68 3. DOH Civil Works . . . . . . . . . . . . . . . . . . . . . . 69 4. POPCOM Civil Works ......... . . * . . . . . 71 5. DOI Training . . . . . . . . ..... . . . . . . * * . . 73 6. POPCOM Training . ............................. . . . . . . * 78 7. Primary Health Care . . . . . . . . . . . . . . . . . . . . . 91 8. POPCOM Furniture, Equipment and VehicleS . . . . . . . . 93 9. DOH Furniture, Equipment and Vehicles . . . . . . . . 95 10. POPCOM Information/Education/Communication . . . . . . . . . 96 11. DOH Information/Education/Communication . . . * s . . 103 12. POPCOM and DOH Research Studies . ... . . . . . . * . 107 ATTACHMENT 1. Borrower's coents on Draft PPAR . . . . 8 125 PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES SECONj POPULATION PROJECT (CREDIT 923-PH) PREFACE This is a Project Performance Audit Report (PPAR) of the Philippines Second Population Project for which a Bank credit in the amount of US$40.0 million was approved June 5, 1979. The Credit Account was closed June 30, 1988, three years behind schedule. US$5.6 milliki was canceled on December 18, 1986 and US$2.2 million on April 13, 1989, the date of the last disbursement. This volume consists of the Audit Report (PPAR) prepared by the Operations Evaluation Department (OED), the Project Completion Report (PCR) prepared by Country Department II of the Asia Region and the Borrower's PCR prepared by the National Economic Development Authority (NEDA) of the Philippines Government (GOP) (Annex) and comments by the Borrower on the Draft PPAR (Attachment). The PPAR is based on a review of the PPAR for the First Population Project (Loan 1035-PH); the Staff Appraisal Report, President's Report, Credit Agreement and the PCRs for this second project; correspondence files, interviews with relevant Bank staff, and a mission to the Philippines in November, 1989, which held discussions with Government and project officials and visited a number of project facilities. The PCR and the Annex (the Borrower's PCR) provide good descriptions of the history and results of this project. The Audit Report elaborates on a number of special issues and draws its additional conclusions. A draft of the PPAR was submitted to the Government for comment. These comments have been taken into account in this revised version and are presented verbatim in the Attachment. * ii - PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES SECOND POPULATION PROJECT (CREDIT 9231.) BASIC DATA SHEET KEY PROJECT DATA Item Appraisal Current Estimate Estimate Total Project Cost (US$ million) 72.0 66.4 Underrun (M) Loan Amount (US$ million) 40.0 7.8 Disbursed 32.3 Cancelled 7.7 Date Physical Components Completed 6130185 6/30188 Months Since Loan Signature 72 108 Proportion of Time Overrun (2) 150 Institutional Performance Inadequate CUMULATIVE ESTIMATED AND ACTUAL DISBURSEMENTS Appraisal estimate (US$ million) 4.4 13.4 23.3 31.8 37.4 40.0 40.0 34.4 34.4 34.4 Actual (US$ million) .36 2.4 5.94 11.84 14.84 19.34 22.9 24.8 26.7 32.2 Actual as 2 of appraisal (Z) 8.2 17.9 25.5 37.2 39.7 48.4 57.5 72.1 77.7 93.8 Date of Final Dishursement: April 13, 1989 - iv - Project Timetable Item Date Date Date Planned Revised Actual Identification 3/77 Preparation 7/7711/78 Appraisal Mission 10/9-11/1178 Credit Negotiation 4/30-5/4179 Board Approval 16/5/179 Credit Signature 6127179 Credit Became Lffective 10/15/79 Credit Closing 6/30/85 6/30/86 6130/88 Disbursement Completed 12131/85 12/31/86 4/13/89 PHILIPPINESs Population Ii, Credit 923-PH Staff-Inputs Recorded by Fiscal Year/Activity PRE-FY79 FY79 FY80 FY81 FY82 FY83 FY84 FY85 FY86 FY87 FY88 FY89 FY90 TOTAL Pro-Appraisal 99.3 23.5 122.8 Appraisal 94.3 94.3 Negotiations 18.1 18.1 Supervision 1.1 41.5 32.4 22.4 27.1 37.4 30.2 22.7 21.8 13.1 3.9 0.5 254.2 Project Completion 0.2 0.9 5.9 16.7 23.7 TOTAL 99.3 137 41.5 32.4 22.4 27.1 37.4 30.4 22.7 21.8 14 9.8 17.2 513.1 MISSION DATES Date No. of Specialisations Performance Type of (mo/yr) persons Represented Rating T,end Problems La La La La Identification/Preparation 03/77 3 1,2 Appraisal 10/78 7 3,4,2,5,7,8 - Supervision 1 07/79 6 3,1,2,4,4,1 1 - F Supervision 2 10/79 4 1,2,4,7 - - - Supervision 3 03/80 5 1,3,4,2,5 2 - F,M Supervision 4 10/80 3 3,2,4 2 -F,M Supervision 5 051A1 3 1,2,3 - - - Supervision 6 08/bl 2 2,3 - - Supervision 7 02182 3 1,2,3 - - - Supervision 8 05/82 4 2 - - - Supervision 9 08/82 5 3,9,2,7,9 2 2 M,T Supervision 10 12/82 1 3 - - - Supervision 11 08/83 3 10,3,9 3 - F,M Supervision 12 11/83 1 2 - - - Supervision 13 03/84 2 3,10 2 2 F,M Supervision 14 09/84 3 3,2,3 2 - F Supervision 15 04/85 1 3 2 - F Supervision 16 08/85 1 2 - - - Supervision 17 09/85 2 3,1 2 - F Supervision 18 04/86 3 1,10,2 - - - Supervision 19 09186 2 2,9 2 - M Supervision 20 02/87 2 9,3 2 - M Supervision 21 05/87 3 9,2,11 2 - M Supervision 22 09/87 1 3 1 - - Supervision 23 07/88 1 3 - - - Completion 06/89 2 3,3 - - - OTHER PROJECT DATA Borrower: Government of the Philippines Executing Agencies: POPCOM and DOH Follow-on Project: Name Health Development Project Loan Number 3099-PH /a 1. Public Health Specialistl 2. Architects 3. Population Specialist; 4. IEC Specialist, 5. Training Specialisti 6. Nutritionisti 7. Information Systems Specialisti 8. Researchl 9. Operations Officerl 10. Division Managerl 11. Economist. /b 1. Minor Problems; 2. Major Problemst 3. a - Not available. L_ F-Financiali M-Managementi T-Technical. - vii - PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES SECOND POPULATION PROJECT (CREDIT 923-PH) EVALUATION SUMMARY Proiect Objectives and Design 1. The objectives of this Second Population Project were to assist the Philippines Government (GOP) in its efforts to reduce fertility, decrease infant mortality and child malnutrition and improve the health statue of semi-urban and rural populations. The project was divided into two parts of roughly equal size to be implemented by separate agencies. Part A was designed to strengthen the Population Commission, an agency responsible for coordinating the population activities of other agencies, promoting population and family planning education and coordinating relationships with external donors. In addition, POPCOM was implementing a significant outreach program for the delivery of family planning information and supplies, funded by USAID. Part B provided funds to the Ministry, now Department, of Health (DOH) to further expand its health and family planning (FP) delivery system into areas without adequate coverage. Each part included components for construction, equipment, training, information, education and communications activities (IEC), management information systems (MIS), and research and innovative activities. Part B also included a component to implement a primary health care (PHC) scheme on a pilot basis in a few regions. Implementation 2. The Credit Agreement was signed in June, 1979 with an original Closing Date of June 30, 1985. The Closing Date was extended twice, first to June 30, 1986, because of slow implementation, and then to June 30, 1988 to undertake additional activities. Twenty percent of the credit proceeds were canceled, in large part because of devaluations of local currency against the US dollar which amounted to nearly 300 percent during the project implementation period. 3. During implementation, the project was amended seven times and, in the process, changed direction in very substantial ways. The most significant change was the expansion of the pilot PHC scheme to a national program. This altered construction, training and IEC components significantly and resulted in a serious neglect of family planning by the DOH. The population and FP activities of POPCOM also fared poorly, in this case because of political and other problems which effectively crippled this agency. Other major changes included - viii - construction to replace or repair rural health centers damaged by typhoons and by a fire which deatroyed POPCOM's headquarters. In addition, a variety of smaller decisions about purchases and contracts were made which it is doubtful the designers of this project had in mind. The PCR's characterization of the final project as something akin to a sector loan is apt, except that no agreement on sector policy was included. 4. Documentation that might explain these changes is very sparse. In some cases--e.g., reconstruction of typhoon-damaged buildings--the explanation is obvioust in others--e.g., the shift from pilot to national PHC program and investments in herbal medicine processing plants--it is not. In the absence of such information, the PPAR sneculates that five factors weL involved: (1) generally accepted development thinking of the time, (2) lack of conviction about better alternatives with which to challenge the proposals put forward, (3) turf battles which made it difficult to obtain agreement about alte-natives, (4) adept maneuvering and bargaining, and (5) eagerness to increase the seriously lagging disbursement rate which may have encouraged development and acceptance of proposals that promised ready action. Results and Impacts 5. The principal accomplishment of this project was the extension of the DOH's service delivery system into under- and unserved rural areas. This was accomplished by the construction of nearly 2000 buildings in remote areas, the provision of primary health care (PHC) training to midwives, the procurement of equipment and the production and distribution of information, education and communications (IEC) materials. The civil works component of this operation was the most successful; indeed, this effort is now considered complete and no additional construction activity has been included in the recently initiated Health Development Project (Ln. 3099-PH). The civil works component for POPCOM was completed as planned in the amended project documents, but many of the buildings produced are underutilized, mainly but not exclusively because of changes in POPCOM's responsibilities. 6. Other components did not fare as well. Many items of equipment have failed to reach their intended users; others arrived so late that they could not be put to use before this project ended. While the quantity of IEC materials produced exceeded plans, inadequate distribution and quality appear to have limited potential effectiveness. While the training activities of POPCOM proceeded roughly as planned, the DOH restructured its training program to meet the needs of the PHC program and in the process seriously neglected FP along with several other subjects requiring specialized training. In addition, refresher courses and training of supervisors were neglected. Despite iS components in the First Population Project as well as both parts of this one, little usable output or analysis has emerged. 7. These outputs were supposed to be used primarily to promote family planning and child health and nutrition. The contraceptive prevalence rate increased modestly during the implementation period, but little if any of that -ix - increase can be attributed to this project because it occurred during the first half of the period. POPCOMI's efforts in this direction were severely limited by serious polltical problems, changes in leadership and terms of referance, and a fire that destroyed the main headqiarters. DOH efforts suffered mainly from neglect- -especially important being the failure to provide adequate FP training-- in large part because of the focus over most of this period on rapid implementation of the nationwide PHC program. As a consequence, the Philippines population and family planning program was probably weaker at the close of this project than it was at its inception. The infant mortality rate declined during the course of the project, but little of this decline could have been due to the project's inputs which were put in place ve late in the period. Health and nutrition indicators that might be associa.ed with the project were not available. On the other hand, a far larger fraction of the population is now within walking distance of at least minimal health facilities than was the case ten years ago; this must have had some beneficial effect on morbidity and mortality rates. Sustainability 8. The infrastructure and equipment provided to the DOH to extend the rural health system is likely to continue being used for that purpose. Limited budget support for maintenance is a problem, hwever, that will require substantially more resources to resolve. A significant portion of the infrastructure and equipment provided to POPCOM, plus some of its staff, however, became redundant in 1988 when its responsibilities for FP delivery, training and IEC activities were turned over to the DOH. These resources could be effectively utilized by the DOH to undertake its new responsibilities, but to date they remain with POPCOM. A problem is also present at the provincial level where some workers trained and hired by the project have not been absorbed because of tight budgets and/or lack of interest by provincial authorities. 9. During the iirst year that the DOH had responsibility for the FP program, that program marked time, raising doubts about its longer term sustainability. In early 1990, however, DOH announced a new 'health risk' approach to family planning which is quite promising on two levels: (1) it provides an understandable rational to health workers, trained to be concerned about morbidity and mortality, to include promotion of FP in their tool kit; and (2) it is more politically acceptable than the older 'population control' approach to the subject. Another favorable sign will occur if and when DOH training programs are restructured to appropriately focus on FP. Perhaps, then, for the first time, all ingredients will be in place to make headway on this problem. Conclusions and Lessons 10. The PCR derives a number of useful lessons of a detailed, operational, nature. More general issues bearing on project design are dealt with here. - x - 11. The principal contribution of the First Population Project, according to its PPAR, was the expansion of the cadre of midwives for the rural health network. This second project, among other things, provided the infrastructure to complete this network. Thus, the basic capacity of the health system to deliver services, FP as well as health, is now in place. These projects, however, especially the second, were supposed to go further, to turn this potential into a reality; that they did not do for FP and did only partially for health. 12. In large part, lack of progress on the population and FP front was the result of political problems after the project started. While these problems could not have been anticipated, all parties were certainly aware of the risks involved. Could anything have been done to better insulate this program from these risks? The Audit argues that the FP program would have been less vulnerable if, instead of splitting responsibility between POPCOM and DOH, it had been assigned to DOH and integrated into the MCH and PHC programs from the outset. For all practical purposes, this integration has now occurred. At the time, however, the Government pinned its hopes on a two-pronged attack, and the Bank went along without seriously questioning the arrangement. The Bank might also have been somewhat less flexible and accommodating in agreeing to some of the more questionable changes in project direction. Other lessons for countries with similar socioeconomic development and sensitivities about population and family planning programs are presented in the concluding section of this Audit. 13. One additional point might usefully be added in conclusion. Availability of information about this project seems especially poor. The main text provides illustrations ranging from lack of asable output from the MIS components included in both the first and the second population project, shortfalls in the research and studies component, lack of several critical financial audits, and incomplete Bank and Government correspondence and other files. This shortfall is especially unfortunate in a project as complex as this one and may help explain the difficulty the Bank, and perhaps the central government as well, seems to have had in resisting requests for changes in direction. - 1 - PROJECT PERFORMANCE AUDIT REPORT PHILIPPINES SECOND POPULATION PROJECT (CREDIT 923-PH) I. Background and History 1.01 In 1968 a small unit for maternal and child health (MCH) and family planning (FP) was created in the Department of Health (DOH). One year later the Government created the Commission on Population (POPCOM) as a planning, coordinating and policy-making body with a board consisting of representatives from private as well as Government agencies associated with population and family planning issues. POPCOM'S functions were subsequently extended to include donor coordination, promotion of information, education and communications (IEC) programs, provision of family planning services through non-clinical channels, and related training and research programs. 1.02 POPCOM is described as being mainly a coordinating agency. Initially, this role had considerable significance since the Government's budget for population and family planning work was provided to POPCOM which then allocated it to various private and public agencies. Over time, however, more and more funds have been allocated directly by the Department of Finance, with the result that this coordinating function, while still acknowledged, carries far less weight. 1.03 POPCOM's family planning activities in large measure centered around Project Outreach, a USAID funded project started in 1975 to establish a network of non-health field workers--Full-time Outreach Workers (FTOWs)--each of whom provided simple health services and motivation for family planning, and recruited, supervised and provided contraceptive supplies to between five and seven volunteers--Barangai Supply Point Officers (BSPOs)--stationed in villages. By 1977, 2,565 FTOWs and 15,600 BSPOs were reported to be in place. This project continued to be funded by USAID until 1987. 1.04 During the seventies, the DOH continued to expand its basic health services, which included family planning provided through clinics. By 1977 it serviced 64 percent of all FP acceptors. 1.05 In 1974, the Bank provides the Philippines Government (GOP) with a loan of US$ 25 million for a population project with four components, one involving POPCOM and the other three DOH% -- a component meant to strengthen POPCOM's "coordinating capability" by establishing an IEC Division, a Training Division, and a series of regional offices; - 2 - - - extension of the rural health delivery system by constructing and equipping clinics, providing transport equipment, employing and training 2,400 midwiveeL, and establishing an associated core staff in DOH; -- creation of training facilities for DOH, including construction, equipping and furnishing of facilities and provision of technical assistance and fellowships; and -- establishment of a Health Statistics Unit in the DOH. Since the GOP did not want to use loan funds for population activities, most of the first component was funded by USAID and UNFPA. In the end this resulted in the Bank focusing most of its attention on the health rather than the population components. 1.06 The principal impact of this project (according to both its PCR and its PPAR) was the recruitment and training of 2800 midwives to increase the coverage of the rural health system. Apart from that, the PPAR believes that little was accomplished: the population program made little progress; and facilities constructed under the project (which accounted for the bulk of the investment) were "overdesigned, underutilized, poorly maintained", and along with equipment often "diverted to other uses" (PPAR, para 26, 27). The project ended in 1983, three and a half years later than originally planned, because of implementation problems and decisions to reprogram unused contingency funds. 1.07 The second population project--the subject of this audit--was initiated in June, 1979 with a credit of US$40.0 million. While this project was more complex in content and administrative arrangements, its principal components were similar to the first project. For POPCOM, it provided funds for constructing and equipping 7 additional regional offices and 13 warehouses and vehicle mal.ntenance workshops, further strengthening of its training and IEC activities, additional transport equipment and research activities to further develop a management information system (MIS). For DOHO it provided funds for constructing and equipping 75 additional rural health centers and 915 barangay (village) health stations, expansion of IEC and MIS activities, plus a pilot primary health care (PHC) scheme. In addition, both agencies were provided with funds for technical assistance and innovative activities. The project was, however, subject to a large number of revisions which changed its character in significant ways (see below). The Credit Agreement was closed in June, 1988, three years behind schedule and the last disbursement was made in April, 1989. US$7.8 million of the original US$40 million was cancelled. Total cost is estimated at US$52.6 million compared to an original estimate of US$72 million. These shortfalls are mainly the result of devaluation of the peso by a factor of nearly three during project implementation. 1.08 The 10 year period covered by this project was one of great IL The actual number, according to the GOP, was 5000 RHM hired and trained under POP I. See ANNEX II, para. 16. - 3 - instability and change in the Philippines. Not only did policies, leadership and institutional responsibilities within the population and health fields change a number of times in significant ways, but economic recession, growing political insurgency during the 1982-1986 period and a change in government in 1986 seriously affected project financing and implementation. II. Main Issues 2.01 Given the well-rounded coverage of this project by both the Bank's and the Borrower's PCRe, this section will focus on a few issues of particular interest in this case. A. Availability of Information About This Project 2.02 Availability of information on which to base an assessment of this project seems especially poor compared to many other projects of this era. -- Despite MIS components in both the first and the second population projects, covering a period of over 15 years, little usable information and no evaluations based on such information, have yet to emerge. UL POP I assisted DOH in the development of an MIS for health. At the same time, other independent systems were developed for population and nutrition with other funds. POP II changed direction and called for the development of a single system to cover all three topics. This never materialized because of lack of agreement between the agencies. In addition, however, DOH never utilized the system developed under POP I; instead it began developing a new system, the Health Information System, which is currently being field tested. This system seems well designed to provide clinic-based information on morbidity and mortality but not fertility and contraceptive prevalence (for example, births in clinic are recorded but not age of mother or parity). These shortcomings are being addressed in the Philippines Health Development Project. According to the Borrower's PCR, the only real accomplishment of the MIS component of POP II was the provision of computers for POPCOM and DOH (Annex, p. 30, para. xvii). But even then, they arrived so late that they could not be put to use during the course of this project. POPCOM's computers arrived in September, 1989, after the project had been completed. This delay was caused, among other things, by rejection of the first study detailing the kind of computers needed and insistence by POPCOM's executive directors on a second round of bidding using a different specification of bidding procedures. Delays were so long that budget funds had to be reapplied for, which of course resulted in additional delays. -- While a large variety of studies were undertaken, many had little bearing on what the SAR originally called for, many were completed too late to be of use in the project, and several crucial ones--in particular, impact evaluations of the IEC efforts--failed to materialize.1 -- A number of financial audits, including a final one covering the whole project, called for by the project agreement, have yet to be received, despite repeated requests by the Bank. -- Bank correspondence and other internal files on this project are seriously incomplete. 4t -- GOP files covering the preparatory period of this project could not be found (Borrower's PCR, para 12.02). 2.03 These deficiencies are especially unfortunate in a project as complex as this one. They might be a factor helping explain the failure on the part of the Bank and the central government to effectively resist some of the more questionable actions and proposals for changes in direction introduced by implementing agencies. Moreover, they have made it necessary to place greater reliance than usual on interviews in the preparation of this Audit. 2.04 One explanation offered for the deficiencies in Bank documentation is that a key project officer during project implementation had an operating style that precluded careful documentation. Lying behind this explanation, however, must be the generally low priority given to data gathering, research and documentation in conjunction with projects which allowed this operating style to UL See PCR, p. 9, para 6.08, Annex, para 19.12 and Table 12. A typical situation occurred in the case of IEC. Information on the number of comic books and posters is available; but there is hardly anything available on their distribution and nothing on their impact. One major study that was added was an effort to test local herbs for their contraceptive qualities. Nothing came of the 3 million pesos spent on this study. It has now ended because of inability to raise additional donor funds for its continuation. The typical procedure when herbs with promising characteristics are found is to send them to an existing laboratory in another country for analysis rather than setting up special facilities for their assessment; had this procedure been followed in the Philippines, this study would never have been started. UL The back-to-office report of the Appraisal Mission is missing. Some supervision reports and supporting materials are missing. Supporting documentation for a number of the amendments to this project, some of which changed the direction of this project in radical ways, could not be found. -5- hold ewaY. B. Proiect Design 2.05 The Philippines, in 1979, was a country with a relatively high level of education and understanding of modern family planning methods, a religious leadership officially opposed (though not always actively so) to the use of these methods, a poor health delivery system, and a number of small but effective NGOs active in the FP field. Other things being equal, an appropriate policy in these circumstances might have been to focus on expansion and improvement of the health delivery system, provision of family planning services through this system, and a non-strident IEC program that focused on 'responsible parenthood' achieved by any means, modern or traditional. The assumption behind this approach is that, in the Philippines context at that time, the principal bottleneck to a higher contraceptive prevalence rate was supply, not demand, and that enhanced stridency and publicity at the national level was both unnecessary and unwise; in other words, that unmet demand for limiting family size was substantial, or could be relatively easily stimulated, and that people would use more effective methods if they could obtain these methods quietly and easily. 2.06 If this approach had been followed in this second population project, the Bank would have provided support primarily to the DOH, as it did in the first project and as it decided to do in the subsequent project (the Health Development Project approved last year). But at the time, there was considerable unhappiness with the way the first project was being implemented, many of these problems being attributed to weak management within DOH and the autonomy accorded to the implementation unit. In contrast, POPCOM was considered to be a promising organization: its newly appointed leadership was thought to be dynamic, enterprising and well-connected politically; and the non-medical outreach program financed by USAID seemed to be working. In addition, there was the successful example of BKKBN, a similar organization in Indonesia. 2.07 For these reasons, the Bank decided to shift more of its attention to POPCOM and to propose somewhat different arrangements for implementation. The result was, effectively, two subprojects of roughly equal size, one administered by POPCOM and the other by DOH, implementation to be carried out by existing staff in the two organizations with no formal coordinating mechanism between them. It was a very untidy arrangement that soon led to turf battles and eventually to the appointment of a formal coordinating body headed by the National Economic Development Authority (NEDA). 2.08 Given the subsequent decline in the authority of POPCOM (see below) and improvements in DOR, this project design ultimately proved to be inappropriate. It is unfortunate that the Bank did not continue providing most of its support to DOH to see it through its difficulties rather than shifting so much emphasis to an organization that was more vulnerable to political and policy changes. Of course, the changing fortunes of these two organizations could not IL The comment made in Para. 2.18 may also be relevant here. - 6 - have been anticipated. But just because of that unpredictability, perhaps the lesson to learn from this experience in designing future projects is to give more weight to longer term issues of the type discussed above in the selection of institutional arrangements. 2.09 That said, the design of each of the subprojects seems appropriate given what was known about the two organizations and the delivery systems in place at the time. C. Changes in Direction 2.10 The Bank is often criticized for being too inflexible, especially in social sector projects where continuous adaptation is necessary. Here is a case where, if anything, the Bank was too flexible during implementation. The Credit Agreement was amended seven times during the course of this project. In addition, approval was requested and granted for funding of individual items of expenditure which sometimes represented a change in direction for the project. Some of these changes--for example, to allow for reconstruction of buildings destroyed or damaged by typhoons--are perfectly justified. More question&ble items are discussed below. 2.11 (1) P rimary Health Care Program. In 1982 the newly appointed Minister of Health decided to expand the pilot primary health care component of this project to cover the nation as a whole. The Bank agreed to a reallocation of Credit proceeds to facilitate this development despite doubts on three major points which the pilot program was intended to clear up: (a) Would an outreach system based on volunteers work well; could it do so along side POPCOM's program which paid its fulltime outreach workers? (b) While earlier programs were vertically organized, this program relied on multipurpose workers provided with integrated rather than specialized training; given the plethora of functions they were likely to be asked to perform and the specialized nature of FP, would not the latter be neglected? And (c) could the DOH, with ite limited managagerial capacity, scale up to a nationwide program of this magnitude and complexity as rapidly as plans called for without sacrificing quality? It was because of concerns such as these that the original agreement called for a trial of this approach. No documentation exists that explains why they Bank agreed to this radical change in direction. 2.12 In the end all three concerns proved to be justified. Mobilization of community support proved far more difficult and time consuming than originally In 1979 when implementation of this project started, the DOH was delivering family planning services as part of its MCH program and specialized training courses had been established for this purpose. With the shift to a PHC approach, FP and MCH were made part of a larger, integrated package. The training, IEC and service delivery programs were all reoriented to reflect this integrated approach. In the process, a number of specialized programs, including FP, received significantly less emphasis than previously. -7- contemplated (see para 2.19 for one aspect of this); family planning was seriously neglected (see paras 2.22 and 2.24); and the DOH did run into serious implementation and quality problems. DOH's service delivery capacity was, however, expanded to rural and underserved areas. 2.13 (2) Herbal Medicine Processing Plants. In 1983 the DOH requested and the Bank agreed to a reallocation of funds to establish 6 plants (later reduce i to 3 plants) for the production of herbal medicines. A feasibility study is on file with the DOH; which it was not located and reviewed by the Audit Mission, it was described as having limited value and seems not to have been reviewed with care within the Bank before this decision. During the course of construction, design problems were uncovered that required additional capital outlays to correct. At the time of the Audit Mission, only one of the three plants was operational, it was producing only one of the five products originally proposed (tablets from the lagundi plant), quality control was a serious problem, costs were vastly higher than originally expected, and doubts existed about the effective- ness and shelf life of these productsa. 2.14 (3) Studies. As noted above (footnote 3) the final list of studies bears little resemblance to the list originally agreed to and included some (for example research into herbal contraceptives) of questionable value. Many of these changes were introduced to accommodate the PHC programu. 2.15 (4) Hospital and Medical Eguipment. Contracts were let for the purchase of a variety of hospital and medical equipment including x-ray machines, generators, anesthesia machines, major operating tables and lights, resucitators and dental equipment. Which undoubtedly valuable in their own right, they are of questionable, or at least very remote, value in a project focused on population, PHC and MCH in rural areas. 2.16 Apart from the scaling up of the PHC program, none of these changes, taken one at a time, was so severe a deperture from the general purposes of the project to justify a serious disagreement that might have hurt the project as a whole. But had they been proposed as a package, they would probably not have been accepted. The PCR's characterization of the final project as something akin to a sector loan is apt (para 5.04) with the important qualification that no agreements on sector policy were included. 2.17 What explains these deviations from the original conception of the project? Because of lack of documentation, the following conjectures are based on interviews. (1) Some of these changes were based on generally accepted IL The Government comments on this PPAR note that these tables were clinically tested by the UP College of Pharmacology, NSTA and the Bureau of Food and Drugs. AL According to the Government, only 6-8 of the 41 studies were directly related to PHC. - 8 - development thinking of the time. This is true of the PHC program,IL the effort to produce indigenous medicines and contraceptives, and the idea of a population program built around a central coordinating body. (2) The Bank had no alternative strategy or convictions it felt comfortable putting forward forcefully. There was skepticism about voluntarism and about the division of responsibilities between DOU and POPCOM, but insufficient conviction to argue for something else. (3) POPCOM, which saw itself as the primary agent responsible for FP, was of no help in arguing that FP should play a greater role in the DOH's PHC program; indeed, it strongly resisted suggestions that its FP delivery program be integrated into the PHC program. (4) The DOH was adept at convincing Bank staff of the importance o' proposed changes for the success of this project and the dire consequences that might follow if not accepted.12L (5) Last but not least, the Bank's eagerness to increase the disbursement rate, which was seriously lagging because of procurement problems, shortage of Government funding and appreciation of the dollar, appears to have encouraged development and acceptance of proposals that promised ready action. Evenwith this pressure, in the end 20 percent of the original credit had to be canceled. 2.18 An additional explanation, supported by the Region, is the difficulty the Bank had "supervising troublesome projects from a COPD" as existed prior to reorganization for PHN projects. D. Output and Impact 2.19 One third of expenditures on this project went for civil works. All buildings planned in the project as amended were successfully completed, although with considerable delays because of periodic shortages of counterpart funds. These buildings were based on upgraded building designs which have now become The PHC approach was adopted by the 1978 WHO Alma Ata Conference; and the decision to implement this approach nationwide was hailed by WHO as a model for other developing countries and led to an award being given to the Minister of Health for his efforts on behalf of the program 101 For example, the Minister of Health argued that the FP would not be neglected in the PHC program because it had been designated as a high priority element of the program and that with or without the Bank he was going to proceed. The provision of relatively sophisticated equipment to regional hospitals was justified on grounds that the health system and its referral backup system had to be strong if it was to be the means for delivering FP and PHC. - 9 - standard. While nearly all buildings provided to DOH are being used for their intended purposes, this is not true of some provided to POPCOM.1-' 2.20 An interesting feature of the PHC program was its effort to encourage local communities to volunteer materials and labor for construction of local health stations. According to the PCR, this effort was ended and the DOH reverted to the use of local contractors, despite an encouraging response from local communities, because the Commission on Audit required "proofs of construction" which could not be obtained for locally financed buildings (para 5.06). According to information acquired by the Audit Mission, other factors were also present, namely the slow pace of progress, inadequate "social preparation" efforts, and refusal of some, mainly poorer, communities to provide the required materials and labor. 2.21 One quarter of project expenditures was devoted to the acquisition of equipment, materials and vehicles. After many delays caused by shortages of funds and procurement problems (PCR, para 5.19), most planned items were in fact purchased. But a 1989 survey by the Government found that a significant number of the equipment items failed to reach their intended users. This shortfall was also observed in field visits by the Audit Mission. The bulk of these missing items are believed to have ended up in other parts of the health system rather than in private hands, but evidence to document what happened is weak. Among the factors accounting for this situation (PCR, para 5.10), the most operationally significant are weaknesses in inventory management techniques and failure to inform end users about the allotment due to them. 2.22 Sixteen percent of expenditures were devoted to IEC. While the quantity of materials produced exceeded plans, distribution problems often resulted in a failure to reach intended audiences and the quality of these materials appears quite variable. The most successful effort was the production and distribution by the DOH of two family health manuals: they (in particular the Family Health Guide) appear to be of good quality and widely available and used. The least successful effort was the failure of DOH to develop IEC materials specifically for family planning. Unfortunately, neither POPCOM nor DOH undertook the studies called for in the SAR to evaluate the impact of these activities. A DOH inspection team operating during the 1983-85 period found its IEC activities up to that point to be ineffective. At the time of audit, few traces of many of these activities could be found. A case in point is the training centers provided to the Regional POPCOM offices. The Audit Mission visited one which consisted of a large bare lecture hall and a dormitory room with bunk beds that had been completed more than a year earlier but had never been used for its intended purpose, namely the training of outreach workers and local health staff in PP. It was used just twice by other agencies for different purposes, but not by DOH which has its own local training center. The Mission was told that this is not an uncommon situation. - 10 - 2.23 Training activities absorbed 14 percent of project expenditures. While the POPCOM training component proceeded apace, the DOH restructured its training program to meet the needs of the PHC program. To get the requisite number of workers in place quickly, the number of courses and their duration were reduced. In addition, the DOH shifted to integrated training programs for provincial workers. This worked well for most subjects but not for schistosomiasis, TB and FP which require more targeted skills training. In addition, refresher courses and training of supervisors were neglected. The result has been a low quality of training for a large number of newly recruited workers and, as the PCR indicates, ten years of neglect in providing adequate FP training to DOH staff (para 5.14). In the absence of this training, there can be no doubt that the provision of FP services was also neglected in the PHC programa. 2.24 Research and MIS components, as indicated above (footnotes 1 and 2), also fared poorly. 2.25 One consequence, or output, that the PPAR failed to consider was the support proviced by POPCOM for the activities of NGO's. One commentator suggested that this was substantial. 2.26 These outputs--so many buildings constructed, so many persons trained and hired, IEC efforts, better detection and reporting, and so on--were supposed to be used to promote family planning, reduce infant mortality, reduce second degree malnutrition in pre-school children and generally improve health of the rural population. So far as FP is concerned, the conclusion must be reached that they failed to do so. The contraceptive prevalence rate for modern methods increased modestly during the implementation period, and even so most of this increase occurred during the early years of the project when it could not have been caused by the project itself." The failure of DOH to provide adequate FP training over this period is telling. So far as POPCOM is concerned, most Bank funds went into capacity building or maintainance which, given the circumstances described in the next section, could not have been effectively utilized over much of the period. 2.27 The situation is somewhat better so far as the other three goals area concerned, but that must be inferred from what has been put in place rather than Mi GOP comments object to this description of training activities and offer a different interpretation. See ANNEX II, para. 15 and 19. iL The estimates for 1978, 1980, 1983 and 1988 are 12, 15, 18 and 21, respectively. The figures are from national surveys analysed and reported i.n a paper by John B. Casterline. Also, discontinuation rates are thought to be high. - 11 - from evidence on impacts."' More than 1,900 additional barangai health stations and 75 rural health units were constructed and staffed with a mixture of salaried and volunteer workers who received at least some training. While quality of care is often poor and clinics near other facilities tend to be underutilized, the sheer increase in numbers must mean that a significantly larger proportion of the population is now within walking distance of at least minimal health or referral services. That quantitative improvement, in turn, must eventually have some impact on mortality and morbidity rates. Also, IEC activities devoted to health were of more significance than those devoted to FP, the most significant achievement being the production and wide distribution of two health manuals considered to be of high and lasting quality. E. The Weakening of POPCOM 2.28 At the time this project started, POPCOM was considered to be a very promising organization, fully worthy of support by the Bank (see para 2.06). Shortly thereafter, a variety of events occurred that effectively destroyed this hope. In 1982, a new chairman was appointed to head NEDA, the organization to which POPCOM was attached. In contrast to his predecessor who was very supportive, this new chairman was opposed to the promotion of FP on religious grounds; while he resigned as chairman of the POPCOM Board so as not to interfere with Board decisions, POPCOM had considerable problems implementing its programs from this time on. Among other things, POPCOM's authority to provide funds to other organizations was restricted. In January, 1983, one of POPCOM's regional offices (which accounted for a fifth of all new acceptors and IUD and pill users) was dismantled over the protest of POPCOM's Executive Director. In April, 1983, the POPCOM headquarters and all its financial records were destroyed by fire. It was also during this period that the Catholic Church withdrew from the Board, among other reasons because of POPCOM's contraception policyiu. 2.29 The situation became so serious that a number of donors, including the Bank, appealed to the Government to remove POPCOM from the administrative control j4L The MIS component of this project was supposed to provide data that would help judge the extent to which this project fostered these goals, but it has not done so. A nutrition surveilance system that was supposed to be part of this component (SAR, para. 3.03) never got off the ground. The PCR notes that the infant mortality rate fell from 74 to 54 per 1000 live births between 1976 and 1987; but obviously, most, if not all, of this decline must have been due to factors other than this project's outputs which were put in place so late in that period. According to one informant, the Church objected to POPCOM's failure to promote 'natural' as well as 'artificial' means of FP. GOP comments suggest a different interpretation, that the objection was primarily because of promotion of artificial methods. See ANNEX II, para. 11. mi - 12 - of NEDA. This was eventually done, but not by moving it into the President's office or into the DOH; instead, it was assigned to the Department of Social Welfare where in the end it fared no better. According to one informant, during the 1984-86 period, part of the problem was that, as the Catholic Church became more openly hostile to him, President Marcos attempted to appease the Church by withdrawing support for the population program. When the Aquino Government took over in 1986, it felt beholden to the Catholic Church and did little to resuscitate the program. In 1987, when USAID's funding of the POPCOM outreach program ceased, that program began to unravel. Finally, in 1988, all POPCOM's responsibilities in the family planning field (but not its resources) were shifted to the DOH, and POPCOM was made responsible for a new program called 'Population Development' which, at the time of Audit, was yet to be effectively definedW. 2.30 As a consequence of these events, plus DOe's neglect of FP during most of this period, the Philippines population and family planning program was probably weaker at the completion of this project than it was at its inception. While these events were reported and concerns about their likely effects on the program sometimes noted in Bank files, the Bank continued to press for increased disbursement of credit proceeds, agreed to reallocate these proceeds to assist in the reconstruction of the POPCOM headquarters destroyed by fire and extended the closing date by 3 years so that this new component, plus all the others, could be completed. F. Sustainability 2.31 At the center, nearly all workers hired and paid for by the project have been absorbed into regular jobs. At the provincial level, only roughly half of such workers have been so absorbed. For example, of the 76 provinces, 40 were, at the time of audit, without provincial health educators, a post for which the project provided funds for hiring and training. This shortfall is explained by lack of priority, tight provincial budgets, and failure of the DOH to absorb the cost. 2.32 In the areas visited by the Audit Mission, maintenance, especially of equipment, was a problem. A survey undertaken by NEDA provides general support for this proposition and also indicates that security was frequently a problem. Local funds are insufficient; and the DOH allocates funds depending on catchment area and number of hospitals, not according to the amount of equipment in plcce or provided by donors. Also, lack of local distributors and maintenance facilities outside of major cities for more sophisticated equipment, including typewriters and some transportation components as well as computers and x-ray equipment, means that down-time, even when funds are available, is inordinately long. GOP comments note that there now exists a Memorandum of Agreement between POPCOM and DOH for use of POPCOM's facilities for family planning and that the Population Development Program is now better articulated. See ANNEX II, para. 12. - 13 - 2.33 With the designation of DOH as the lead agency for family planning services, training and IEC, the future of POPCOM is in considerable doubt. At the time of audit, POPCOM had substantial redundant facilities, equipment and staff. Much of these resources are now being used by DOH. 2.34 Up to the time of Audit, the FP program under DOH has faired no better, perhaps worse, than it did under POPCOM during the last few years. The distribution, outreach, training and IEC programs were functioning poorly, to say the least. But some promising rethinking is occurring which may eventually resuscitate the program. This involves defining the target group for the provision of FP services to be those whose health is at risk because of their reproductive behavior. The hope is that this "health risk" approach will provide a better rational for integrating FP into the delivery of health services and at the same time make the program less politically vulnerable than it was when the, rationale was control of population growth. This approach was accepted in early 1990 but has not yet (as of December, 1990) been effectively incorporated into training and operational work programs. At the same time, the DOH has called upon donors to assist in the improvement of various operations, for example its logistic and management information systems, necessary for an effective FP delivery system. The Bank is contributing to these efforts through the Health Development project (LN 3099-PH). 2.35 The PCR expresses the judgement that the herbal medicine processing plants will eventually play an important role in decreasing the shortages of drugs and medicines in DOH facilities. For the reasons given above (para 2.13), this Audit disagrees; in any event, substantial subsidies would have to be involved. III. Conclusions and Lessons 3.01 Most of the lessons drawn by the PCR refer to rather detailed, operational aspects of this project. Since this Audit is in general agreement with these judgements, this section will focus on somewh&t broader issues. 3.02 The best this project did was to build up the physical infrastructure of the health system and extend it into remote regions. This structure is now considered adequate and no new construction is included in the Health Development Project. Along with other contributions of the project, this has led to an improvement in the capacity of the health system to deliver services, FP as well as health. This project, however, was supposed to go further, to turn this potential into a reality; that it did not do for PP and did only partially for health. 3.03 So far as FP is concerned, failure to go further was caused primarily by political problems after the project started. There are at least seven possible lessons that countries with similar political risks, culture and level of socioeconomic development might wish to consider from this experience. (1) - 14 - If there is significant latent demand for FP that is not being met by existing programs--the case of the Philippines--focus on provision of services rather than on promotion of demand, at least in initial stages. (2) To avoid turf battles and achieve maximum accountability, assign responsibility to one agency."' (3) Assign principal responsibilty to the least politically vulnerable of the reasonable candidates. In most cases that will be a line ministry with well- accepted responsibilities. (4) Consider shifting the program focus from fertililty reduction to spacing and from population control to health. (5) Wherever feasible, rely more heavily on NGO's and the private sector.-81 (6) Provide a cafeteria of contraceptive methods that include "natural" as well as "artificial" methods. (7) An effective outreach system for FP is extremely important; but reliance on non-paid workers is likely to prove unsatisfactory. 3.04 So far as the Bank is concerned, the lesson that might be learned is that there is such a thing as too much flexibility as well as too little. The Bank's approach in the Philippines was to go along with what the Government wanted to do so long as it felt the Government was not blatantly wrong and that capable people were involved. To some extent the Bank must always behave this way. In this case, however, it went too far. Had the Bank acted with a bit more firmness and conviction--for example, resisting the scaling up of the PHC program before its doubts were aswaiged, insisting on more adequate explanations before agreeing to certain expenditure requests, perhaps refusing to agree to some requests until adequate assurances were forthcoming about future policy directions so far as FP is concerned--the outcome might have been substantially better. l In the Philippines case, the DOH at times justified its weak FP program by aguing that POPCOM had principal responsibility. According to oyr commentatior on the draft PPAR, POPCOM played a "considerable role" in facilitating NGO activities. Whether this is continuining under the DOH is not known. - 15 - PROJECT COMPLETION REPORT PHILIPPINES SECOND POPULATION PROJECT (Credit 923-PH) MAY 29. 1990 Population and Human Resources Division Country Department II Asia Regional Office - 17 - PHILIPPINES SECOND POPULATION PROJECT (CREDIT 923-PH) PROJECT COMPLETION REPORT Proiect Identity Name : Second Population Project Credit Number : 923-PH RVP Unit : Asia Region Country I Philippine3 Sector : Population, Health and Nutrition Subsector : Population 1. Summary and Conclusions 1.01 Proiect Objectives. The Second Population Project was designed to assist government efforts to reduce fertility over a five-year period and, at the same time, to decrease infant mortality and malnutrition among children and improve the health status of the semi-urban and rural populations. The project design was based on the following premises: that fertility reduction on the one hand and improved child survival and better family health on the other were interconnected and mutually influencing events; that improvements in health services and health education were necessary to make the practice of family planning widely acceptable; that health services were the major structure for delivering family planning services and to improve these services it was necessary to address the major problems and constraints of the parent health system. The project was intended to constitute an integral part of the Philippines' 1978-82 national family planning program. 1.02 Two agencies of the Philippine Government were involved in providing family planning services under the project: the Population Commission (POPCOM), responsible to coordinate the work of other agencies engaged in population activities, promote population/family planning education and coordinate relationships with external population donors; and the Department of Health (DOH), responsible to provide family planning services through its health facilities such as hospitals, rural health centers and barangay (village) health stations. The project was therefore designed to expand the capacity of POPCOM and DON to support the national population program. For POPCOM, the project included strengthening the agency's coordination capability and improvement of its training and information activities; for DOH, the project supported the expansion of health service coverage to the one-third of the rural population then without adequate health care. The project provided construction, furnishings, equipment, technical assistance and operating costs for development of: (a) regional POPCOM offices and DOH peripheral health facilities; (b) information, education and communication (IEC) materials for POPCOM and DOH; POPCOM and DOH training programs; (c) a DOH pilot primary health care (PHC) scheme; (e) a management information system (MIS) for both POPCOM and DOH; (f) innovative activities under POPCOM's - 18 - population programl and (g) population program research and expansion of POPCOM's research management capacity. 1.03 Implementation Experience. An IDA credit to help finance the project was signed in June 1979, with credit closing originally scheduled for June 30, 1985. Credit closing was extended to June 30, 1986 due to slow project start-up and was further extended to June 30, 1988 to carry out additional activities supporting a new policy emphasis on primary health care (PHC) as well as the priorities of the Aquino administration. The total project cost was US$52.6 million, or 73% of the estimated cost of US$72 million. The decrease was due largely to the devaluation of the peso from P 7.4 per US$1.00 at appraisal to P 21.0 per US$1.00 at project closing. Only US$32.2 million of the original US$40.0 million credit was disbursed, with US$5.6 million cancelled in 1986 and the remainder at the time of final disbursement. Government expenditures for the project totaled US$20.4 million, or 64% of the appraisal estimate of US$32.0 million. Sharply constrained government budgets in the mid-1980s and continuous delays in fund release due to complex government budgeting procedures slowed implementing agencies' access to allocated funds. 1.04 Results. On the whole, the infrastructure, furniture, equipment, and vehicles provided under the project were used successfully to support the Government's health and population programs, and they continue to be used for their originally designed purposes. Less effective, however, were the non- infrastructure components of the project, including training and IEC. 1.05 The project's major goal, that of fertility reduction, was achieved in the sense that fertility levels in the Philippines have declined steadily since the inception of the family planning program. A March 1990 report by the University of the Philippines Population Institute, "An Analysis of Age- Specific Demographic Events in the Philippiness Trends and Prospects," indicates declines in the total fertility rate from 5.92 in 1970, to 5.20 in 1975, 4.96 in 1980, 4.51 in 1983 and 4.28 in 1985. The same report estimates that, based on a preliminary review of the 1988 National Demographic Survey data, the 1990 total fertility rate may be as low as 3.73 under moderate population growth rate assumptions. 1.06 This achievement, however, was not necessarily due to the project, which gradually lost its original focus on family planning activities. While the specific activities carried out under social sector projects often change over the project period for a variety of acceptable reasons, in this project the content of many components diverged sharply over time from the original framework and the project began to lose its investment credit structure and appear more as a sector financing instrument. Some IDA staff felt the project experienced a possible loss of project "discipline", although each of the changes, when proposed, was accepted by the Association on its individual merits. The most important change was the expansion of the DOH primary health care component in the early 1980s from a pilot program to one designed to cover the entire country in a short time. In 1982, DOH decided to move - 19 - rapidly in this direction and adopt primary health care as a national commursity-based system, using voluntary community-level workers and decentralized program management and budgeting. DOH's desire to mobilize all available resources to support PHC introduction nationwide led to the de- emphasizing of its other activities, including family planning. Although much of the project support to DOH was designed to improve the overall health system, rather than directly to assist family planning, there was nevertheless a real decline in DOH attention to family planning over the next several years. This lack of attention was particularly notable in the project's IEC and training components. 1.07 Sustainability. Although temporarily eclipsed, project achievements generally appear to be sustainable. Following the change in government in 1986, a vigorous debate arose within the new Government regarding its appropriate role in the national family planning program. The major outcome of that debate was a shift in institutional responsibilities in 1988, with DOH becoming the lead agency for family planning. The subsequent need for program restructuring resulted in a period of considerable uncertainty and in serious breakdowns in the delivery of family planning services. After several years of delay, however, DOH is now moving strongly to reactivate the program, and has requested Bank Group assistance in doing so. A technical assistance mission visited the country in late April 1990 to help DOH produce a strategic and operational plan for family planning service delivery. 1.08 Findings and Lessons Learned. The major government policy shifts during the project's decade-long implementation period indicate the need for the Government to have a politically-endorsed, technically-defined and fully- costed operational plan for greatest success in population activities. Development of such a plan is now under way with Bank Group technical assistance. A number of lessons were learned from the project and have already been incorporated in the Health Development Project (Ln. 3099-PH), which became effective in January 1990. These lessons include the followings (a) additional ways should be sought to involve communities in the health decisions made on their behalf as well as in facility placement and construction, and risk assessment; (b) prior to undertaking drug or medical supply production, DOH should carry out feasibility studies uf sufficient breadth to help determine the likelihood of success of such a venture; (c) greater attention should be paid to the mechanics of distributing furniture and equipment to rural health facilities. Staff of these facilities should be informed in advance of what they can expect to receive, so that they are able to monitor receipt from master lists. Inventory management systems for furniture and equipment need to be upgraded; - 20 - (d) the logistics system for all DOH drugs and supplies should be upgraded to support its increased range of responsibilities; (e) detailed distribution plans for IEC materials should be developed as elements of any IEC campaign. Training and IEC activities specific to family planning should be integrated into overall DOH operations to maximize their effects and assure continuity of effort; (f) greater effort should be made to develop the management information system and to overcome any restrictions caused by continuing interagency differences as to program priorities and information needs; (g) government rules relating to use of the project Special Accounts should be adjusted to assure that these accounts are conveniently available to implementing agencies; and (h) prompt submission of project audit reports should be sought. 2. Background 2.01 A national population program was launched by the Government in 1970 with the objective of reducing the high level of population growth. Prior to that time, family planning services were offered by non-governmental organizations (NGOs), whose activities expanded in the 1960s with external assistance. Under the new national program, two organizations held major responsibilities: the Population Commission (POPCOM) to coordinate the work of other agencies engaged in population activities, promote population/family planning education and coordinate relationships with external population donors; and the Department of Health (DOH) to provide family planning services through its fixed health facilities such as hospitals, rural health centers and barangay (village) health stations. 2.02 In the late 1970s, after nearly a decade of implementation, the Government decided that the problems confronting the national family planning program indicated the need for a shift in strategy. A downward trend in the number of family planning acceptors and persistent managerial and technical shortcomings in the population program led to the adoption of a new service delivery approach. Under this new approach, the program was to move from services provided by DOH in its own clinics to one which provided services at the community level by multipurpose field workers, including DOH midwives and POPCOM's newly-created full-time family planning outreach workers. The shift was the result of a government decision to integrate family planning into an expanded government health delivery system in order to attract greater numbers of family planning acceptors. 2.03 At the time of project development, the Government was completing preparation of the Five Year Philippine Development Plan for 1978-82, which endorsed the specific demographic goal of reducing the annual population growth rate from an estimated 2.5% per year in 1978 to 2.3% by 1982 and 2.1% by 1987. It was expected that the national population program would contribute significantly to this goal and, with this contribution in mind, specific program achievement targets were developed for numbers of protected couples, increased contraceptive effectiveness and improved follow-up - 21 - services. The plan also noted that improvements in socioeconomic conditions, particularly in health and nutrition status, were expected to help reduce fertility and mortality and, with a suitable time lag, influence population growth rates downward. 2.04 IDA's involvement in the sector began with a loan of US$25.0 million for the First Population Project (Loan 1035-PH) in 1974 to (a) strengthen POPCOM's coordinating capacity by helping to establish new technical units for training and information, education and communication (IEC) as well as 12 regional offices (supported by parallel financing from the United States Agency for International Development (USAID) and the United Nations Fund for Population Activities (UNFPA); and (b) support the service delivery aspects of the program by assisting DOH (then called the Ministry of Health) to improve its rural health and family planning delivery system. 3. Project Objectives and Description 3.01 Project Objectives. The Second Population Project was designed to assist government efforts to reduce fertility over a five-year period and, at the same time, to decrease infant mortality and malnutrition among children and improve the health status of semi-urban and rural populations. The project was intended to constitute an integral part of the Philippines' 1978- 82 national family planning program. The project design was based on several key premises: that fertility reduction on the one hand, and improved child survival and better family health on the other, were interconnected and mutually influencing events; that improvements in health services and health education were necessary to make the practice of family planning widely acceptable; that health services were the major structure for delivering family planning services and that to improve these services it was necessary to correct major problems and remove constraints of the parent health system. 3.02 Project Description. The project provided construction, furniture, equipment, technical assistance and operating funds for the following: (a) Regional POPCOM offices and DOH peripheral health facilities; (b) POPCOM and DOH IEC capabilities; (c) POPCOM and DOH training capabilities; (d) A DOH pilot primary health care (PHC) scheme; (e) A management information system (MIS) for both POPCOM and DOH; (f) Innovativeandtivities in the population program for POPCOM; (g) Population program research and expansion of POPCOM's research management capacity. - 22 - 4. Project Design and Organization 4.01 Project Design. The project was designed to expand the capacity of POPCOM and DOH to support the national population program. For POPCOM, the project included strengthening of the agency's ability to coordinate the population/family planning activities of other agencies and to improve the operation of its own training and IEC programs; for DOH, the project assisted the expansion of health service coverage and related support functions to the one-third of the rural population then without adequate health care. Project timing and scope were appropriate to the needs of a family planning program, the continued expansion of which required integration into existing health services. 4.02 Project Organization. Like the First Population Project, this project included two implementing agencies. In order to ease coordination difficulties experienced during the previous project, in which DOH managed project disbursement and reporting arrangements for both agencies, this project was organized into Parts A (POPCOM) and B (DOH) to reflect the separate budgeting, reporting and auditing responsibilities of the two implementing agencies. Despite these arrangements, however, coordination difficulties did appear and in 1982 the Interagency Monitoring and Coordinating Committee (IAMCC) was established under National Economic Development Authority (NEDA) auspices to act as a formal expediting body for project work being carried out by the two implementing agencies and to help expedite lagging disbursements. 5. Implementation 5.01 Changes in Project Design. The project was implemented with little change in its basic objectives, but with a substantial number of changes in specific project activities. The Credit Agreement itself was amended seven times at intervals throughout the project to adjust descriptions of disbursement categories, with corresponding reallocations of funds among categories. The amendments contained numerous changes in the sizes and types of items to be acquired or constructed, and in the descriptions of specific items. (See Tables 1, 3 and 4 of the Borrower's PCR.) 5.02 The most important amendment expanded the DOH PHC component in the early 1980s from a pilot program to one designed to cover the entire country in a short time. At that time, developing country health authorities were being urged by the World Health Organization to adopt primary health care strategies as a cost-effective way of delivering basic health services to peripheral areas. In 1982, the newly appointed Minister of Healtb decided that DOH should move rapidly in this direction and adopt primary health care as a national community-based system, using voluntary community-level workers as well as decentralized program management and budgeting. These systems encouraged the integration of preventive and curative services at the provincial level and below. - 23 - 5.03 Although family planning is a priority service within primary health care programs, the DOH desire to mobilize all available resources to support PHC introduction nationwide led after 1982 to the de-emphasizing of all its other activities, including family planning. Although much of the project support to DOH was designed to improve the overall health system, rather than to directly assist family planning, there was nevertheless a real decline in DOH attention to family planning over the next several years. This lack of attention was especially notable in the project's IEC and training components. 5.04 Social sector projects often experience changes in activity content during implementation for a variety of acceptable reasons. In this project, however, the content of many of its components diverged sharply over time from the original framework and the pi. ject began to lose its investment credit structure and appear more as a sector financing instrumen*. As a result, some IDA staff criticized the possible loss of project "discipline". As a practical matter, each of the changes was accepted at the time of its proposal on its individual merits by the Association. It is important to note that, despite the changes throughout implementation, the project continued to include the civil works and goods.in types, amounts and costs very similar to those of the original appraisal plans and that its health objectives were fully realized. 5.05 Costs. The final total project cost was US$52.6 million, or 73% of the original total cost of US$72.0 million. The decrease was due largely to the devaluation of the peso from P 7.4 per US$1.00 at appraisal to P 21.0 per US$1.00 at project closing. Disbursements from the Credit totalled US$32.2 million of the original US$40.0 million with the remaining US$7.8 million being cancelled in two stages, US$5.6 million cancelled in 1986 and the remaining amount at the time of final disbursement in April 1989. Total Borrower expenditures were US$20.4 million, or 64% of the appraisal estimate of US$32.0 million. Sharply constrained government budgets in the mid-1980s and continuous delays in fund release due to complex government budgeting procedures slowed the implementing agencies' access to allocated funds. 5.06 Civil Works. Civil works, the largest project component, accounted for US$16.9 million (32%) of total project expenditures. Virtually all planned civil works were constructed, and a number of additional facilities added during implementation. (See Tables 3 and 4 of the Borrower's PCR.) Improved design standards for rural health units (RHUs, large clinics) and for barangay health stations (BHSs, small health posts) were developed as part of project preparation and adopted for nationwide duplication. An innovative aspect of the project was community mobilization to generate gifts-in-kind of materials and labor for construction of BHSs. About 400 BHSs were built using this arrangement in the first project year, at about one-half the cost of comparable facilities built by the Department of Public Works. After their construction, however, the Commission on Audit determined that the new procedure required the same proofs of construction required for regular construction contracts; these were not available under the innovative approach and, as a result, DOH abandoned its creative experiment in community - 24 - involvement in BHS construction and turned again to the use of local construction contractors. 5.07 The project financed a number of civil works not included in the original project description, including: (a) a new headquarters complex for POPCOM following the destruction of its existing one by fire; (b) training rooms at 6 POPCOM regional headquarters; (c) 40 integrated provincial health offices, combining warehousing and administrative space; (d) reconstruction of 28 typhoon-damaged RHUs and 98 BHSs; (e) a print shop at DOH headquarters; and (f) 3 DOH herbal processing plants. 5.08 The three herbal processing facilities were added to the project in response to the DOH desire to expand domestic production capacity for plant- based therapeutic products for minor illnesses. A limited feasibility study, using very limited production assumptions, was carried out by the University of the Philippines College of Pharmacy. All three facilities were eventually constructed but only one is now in operation, and it is producing only one of its original five proposed products. The three facilities do, however, have further operations potential through the 1988 DOH Generic Drug Program, which strongly recommends increased use of such products to reduce drug costs. To be effective, these facilities must do far more than they have achieved to date. 5.09 Furniture, Equipment, Materials and Vehicles. These items constituted the second largest project expenditure with a final cost of US$12.9 million, or 25% of total project cost. Although no complete list of items procured was ever compiled by the implementing agencies, it appears that most planned items were purchased. Adjustments in numbers of items of furniture and equipment were made to match increases in the number of facilities or for needs identified during implementation, e. g., dental chairs for RHUs, additional personal computers and additional POPCOM central office vehicles. Boats for inter-island transport were never acquired. 5.10 As part of the Government's PCR preparation effort, NEDA Regional Offices carried out a survey in April 1989 of furniture, equipment and vehicles acquired under the project for both POPCOM and DOH. This well- conducted survey revealed that a variable but significant number of items per facility procured under the project were not in place for a variety of reasons, including non-delivery at the time of procurement, non-acceptance of delivered items by end-users and appropriation of items by unauthorized parties. The survey further indicated that inventory management techniques were weak at all levels of both implementing agencies and that end-users were never informed about their facility allotments of furniture or equipment. Data on vehicles were aotably more positive, indicating that most had reached their appropriate destinations and were still receiving adequate maintenance. 5.11 Technical Assistance. Technical assistance expenditures were US$3.4 million or 6.5% of total project cost. Much of this expenditure went for external fellowships, and for local consultants to develop IEC products and training modules. This category also supported preparation of the follow-on - 25 - Health Development Project (Ln. 3099-PH). Expenditure on external consultants was minimal. 5.12 Information, Education and Communication (IEC). IEC expenditures were US$8.5 million, or 16% of total project costs, making this the third largest component of the project. The volume of most IEC products for both POPCOM and DOH was increased substantially above appraisal estimates during implementation; for some products, the number increased many times over. About half the funds in this category were expended by DOH on development and publication of over 200,000 Family Health Guides and 70,000 Household Teaching Manuals, designed to provide basic health and family planning information in seven regional languages to rural families and to health workers on the periphery, respectively. Both sets of materials were carefully designed, user tested and attractively printed during 1988. Distribution of these materials across the country is ongoing and their potential as health education sources is large. 5.13 In numbers, the development and production of IEC materials exceeded all expectations, but the lack of a good distribution strategy undermined their potential to attract and maintain interest in family planning. Neither implementing agency had devised an effective way to make these materials available to audiences of different types, in different geographic areas, using different dialects. The IEC materials were also not linked to the ongoing DOH program to train health providers in family planning skills. The impact of IEC activity was not evaluated by either implementing agency. Despite these drawbacks, a series of national studies of Philippine women (analyzing family planning knowledge, attitude and practice) show that a very high 97% of women of reproductive age do know about family planning. IEC materials produced by this project deserve a share of the credit for this level of knowledge, but can be blamed as well for the surprising lack of actual contraceptive practice in light of these high knowledge levels. 5.14 Training. The Credit Agreement originally provided US$7.7 million for travel expenses for field supervision activities. In the Credit Agreement's first amendment in July 1982, travel expenses were dropped from coverage under the credit and replaced by training, studies and information systems with the same level of funding. The purpose of the change was to transfer funding for the incremental recurrent costs of travel to the Borrower and to permit IDA financing for the specified items. The Borrower's PCR confirms that large amounts of training were carried out during the project in terms of numbers of courses and participants. Most of this training, however, served to orient DOH workers across the country in PHC activities and there is little evidence that the intended large numbers of family planning skills training courses were ever carried out. The almost ten-year absence of such training for DOH staff has seriously undermined the ability of its staff to maintain a desired quality of family planning services and has contributed to declining numbers of new acceptors and declining contraceptive continuation rates. - 26 - 5.15 The PHC training did, however, play an important role in providing additional technical and community mobilization skills for the 8,000 or so midwives who underwent training during the next several years. The establishment of this category of DOH staff was supported under the First Population Project (Ln. 1035-PH) and midwives now play a critical role in enabling the DOH to deliver services, including family planning, to underserved and poor barangays. 5.16 Research. About 41 modest research activities covering a wide range of topics related to population and family planning were carried out during implementation. Although 12 specific research topics were agreed at appraisal, this proved to be an unrealistic approach in light of continuing program changes; the actual topics studied were different. (For a full listing of studies, see Table 12 of the Borrower's PCR.) While serious efforts were made by POPCOM to disseminate the research findings, no continuing effect of the research can be determined. 5.17 Management Information System. The assessment of the MIS component in the Borrower's PCR (paras. xvii, 1.30 and 2.10) summarizes the course of this component and notes that the tri-agency system for health, nutrition and family planning information did not materialize due to continuing uncertainties regarding program priorities and information needs. An information system for DOH quite similar to the one proposed under this project has recently been completed with funding from USAID. The Bank- assisted Health Development Project includes support for introduction of technologically-innovative computer mapping systems which permit better targeting of health resources. 5.18 Innovative Activities. Several Bank Group-supported population projects appraised at about the same time as this project provided support for innovative activities; in each case, most of the funds were unused and eventually reallocated to other project activities. This project had a comparable experience as only US$34,000 of the US$1.0 million allocated for this purpose was actually disbursed. 5.19 Procurement. Procurement of most civil works under the project was carried out under local competitive bidding procedures and encountered only routine difficulties. Procurement of goods, however, especially by DOH, experienced a number of serious difficulties in both international and local competitive bidding and numerous supplier complaints were received, particularly regarding incomplete technical specifications, inadequate bid evaluation criteria, and time allowances too short for bid preparation and too long for bid evaluation. These problems required substantial amounts of Association and Government counterpart staff time to resolve and were an important factor in disbursement delays. In the case of procurement of X-ray machines and generators--the two most protracted procurement actions--the Association was slow to take action to help ensure compliance with the procurement guidelines. - 27 - 5.20 Disbursements. Disbursements lagged behind appraisal estimates by about three years and never reached their forecast rate. A Special Account was established in 1983 to facilitate disbursement but had little effect on disbursement performance due to unnecessarily complex Borrower rules for its use. Table 3 and Figure 1 show disbursement progress. 5.21 Audits. The scope and timing of project audits have been of concern to the Association since project inception. To date, no audit of the consolidated expenditures and activities of either implementing agency has been received. Although the Association has received separate audits covering project expenditures through 1986 prepared by the Commission on Audit, these audits did not cover Statements of Expenditure records nor have they separated POPCOM's IDA-supported activities from its overall agency budget. 6. Impact 6.01 The project was to support government efforts to reach targeted improvements in both family planning and in health by 1987, as stated in the 1978-82 Five-Year Philippine National Plan, as follows: (a) a 50% contraceptive prevalence rate; (b) an expectation of life at birth of 66 years; (c) an infant mortality rate of 56 deaths per 1,000 live births; (d) a reduction of second degree malnutrition to 11% of the target population; and (e) coverage of at least 50% of the rural population by health facilities. 6.02 Fertility levels in the Philippines have declined steadily since the inception of the family planning program. A March 1990 report by the University of the Philippines Population Institute, "An Analysis of Age- Specific Demographic Events in the Philippines: Trends and Prospects," indicates declines in the total fertility rate from 5.92 in 1970, to 5.20 in 1975, 4.96 in 1980, 4.51 in 1983 and 4.28 in 1985. The same report estimates that, based on a preliminary review of the 1988 National Demographic Survey (NDS) data, the 1990 total fertility rate may be as low as 3.73 under moderate population growth rate assumptions. 6.03 Despite these data, it is much less clear what impact, if any, project inputs had on the fertility decline described above. No widely- accepted methodology exists for determining such effects on the indicators shown above, due in large part to the multiplicity of socioeconomic factors at work influencing these indicators. Beneficial changes in the level of infant mortality, which did decline from 74 deaths per 1,000 live births in 1976 to about 54 per 1,000 in 1987, and in expectation of life at birth, which rose slightly from 61 years in 1975 to 63.7 years by 1987, cannot be attributed to project inputs. Information on nutrition status is incomplete, but available data indicate the continuing presence of serious levels of malnutrition in many areas of the Philippines. 6.04 Determination of the impact of the project on the most important program indicator, the contraceptive prevalence rate (CPR), is also difficult due to continuing concerns regarding the validity of Philippine contraceptive prevalence survey data in the 1980s. The UPPI report referred to in paragraph - 28 - 6.02 indicates that the CPR for modern methods (as opposed to the all-method count which includes natural family planning, rhythm and other less measurable methods) has risen very slowly from 4.6% in 1970, to 11.4% in 1975, to 14.62 in 1980, to 16% in 1983 and to 20.0% in 1985. Program weaknesses in the later 1980s have probably prevented it from rising much above the 1985 level. There appears to be little question that even the all-methods rate has not reached 502. One of the more interesting questions to be answered from the 1988 NDS is why the total fertility rate has continued to decline when the CPR is static or even declining. Logic would indicate that the two measures move in opposite directions. 6.05 The fourth indicator, that of coverage of at least 50% of the rural population by health facilities, is also difficult to quantify given the definition problems involved in the term "coverage". It is clear, however, that the construction of over 1,000 DOH health and family planning buildings, especially barangay health scAtions and rural health units at barangay and district levels in all regions of the country, has greatly increased the health coverage of the rural population. This expansion of infrastructure also meant that no additional buildings were deemed necessary for inclusion in the recently initiated Health Development Project (Ln. 3099-PH). DOH facility design standard levels were upgraded, but at appraisal, or lower, costs. Furniture and equipment were also provided for these facilities. 6.06 As a part of DOH's PHC program, project funds were used to support two major new initiatives in strengthening the overall DOH management system. The first was to decentralize its responsibility for planning, programming and budgeting to the provincial level and below; the DOH continues to be further along in this process than other Philippine departments. The DOH also undertook the integration of curative and preventive health services under the same leadership within the provincial health office and district hospital in order to maximize scarce budgetary and staff resources and to help ensure a balance of expenditures between hospitals, often favored in the earlier budgeting system, and public health programs. These changes, although still under way, may yield major improvements in DOH management and service delivery capacity. 6.07 The most important impact of the Second Population Project, therefore, was its role in reorienting DOH to improve and expand its service delivery capability to rural, and especially tc remote and underserved, areas. It was always intended that this project would support such activities: the SAR states that "health services are a major structure for delivering family planning services and that in order to improve these services it is necessary to address the major problems and constraints of the parent health system." Public sector family planning services are often provided through a country's public health system and the Philippines was no different. The project supported important improvements in the infrastructure and management of the public health system, and these improvements have served as the basis on which the new Bank-supported Health Development Project was designed. The alternativeservice delivery model supported by the Health Development Project, involving a partnership between DOH, the community and local non- - 29 - governmental organizations to reduce health risk, could be a powerful base for strengthening all DOH services, including family planning. 6.08 A large number of IEC products were prepared under the project. Their assumed impact cannot be determined because no systematic dissemination plan was developed for the materials and no impact evaluation was carried out. The DOH has, however, taken important steps to utilize the Family Health Guide and the Household Teaching Manual as major health education texts nationwide. The distribution of these materials to households and midwives is under way and a large-scale training program in their use is now in progress. These two texts are exemplary in the high quality and relevanze of the materials, including their family planning sections, and if used as planned will be a valuable addition to the DOH health education programs. 6.09 Regarding training, very large numbers of village volunteers and rural health workers were trained in the goals and methods of primary health care under the project. About half of the volunteers trained still perform various preventive health activities in support of the midwives in their barangays. There is no record, however, that the proposed training in family planning service delivery using up-to-date protocols was ever carried out. The DOH has recently identified the need to re-establish a training program for contraceptive delivery skills training as one of its highest priorities. 7. Proiect Sustainability 7.01 The national eivironment in which the project was designed has altered greatly. As already noted, the health system underwent great change in the early 1980s, brought about by the introduction of PHC. In the political realm, a revolution occurred in 1986 and the Government change paved the way over time for major changes in population policy and in family planning program structure. Since the change in Government, a significant national policy debate has taken place regarding the role of government population and family planning policy. In 1987, the Government adopted a new population policy which endorsed both family planning for family welfare and the right of women to choose for themselves the means to control their fertility using medically safe and legal methods. 7.02 In 1988, the final year of project implementation, the Government carried out a major reorganization of the family planning program through its designation of DOH as the lead agency for family planning services. This was done to strengthen future program accountability and effectiveness. To this end, the Government removed all operational responsibility for these services from POPCOM, which had held them since program inception, and designated POPCOM's future role as one of policy coordination and monitoring and evaluation. 7.03 By project closing, POPCOM's role had changed substantially due to the shift of all family planning operational responsibility to DOH. POPCOM's earlier responsibilities of providing nationwide family planning outreach services, contraceptive logistics and oversight of the family planning NGOs - 30 - had fully justified the major civil works and equipment support it received under the project. While no plan for disposition of POPCOM's assets has yet been approved by Government, it is likely that some POPCOM civil works, if properly allocated, could be cost-effectively used by DOH in its family planning operations. Comparable transfers of remaining logistics staff and contraceptive supplies from POPCOM to DOH would help strengthen the program. 7.04 The three herbal processing facilities, although currently not operating effectively, have the potential to provide inexpensive, locally- produced over-the-counter remedies for DOH. While these facilities would have benefited from a more comprehensive feasibility study at the time of construction, they are nevertheless able to play a role consistent with the goals of the recently-adopted DOH Generic Drug Law in decreasing the shortages of drugs and medicines in DOH facilities. 8. Association and Borrower Performance 8.01 The total amount of staff time spent on this project (496 staff- weeks), although high, was comparable to the staff inputs for other population projects at that time. The civil works components of the project were carried out well, with good performance from implementing agency staff and careful supervision by IDA staff. Flawed government procurement procedures for furniture and equipment, however, led to a series of disputes with unsuccessful bidders, with several of these delays worsened by confusing IDA responses. In general, the Association's strength lay in its willingness to agree to adjustments in project specifies w4thin the overall project design to meet changing sector needs. In some cases, such as the herbal processing plants, this flexibility led to incomplete assessment of the requirements of such revisions, but for the most part the changes have served the implementing agencies and their clients well. On the Government side, both implementing agencies ably carried out much of the project, although neither appears in retrospect to have been able to dedicate sufficient staff and time resources to implement the family planning goals of the project. 9. Lessons Le4rned and Recommendations 9.01 The number of government policy shifts during the project's decade- long implementation period indicates the need for the Government to have a politically-endorsed, technically-defined and fully-costed operational plan for greatest success in population activities. Development of such a plan is now under way with Bank technical assistance. A number of lessons were learned from the project and have already been incorporated in the Health Development Project (Ln. 3099-PH), which became effective in January 1990. These lessons include the following: (a) additional ways should be sought to involve communities in the health decisions made on their behalf as well as in facility placement and construction, and risk assessment; - 31 - (b) prior to undertaking drug or medical supply production, DOH should carry out feasibility studies of sufficient breadth to help determine the likelihood of success of such a venture; (c) greater attention should be paid to the mechanics of distributing furniture and equipment to rural health facilities. Staff of these facilities should be informed in advance of what they can expect to receive, so that they are able to monitor receipt from master lists. Inventory management systems for furniture and equipment need to be upgraded; (4) the logistics system for all DOH drugs and supplies should be upgraded to support its increased range of responsibilities; (e) detailed distribution plans for IEC materials should be developed as elements of any IEC campaign. Training and IEC activities specific to family planning should be integrated into overall DOH operations to maximize their effects and assure continuity of effort; (f) greater effort should be made to develop the management information system and to overcome any restrictions caused by continuing interagency differences as to program priorities and information needs; (g) government rules relating to use of the project Special Accounts should be adjusted to assure that these accounts are conveniently available to implementing agencies; and (h) prompt submission of project audit reports should be sought. - 32 - Table 1. Related Bank Loans and/or Credits Loan/Credit Year of Title Purpose Approval Status (1) (2) (3) Loan 1035-PH, To strengthen the 1974 Completed First Population Philippines population December 31, 1982 Project program and improve the rural health and family planning delivery system. Loan 3099-PH, To expand and improve 1989 Just underway. Health Development public and primary Project health care. - 33 - Table 2 Page 1 of 2 Table 2. Project Financing and Costs A. Project Financing (US$ millions) Expense Category Original Original Final (1) + (2) (2) + (3) IDA Credit GOP Allo- IDA Credit Original Final cation IDA + GOP IDA + GOP [a] rb] (c) (1) (2) (3) (4) (5) Civil Works 8.0 8.0 8.2 16.0 16.2 Furniture, Equipment, Materials and Vehicles 8.4 - 11.7 8.4 11.7 Technical Assistance 6.4 - 3.3 6.4 3.3 IEC Prototypes and Production 6.2 6.3 6.6 12.5 13.0 Training, Studies, MIS 4.7 4.9 2.8 9.6 7.7 Innovative Activities 1.0 1.0 0.1 2.0 1.1 Reconstruction - - 1.7 - 1.7 Recurring/Incremental Costs - 4.4 - 4.4 4.4 Unallocated/Contingencies 5.4 7.4 - 12.8 7.4 TOTAL 40.0 32.0 34.4 72.0 66.4 NOTE. Detail may not add to totals because of rounding. IDA - International Development Association GOP - Government of the Philippines IEC - Information, Education and Communication MIS - Management Information Systems [a] - IDA Staff Appraisal Report (SAR), May 23, 1979 (b) - Ibid. [c] - IDA Credit Agreement Amendment No. 7, December 31, 1987. - 34 -Table 2 Page 2 of 2 Table 2. Project Financing and Costs (Continued and concluded) B. Project Costs (US$ millions) Expense Category (2) + (3) Actual Actual Actual Final IDA Dis- GOP Dis- Total Cost IDA + GOP bursements bursements (6) + (7) [dJ fel (5) (6) (7) (8) Civil Works 16.2 8.8 8.1 16.9 Furniture, Equipment, Materials and Vehicles 11.7 12.9 0.1 13.0 Technical Assistance 3.3 3.1 0.3 3.4 IEC Prototypes and Production 13.0 3.3 5.2 8.5 Training, Studies and MIS 7.7 2.4 2.5 4.9 Innovative Activities 1.1 0.0 0.1 0.1 Reconstruction 1.7 1.8 0.5 2.3 Recurring/Incremental Cost 4.4 - 3.7 3.7 Unallocated/Contingencies 7.4 TOTAL 66.4 32.2 20.4 52.6 NOTE. Detail may not add to totals because of rounding. (d] - GOP Project Completion Report (no date, but approximately November 1989] (e] - GOP response to IDA inquiry [no date, but approximately February 1990]. -36- Table 3 Page 2 of 3 Table3. Status of Covenants (Continued) Covenant Subject Deadline Status Credit for Agreement Compliance (1) (2) (3) Section 4.02 Preparation and sub- Not later than six MOH submit- mission of Annual months after calendar ted separate Audit Report year end annual Commission on Audit (CoA) reports for POP II 1981-87 projects. For 1983-87, these are integrated in the general annual audit issued for POPCOM by CoA. Section 4.03 Installation of POP- December 31, 1979 Accomplished prior COM accounting system to project imple- acceptable to Bank mentation Section 4.04 Preparation and sub. Annually by Septem- Annual work- mission of annual ber 30 plan submit- workplan ted every first quart- er, 1980-88 Section 4.06 Completion of 5-year December 31, 1979 5-year popu- population plan; con- lation plan veyance of same plan submitted to Bank Section 4.06 Consultative meetings March 30, 1980 IDA consul- on population plan tations timetable Section 4.06 Complementarity be- December 31, 1979 PHC Commit- tween population field tees at all workers and clinical organizational services under the levels includ- GOP's population pro- ed both popula- gram tion and primary health care workers - 35 Table 3 Page 1 of 3 Table 3. Status of Covenants Covenant Subject Deadline Status Credit for Agreement Compliance (1) (2) (3) Section 2.04 Credit closing, date June 30, 1985 Third and final of the Agreement extension up to December 31, 1988 Section 3.02 Hiring of consultants As necessary, POPCOM hired 4 throughout project CMCs and 6 EAs; life DOH hired 2 architects, 4 IEC consultants, 1 PHC consultant, and 1 printing consult- ant Section 3.03 Review of IEC dis- October 31, 1980 Submitted tribution system for major re- POPCOM; submission of commendations recommendations aris- ing therefrom Section 3.06 Preparation and June 30, 1989 Work in progress submission of Pro- ject Completion Re- port (PCR) POPCOM - Population Commission of the Government of the Philippines CHC - Construction Management Consultant EA - Engineer-Architect DOH - Philippine Department of Health (was Ministry of Health) IEC - Information, Education and Communication PHC - Primary Health Care - 37 - Table 3 Page 3 of 3 Table. Status of Covenants (Continued and concluded) Covenant Subject Deadline Status Credit for Agreement Compliance (1) (2) (3) Section 4.07 Study of functional December 31, 1979 Submitted to analysis of health the Eank as services required Section 4.08 Installation of DOH December 31, 1979 Accomplished accounting system for POP II funds acceptable to the Bank Section 4.09 Development of Policy April 30, 1989 PHC Policy Paper on Primary Health Paper de- Care veloped and submitted as required. Figure 1. CUMULA1VE ESIMMED & ACTUAL. DOSUSEMEN SCHEDULES (PCR 923 PH) 50 40 34A 0 ... ........ / 32.2 30(a) 0 a -Saf Appra salcepr(SR,My2,17 f-4 (b) A1M/8U46512 bin 21) 10 A SM Ad / axMMOSMG / AA A A A A "4md 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 a - staff Appraisal Report (SAR), May 23, 1979 WM4612 b - Government of the Philippines, Project Completion Report (PCR), August 1989 - 39 - ANNEX PHILIPPINES: SECOND POPULATION PROJECT CREDIT 923-PH PROJECT COMPLETION REPORT AUGUST 1989 National Economic Development Authority Hanila, Philippines - 41 - ANNEX PHILIPPINES SECOND POPULATION PROJECT (CREDIT 923-PH) PROJECT COMPLETION REPORT The Borrower's Review of the Project Summary and Conclusions Background i. The Philippine Government, cognizant of the need to strengthen the Population Commission's (POPCOM's) coordinating role in the population program, as well as the need to expand and improve the management, supervision and overall performance of the health and family planning services of the Department of Health (DOH), entered into an agreement with the International Development Association (IDA) on June 27, 1979 for the implementation of the Second Population Project. An IDA credit for US$40 million was provided, covering six components, namely: infrastructure and service expansion, training, information/eaucation/comunication (IEC) activities, research, development of a management information system (MIS), and implementation of a primary health care (PHC) program. ii. The original credit &mount was reduced to US$34.4 million in 1987 as a result of the general policy of the new administration which came into power in 1986 to review all ongoing foreign-assisted projects (see Tables 1 and 2). As of the original credit closing date (June 30, 1985) the actual amount disbursed was US$19.4 million or about 48% of the original amount. However, the total credit utilized as of June 1989 was US$32.2 million or 94% of the revised credit of US$34.4 million. iii. The original closing date of June 30, 1985 was extended three times: (a) June 30, 1986; (b) December 31, 1987; and (c) June 30, 1988. The first extension was due to unfinished activities because of slow project start-up. The subsequent extensions were primarily due to new policies and program thrusts in support of PHC and family planning as well as those that were adopted by the Aquino administration, requiring the inclusion of additional activities to strengthen further the family planning and health service delivery systems of the country. Project Organization iv. POPCOM implemented the project using its existing organizational structure. The POPCOM Board of Commissioners, composed of the heads of seven - 42 - government and private organizations, acted as the policymaking body, with the POPCOM Secretariat acting as its implementing arm. The Secretariat was headed by an Executive Director, assisted by a Deputy Executive Director and five Division Chiefs representing planning and research, information/education/ communication, training, finance and logistics. The Executive Director was designated as the project coordinator and the Division Chiefs as component coordinators. At the field level, 13 Regional Officers, assisted by technical and administrative staff, managed the coordination and monitoring of the project. Provincial, city and municipal outreach personnel throughout the country assisted regional office staff in implementing the project. v. The Ministry of Health, now called the Department of Health, appointed one of its undersecretaries as its project coordinator. He was assisted by a deputy and nine senior staff acting as component coordinators for training, logistics and procurement, finance, civil works, IEC, MIS, family planning and primary health care. Thirteen regional health directors, provincial and city health officers, municipal health officers and the rural Barangay Health Service (BHS) midwives at the village level, assisted in the implementation of project activities. Primary health care committees were also organized at various levels to assist the regular health personnel in the provision of services. vi. To facilitate the coordination and implementation of the project by the two agencies, an Inter-Agency Monitoring and Coordinating Committee was organized, composed of representatives from the Departments of Finance, Budget and Management and Health, POPCOM, and the National Economic and Development Authority. It had a Steering Committee that resolved problems concerning project operations, fund releases and coordination. Assisting the Steering Committee was a Technical Working Group which monitored and periodically assessed project implementation. Project Implementation vii. Project implementation was very slow during the first three years (1980-82) when only about US$5.9 million or 25% of the credit was disbursed (see Table 2). The slow start-up was partly due to the simultaneous implementation of the First Population Project which was still ongoing when the Second Population Project was starting. It was also partly due to some internal and external problems including: (a) the relative inexperience of both POPCOM and DOH in implementing a World Bank Group-assisted project of such magnitude; (b) frequent shifts in leadership concomitant with changes in personnel assignments, policy directions, thrusts and strategies which called for the revision of the originally identified and approved activities; (c) delayed submission of field reports; (d) delayed processing of reimbursement applications resulting in slow credit disbursement; and (e) difficulties experienced by both agencies in following IDA reimbursement procedures. viii. Project implementation began to accelerate in 1983 when the following measures were adopted: (a) formulation of an accelerated work program by the implementing agencies at the start of CY 1983; (b) improvement of DBM's procedure for releasing funds; (c) improvement of the implementing agencies' - 43 - reporting systems and procedures in processing documents coming from the field; (d) establishment of a Special Account in the amount of US$2.3 million during the last quarter of CY 1983 to facilitate fund disbursement; (e) a change in IDA-Government cost-sharing in favor of the Government as per the revised credit allocation schedule (see Table 1); and (f) simplification of IDA requirements and procedures for the availment of funds. ix. Additional activities falling within the original project objectives and strategies were included in the course of implementation. These additional activities were identified and developed to respond to the changing policy directions and program thrusts of the health and family planning programs and included, inter alias (a) changes made in the training component, de-emphasizing family planning in favor of primary health care; (b) development of a Family Health Guide and the Household Teaching Manual; (c) the conduct of other research studies; (d) purchase of printing press equipment; and (e) construction of additional structures. Overall Project Accomplishments x. In general, the agencies were able to meet the majority of the project targets as modified. They were also able to complete most of the additional activities. In civil works, about 90% of activities planned for 1980-84 were completed by end-1984. POPCOM's regional offices were 90% completed while about 80% of its warehouses and vehicle maintenance workshops were completed in 1984. DOH completed construction of 75 main health centers (MHCs) in 1984 or 100% of the original target for 1980-1984 and reconstructed 28 additional MHCs by end-1988.1/ The number of barangay health stations (BHSs) completed and reconstructed totaled 1,006 or 111Z of the original target. Activities under the PHC component were achieved as planned, including the training of health workers and volunteers and the organization of several PHC committees at all levels. Logistics support was procured, delivered and installed in the POPCOM regional offices, warehouses and vehicle workshops and DOH's regional offices, herbal processing plants, integrated provincial health office (IPHO), MHCs and BHSs. Accomplishments by Component xi. Civil Works. About 90Z of civil works planned for 1980-84 were completed in 1984 (see Tables 3 and 4). All the original and additional activities were completed before the final completion date of March 31, 1989, utilizing about US$8.8 million or 1082 of the IDA allocation for civil works. In addition, US$1.8 million was spent for typhoon-damaged MHCs and BHSs. Specifically, this component accomplished the following: (a) construction of 75 MHCs and, in addition, the reconstruction of 28 typhoon-damaged MHCs; (b) construction of 908 BHSs and, in addition, the reconstruction of 98 typhoon-damaged BHSs; 1/ Main health centers are now called rural health units (RHUs). - 44 - (c) construction of one IEC printshop for DOH, including the expansion and renovation of the existing IEC printshop; (d) construction of 39 IPHO warehouses and three herbal processing plants; and (e) construction of five regional population offices and a complex housing the central office and the regional offices of POPCOM for Metro Manila and Southern Luzon. xii. Training. Another significant accomplishment of the project was the training of health and para-medical personnel, health and family planning village volunteer workers numbering about 545,000, almost 902 of whom were involved in the primary health care program, with the rest involved in the promotion of family planning. This represents a 1,000? accomplishment rate. Total training costs amounted to about US$2.5 million or only 84? of the IDA allocation of US$2.8 million. One significant change in this component was the much greater emphasis given to PHC-related training programs than to family planning skills development and upgrading. xiii. Primary Health Care. Initially designed to pilot test the PHC scheme, this component was expanded after being tested in 12 regions and 12 provinces to cover all municipalities and cities in the country (except Metro Manila); 37,827 barangays out of a national total of 41,114 barangays (excluding the National Capital Region) were therefore included. The project succeeded in enlisting and training 422,447 volunteer barangay health workers (BKWs) or &chieving one BHW for every 18 households, thereby exceeding the original target ratio of 1:20. It also increased the number of MHCs by 42 and the BHSs by 202, thereby increasing the population coverage by about 4% compared with 1979 data. On average, in 1989 one BHS served a total of 4,500 people within its catchment area and was situated an average of 6.3 km from the nearest health facility. Based on NEDA's regional reports, an average of about 1,000 patients were served and treated per month by the BHSs and MHCs. Services offered include maternal and child h3alth, pre- and post-natal care, nutrition, immunization, family planning, etc. Furthermore, to increase self- reliance in PHC services, three herbal processing plants were constructed to produce five scientifically tested plants that will produce low-cost drugs and medicine for ailments commonly occurring in the rural areas such as colds, cough, diarrhea and fever. For this component, excluding construction, DON was able to disburse US$395,369 or 61% of the IDA allocation of US$650,000 for PHC seed funds. xiv. Furniture, Equipment and Vehicles. Almost all furniture, equipment and vehicles were procured and delivered within the original project life. Equipment for the 75 MHCs, 915 BHSs and IEC printshop was procured in 1984 while equipment for the 40 IPHO, x-ray machines for 90 hospitals and health centers, three tabletting machines, 112 dental sets, 87 generating sets, 90 SSB, vehicles and computers were purchased and delivered from 1985 to 1988. Acquisition of equipment and furniture for POPCOM's central and regional offices was completed in 1987, except for computer hardware which was delivered in July 1989. However, results of an inventory conducted by NEDA 45- regional offices revealed that some equipment and furniture procured for BHSs and MHCs were unaccounted-for due to either non-delivery or non-acceptance of the equipment and furniture by health personnel in the MHC and BHS or the use/ placement of the equipment and furniture in another facility. Overall, this component utilized US$11,233,948 or 96? of the IDA allocation of US$11.7 million. xv. Information/Education/Communication. The major accomplishment under the IEC component was to respond to the problem of lack of print materials in the field and the need for development of radio, film and audio-visual materials to promote health and family planning in the countryside. One particularly significant accomplishment of the project was the development, production and distribution of two very important manuals: the Household Teaching Manual and the Family Health Guide. The former is a reference manual for the training and use of field health personnel while the latter provides training and reference material for the enrolled households (one copy for every 20 households managed by a rural health midwife and Barangay Health Worker). DOH promoted AKO (Ang Katawang Okey) in the early stage of the project, highlighting the use of tri-media to promote positive health values and practices, and POPCOM adopted this strategy to strengthen its regional capability in order to support service delivery and reinforce central and regional IEC efforts. Thus, prototypes or master copies of IEC materials were developed and reproduced, IEC equipment was purchased, and advisory services and fellowship programs were availed of, amounting to US$4.9 million or 74% of the US$6.6 million IDA allocation for IEC. Zvi. Research. The 41 research studies conducted under the project were used as bases for policy development, planning, programming and development of new projects for health improvement and family planning program development. The findings of these studies were discussed and shared with the various government and non-government agencies through research utilization workshops and conferences as well as print and other media. xvii. Management Information System. The procurement of computer hardware for the two agencies was the only accomplishment under this component. While the POPCOH-MIS had several systems developed under another funding source, its computerization was hampered by late procurement of hardware. On the other hand, the DOH-MIS developed during the First Population Project was not utilized. It is presently undergoing a thorough revision. Unfortunately, the expected development of a tri-agency system for health, nutrition and family planning did not materialize due to differences in program priorities, information needs and concerns. Project Benefits xviii. The following are the direct and indirect benefits derived from inputs provided under the project: (a) increased health and family planning service and clientele coverage due to the construction of 908 new BHSs manned by trained midwives and 75 new MHCs manned by doctors, nurses, sanitary engineers, and midwives; - 46 - (b) improved service and better logistical support due to procurement of new medical equipment and vehicles; (c) better storage capacity for contraceptives, medical supplies and equipment due to construction of POPCOM warehouses and 39 new IPHO warehouses; (d) wider provision of low-cost herbal drugs for ailments commonly experienced by the rural population through the operation of herbal processing plants; (e) better working, training and conference facilities for POPCOM personnel and participating agencies due to construction of five regional offices as well as the central office complex housing the National Capital Region and the Southern Tagalog Region; (f) better trained midwives and other health personnel to deliver health and family planning services due to the various training programs conducted; (g) better IEC campaigns through the production and dissemination of various IEC materials; (h) provision of a better basis for strengthening the delivery of health and family planning services through the conduct of various research studies; (i) almost universal awareness (97%) of family planning among the eligible population; (j) increased use of family planning methods from 32% in 1983 to 45Z in 1987; (k) a decreased total fertility rate from 5.0 in 1980 to 4.3 in 1988; and (1) a decline in the desired family size among couples from 5.8 children in 1970 to four children in 1986. Lessons Learned and Recommendations xix. During project implementation, the Government learned some lessons which will be useful in designing and implementing future related or similar projects. (a) Project Design (i) The implementation indicators used for a project should not be changed in the course of monitoring project progress. (ii) As policies, priorities, and program thrusts change, the medium-tem project plan of action should be revised so that - 47 - appropriate changes in annual work plan activities and targets are properly made. (iii) Specific steps to synchronize all activities under each major project component should be properly spelled out to avoid overlapping of activities and wastage of limited resources. Similarly, the activities of all components should be synchronized with each other. For example, equipment should not be purchased until after the majority of facilities have been constructed and delivery should be timed so that the implementing agency does not have to pay an additional cost for warehousing the equipment as it depreciates. (b) Project Organization and Implementation (i) A project with two major parts implemented by two agencies should have an organizational arrangement ensuring effective coordination and achievement of specific activities/targets. Such an arrangement could be provided by an inter-agency committee composed of representatives of all concerned major agencies like NEDA, DBM, DOF and COA. (ii) Use of the existing organizational structure for the Second Population Project was preferrable to the previous project's establishment of another project management staff. The approach under the second project provided DOH and POPCOM with valuable experience in managing a large, foreign-funded project. (iii) Prior to project implementation, all procedures and regulations governing implementation of foreign-assisted projects should be made clear to all offices and personnel concerned, from the national level to field units. This includes what reports should be submitted to what office at what specified frequency, what report format to use and the supporting documents to attach, what financial system to follow, how communications should flow, how operational problems could be resolved, among others. (c) Project Monitoring Prior to project implementation, specific implementation indicators should be identified and agreed upon by the funding and implementing agencies. Furthermore, a project monitoring system should be designed to include how and when financial and physical progress reports should be prepared, audited and submitted, and how records are analyzed; this should be kept for future use in status report writing and preparation of Project Completion Reports, etc. It is also strongly recommended that more frequent supervision missions be scheduled in the early and middle stages of project implementation to - 48 - facilitate start-up activities and implementation of new or additional activities. 1. Project Review Project Context 1.1 The Second Population Project grew out of Government's concern that a high level of population growth would impair its efforts to improve the quality of human life, and that the population continued to grow because fertility levels were high, the population was basically young, and the mortality rate had declined due to improved health and nutrition services. The project was therefore formulated to reduce the fertility level and improve child survival/family health, two interconnected and mutually influencing contributions to achieving family welfare. The project was also designed to assist in the institutional development of the coordinating structures of the national population program from the national to the municipal level, and to gain the widespread participation of an informed community in the promotion and adoption of health and family planning practices. The project was expected to result in regulated population growth, which would increase the return on government investments in social and economic programs and improve the quality of life of the population. Project Description 1.2 The Second Population Project was an integral part of the Government's goal to provide rural and semi-urban areas with population and health services, particularly underserved and unserved communities. The project comprised a two-part program, providing financial assistance to POP'OM and DOH. For POPCOM, the strengthening of its coordinating role in the population program was to be assisted by means of: (a) constructing, equipping and furnishing seven regional offices 2/ and 13 combined warehouses/motorpools for storage of program commodities and maintenance of vehicles; (b) procuring 106 vehicles and boats, special equipment for training, IEC and MIS, and materials for preparing IEC finished products; (c) employing technical staff for central and regional offices, increasing supervision of IEC training and MIS field activities, maintaining vehicles and equipment, and distributing IEC materials; (d) providing 100 person-months of advisory services to support MIS, research, IEC, training, logistics and infrastructure activities; 2/ The other six regional offices were financed in 1974-75 through a USAID grant. - 49 - (e) providing 195 person-months of fellowships and 3 person-months of study tours for IEC, MIS and training; (f) conducting training courses in management, family planning, IEC skills and trainers' development for POPCOM staff and its participating agencies; (g) designing IEC population and family planning prototypes, mass repro- ducing and distributing them for use in educating and infarming the family planning (FP) clients and the general public as well as service delivery and motivational workers; (h) undertaking population research and other studies; (i) designing and operating an effective MIS to monitor the population program; and (j) undertaking innovative activities in support of the population program. 1.3 For DOH, the expansion and improvement of its management, supervision and overall performance of health and family planning services was to be assisted by means of: (a) constructing, furnishing and equipping 75 main health centers and 915 barangay health stations in unserved areas; (b) procuring 40 vehicles and boats, equipment for IEC, MIS and training for the use of central, regional and provincial offices; (c) employing technical staff for IEC and training in central, regional and provincial offices, increasing the field supervision of IEC, training, MIS and primary health care activities, maintaining vehicles and equipment, and distributing IEC materials; (d) providing 200 person-months of advisory services for training, IEC, MIS, logistics and primary health care activities; (e) providing 145 person-months of fellowship in training, IEC and MIS; (f) conducting management, planning, teaching, IEC and MIS courses for DOH staff working in its health/population/nutrition programs; (g) designing IEC prototypes, mass reproducing and distributing them for use in educating and informing the public on health, population snd nutrition; (h) designing and operating an effective MIS to monitor the health, popu- lation and nutrition programs; (i) undertaking primary health care schemes using barangay health workers in 12 provinces, one in each of the 12 health regions; and - 50 - (j) undertaking innovative activities in support of the population program. 1.4 The general objective of the project was to assist the Government of the Philippines to reach the target of providing 402 of couples in repro- ductive ages with family planning services by 1982 and 50Z by 1987; to extend life expectancy (in years) from 61 in 1975 to 63 in 1983 and 66 in 1987; to reduce infant mortality from 74 per 1,000 live births in 1976, to 60 per 1,000 in 1983 and 56 in 1987; to reduce the prevalence of second degree malnutrition among children under six years of age from 252 to 162 in 1982 and 11% in 1987; and to reduce morbidity from priority communicable diseases 3/ by 202 by 1983 and by 452 by 1987 from the 1979 level.4/ 1.5 In terms of desired change, the project was specifically expected to: (a) increase the number of couples practicing family planning as a result of considerably intensified IEC efforts, improved clinic services by well- trained, well-supervised staff, the establishment of new health facilities and the introduction of primary health care schemes; (b) reduce infant mortality through better health care services to mothers and children, more effective birth spacing, and the inculcation of better health practices by an intensive IEC program; (c) reduce second degree malnutrition of pre-school children by means of improved counseling to mothers, early detection and follow-ups, intensified nutrition education, and a faster response to nutrition problems in areas identified by the nutrition surveillance system;5/ and (d) reduce morbidity and mortality from priority communicable diseases as a result of preventive IEC campaigns and prompter treatment of cases by better trained staff well-supplied with appropriate medicines. 1.6 The project had the following components: (a) infrastructure and service expansion through construction and the procurement of furniture, equipment and vehicles; (b) training; (c) information, education and communication activities; (d) research; (e) management information system development; and (f) primary health care development. 3/ These are gastroenteritis, tuberculosis, malaria and schistosomiasis. 4/ Source: Five-Year Philippine Development Plan, 1978-82. 5/ This formed an integral part of the MIS component. - 51 - Project Design and Organization 1.7 The project design was based on the premise that fertility reduction on the one hand, and improved child survival and family health on the other, are interconnected and mutually influencing events. A review 6/ of several studies on population, health and nutrition suggested that large family or closely spaced births were related to increased morbidity and mortality of infants and children, as well as to the children's subnormal physical growth and intellectual development. In the same way, they were also found to be related to maternal morbidity and mortality. 1.8 It was recognized that Filipinos valued large families partly due to the high infant mortality rate. Conversely, it was hoped that awareness by parents that they can raise healthy children would stimulate the practice of family planning. From the economic standpoint, population, nutrition and health are considered critical in the attainment of the fundamental goals of development. Total human and economic development requires the capacity of each individual to participate meaningfully in development activities. On the whole, a rapid increase in population exacerbates social and economic problems. 1.9 The Government seemed to have shared and understood the project concept. At the policy level, three consecutive Philippine Development Plans (1978-1982, 1983-1987, 1988-1992) have clearly acknowledged the strong association of population growth with health and nutrition. This close linkage is embodied in the Government's adoption of a multi-faceted, multi- sectoral approach towards the attainment of improved health and nutrition as well as a population growth rate at a level conducive to economic development. Following this policy, planners in the concerned government agencies outlined the following guidelines for developing the project design: (a) health services were to be a major structure for delivering family planning services, and in order to improve these services, it was necessary to address the major problems of the parent health system; (b) apart from the direct effects of improved health and family planning services on fertility reduction, there was a need for support and institutional development of the coordinating structure of the national population program at all levels; and (c) in order to effectively increase health and family planning services outreach, it was not enough to expand the formal infrastructure of facilities and personnel, it was also essential to obtain widespread participation of an informed and knowledgeable community. 1.10 The project concept was not in itself innovative but was largely intended to build on the results of the First Population Project. It was based on an existing policy of the Philippine Government to reduce fertility through an integrated framework which takes into account the interactions between the fertility behavior of couples, and health, nutrition and educa- tion. The project also included a substantial number of innovative activities which developed during the project life. These included pilot testing of the Primary Health Care concept; strengthening of the Restructured Health Care 6/ Source: Dr. Alejandro Herrin, Population and Development. - 52 - Delivery System; establishment of three Herbal Processing Plants located in the three major islands of the country--Luzon, Visayas and Mindanao; the development, production and distribution of the Family Health Guide and the Household Teaching Manual, materials designed to bolster the primary objective of the health program under the PHC concept; the conduct of integrated research on indigenous medicinal plants for FP; and the expansion of the population program coverage by addressing all population sectors. 1.11 The scope and scale of the project was appropriate in the light of the objectives for the following reasons: (a) the requirements for infra- structure, equipment and furniture essential for an effective networking and delivery of services were taken into account; (b) recruitment, training, hiring and deployment of paid and voluntary health and family planning workers were given high priority; and (c) the project components were mutually reinforced by activities supported by other funding agencies, notably the USAID, WHO, JICA and UNFPA. 1.12 The project was well prepared in that the major aspects of instituting an integrated health-family planning program were adequately considered by the planners. They alsu carefully evaluated the experience under the First Population Project and improved where necessary in the second project. The two projects thus constituted for the Philippine Government an opportunity to set up a viable operational base for a country program on population, health and nutrition. 1.13 The timing of the project was appropriate. At the time the project was launched, the annual population growth rate was estimated at 2.52 due to an increase in the proportion of women of child-bearing age, a decline in the mean age of marriage of women from 24.4 years in 1975 to 23.3 in 1980, and a decline in the contraceptive prevalence rate of currently married women from 37Z in 1978 to 35% in 1980. On the other hand, the country's infant mortality rate was estimated at 63.2 per 1,000 live births in 1980, the maternal mortality rate in the same year was 100 deaths per 100,000 live births, and malnutrition remained an extensive problem. In 1979, it was estimated that 6% of all infant deaths were directly attributable to malnutrition. 1.14 In retrospect, the construction of the main health centers, the barangay health stations and the regional offices of POPCOM; the provision of the necessary equipment and furniture to these newly constructed facilities; the recruitment, training and fielding of personnel to staff them were some of the major aspects of the project design that contributed to its success. The services provided through these facilities covered major DOH programs promoting the primary health care concept. Under this concept, family planning is part of the maternal and child health program. 1.15 The roles and responsibilities of DOH Rnd POPCOM as the two main government agencies charged with implementing the project were clearly defined. DOH was to develop its health services as the major structure to deliver family planning services and POPCOM was to build its capability to coordinate a multi-sectoral population program. This delineation of roles required DOH and POPCOH to maintain a close working relationship. The organization of the project differed significantly from that of the First - 53 - Population Project. The use of the existing organizational structure of DOH and POPCOM and the designation of responsible officials to coordinate the implementation of specific project components under the second project were found to be more cost-effective, systematic, efficient and logical than arrangements under the first project. The establishment of an inter-agency monitoring and coordinating committee (IAMCC) composed of DBM, DOF, NEDA, POPCOM and DOH further strengthened project coordination. Proiect Implementation 1.16 Revisions in the Proiect Description. The project suffered major changes in the course of its implementation, notably in training, IEC and researchs (a) In training, DOH concentrated on activities supporting the promotion of primary health care (see Table 5). While training activities on health were ongoing, training in family planning went unnoticed. The duration of the FP training program was substantially reduced in favor of other health programs; (b) In IEC, the original activities were changed to conform with the changing needs of the health and family planning program. Thus, a Household Teaching Manual and Family Health Guide were developed and produced for DOH health workers and households (see Table 10); and (c) In research, none of the studies actually conducted were as envisioned at project appraisal due to emerging program issues and concerns which were based on changes made in program directions and priorities. 1.17 Changes in the thrusts, priorities and strategies of the health and population program were due to changing needs as perceived by the heads of the two programs. The expansion of primary health care (PHC) began when a new Minister of Health was appointed in 1982. In this major change, family planning became one of a variety of services under the maternal and child health program. With the appointment of a new Chairman of POPCOM's Board of Commissioners, the family planning program perspectives expanded to cover the concerns of family welfare. Thus, the FP targets widened to include pre- schoolers and the elderly. 1.18 The MIS development plan to link up the population, health and nutri- tion information systems of the three lead agencies (POPCOM, DOH and the National Nutrition Council) was not pushed through due to differences in program priorities, information needs and concerns. 1.19 Other deviations from the original plan included: the construction of additional structures such as the herbal processing plants in Luzon (Cagayan), Visayas (Southern Leyte) and Mindanao (Cotabato) and Integrated Provincial Health Office warehouses; rehabilitation of typhoon-damaged HHCs and BHSs; site changes for MHCs and BHSs; construction of most BHSs by force account; and the construction of a building complex to house the central office, the Southern Tagalog regional office and the National Capital regional office of - 54 - POPCOM. These changes were introduced as being more economical and cost- effective. 1.20 Host of the variances from the original project design could have been avoided had there been a continuity in the line of priorities, a better synchronization of the components and a higher level of commitment of the organizations to preserve the integrity of project design. DON's strong commitment to the promotion of PHC beginning 1982-83 was a main cause of the realignment of activities, development of new ones and adjustment of project targets. 1.21 Project Accomplishments. Construction of DOH's main health centers, barangay health stations, IEC printshop and POPCOH's regional offices/ warehouses/motorpool were largely carried out in 1980-84 as originally programed (see Table 3). The construction of the integrated provincial health office (IPHO) warehouses, herbal processing plants, reconstruction of typhoon-damaged MHCs and BHSs were completed during 1985-88. 1.22 Of the 1,031 DON structures originally to be constructed, 984 were completed including: 75 MHCs, 908 BHSs, and 1 IEC printshop. Of the targeted 915 BHSs, 5 units were reprogrammed to fund the electrical system of one herbal processing plant and two units were not constructed. The IPHO warehouse in Palawan is still under construction. Additional construction activities were also completed, namely: fencing and landscaping of 21 MHCs; construction of three herbal processing plants; reconstruction of 13 MHCs and 83 BHSs damaged by a typhoon, another 15 MHCs and 15 BHSs damaged by a subsequent typhoon; renovation of a DOH dormitory; additional works for herbal processing plants; and expansion of the IEC printshop building. 1.23 POPCOM regional offices were constructed in Regions 3, 8, 9, 11 and 12; a complex was constructed to house the central office, NCR and Southern Tagalog (Region 4) regional offices in lieu of having one separate building each for NCR and Southern Tagalog. In addition, training facilities for six regional offices and warehouses/vehicles maintenance workshops for the central office complex and 11 regional offices were constructed (see Table 4). 1.24 During 1980-84, both agencies registered some major shifts in the conduct of training and the areas to be given top priority. Table 5 and 6 show that from 1980 to 1984, DOH achieved a very low 18? accomplishment rate as against the original target in the conduct of family planning courses for service providers. However, it registered very high accomplishment rates in training of trainers at the national level (214?), workshops on health, nutrition and the family planning program (3662), training evaluation workshops (5532), continuing education for rural sanitary inspectors in family planning (767Z), the basic course for baranFay health workers (10,344?) and the workshop on the purok leader approach (2692). 1.25 POPCOH, on the other hand, changed its strategy in 1983 to focus on the five major sectoral groups (e.g., professionals, adolescents, pre- schoolers, married couples of reproductive age, and elders); this affected the original activities/targets aimed at improving POPCOM's technical and management capabilities. Thus, training inputs were directed toward the - 55 - orientation and skills development of these various sectoral groups. Succeeding activities, however, conducted in 1985-87 showed that DOH training program supported PHC promotion and the five impact programs while POPCOM focused on pre-marriage counselling, training of social workers in value inculcation for pre-schoolers, adolescent fertility, family planning training for doctors and nurses, among others. 1.26 The primary health care component became the major focus of the project. Supported by the other project components like training, IEC and civil works, the project largely achieved its PHC targets for 1980-84 (see Table 7) and has expanded in scope and coverage. 1.27 Office furniture and equipment for POPCOM were procured and delivered in 1986. Fewer vehicles than originally planned were procured, with different specifications (see Table 8). DOH, on the other hand, was able to procure and deliver equipment and furniture in 1985-88 (see Table 9). 1.28 As shown in Tables 10 and 11, the IEC targets of both POPCOM and DOH were generally achieved. 1.29 A total of 41 studies were conducted by POPCOH (35) and DOH (6). While many of the studies did not specifically fall within the areas originally stipulated, the studies were utilized to improve the promotion of PHC, the development of new policies and programs, and the identification, development and implementation of new projects (see Table 12). Furthermore, the findings of the studies were presented to concerned government and private agencies through research utilization workshops/conferences and population/ health publications such as POPCOM's "Population Forum" and the Population Center Foundation's "Options" and "New Initiatives in Population." 1.30 MIS development was scaled down to address a portion of agency requirements; the integrated system originally envisioned for population, health and nutrition was not carried out. Training was provided to MIS staff both abroad and locally. DOH purchased several computers while POPCOM is currently awaiting the delivery of computer hardware for its central and regional offices. The MIS of both DOH and POPCOM are now in the process of being improved. 1.31 Constraints to Implementation. The factors affecting project implementation during 1980-82 were as follows: - internal problems: o relative inexperience of both DOH and POPCOM in implementing an IDA-assisted project of this magnitude. o frequent shifts in leadership concomitant with changes in personnel assignments, policy directions, thrusts and strategies which called for revisions of the originally-identified and approved activities. o delayed submission of field reports. - 56 - o delayed processing of reimbursement applications, resulting in slow credit disbursement. - external problemsi o delay in fund releases by the Department of Budget and Management during 1980-82. o delay in the issuance of clearances by higher authorities to purchase vehicles and micro computers. o budgetary constraints and other restraining orders. o successive peso devaluations which resulted in low drawdowns in terms of U.S. dollars. o difficulties experienced by both agencies in following IDA reimbursement procedures. 1.32 These problems were partially solved by project management, which accelerated project implementation. The measures adopted were as follows: o formulation of an accelerated work program by the implementing agencies beginning CY 1983. o timely releases of funds by DBM. o prompt reporting from the field and processing of documents. o establishment of a Special Account in the amount of US$2.3 million during the last quarter of CY 1983 to hasten fund disbursement. o change in the allocation of credit by increasing the IDA share in favor of the Government. o simplification of IDA disbursement requirements and procedures. Project Results 1.33 The project generally accomplished its objectives and specific activities, after a very slow start-up in 1980-82 and a gradual acceleration of activities beginning in 1983. The Development Credit Agreement (Schedule 1) underwent several amendments in order to achieve the originally planned targets as well as those added as the thrusts and strategies of the health and population programs changed throughout the project life. 1.34 The latest survey on contraceptive use reveals that the overall contraceptive prevalence rate was about 46Z in 1986, just slightly below the project target of 50% by 1987. The project target of providing at least 50? of the population with health and nutrition services was probably exceeded. Under the project, more than 400,000 volunteer health workers and DOH medical/ - 57 - paramedical personnel were trained in health and nutrition and IEC materials developed during a seven-year period (see Table 5). Life expectancy was estimated at 63.7 years in 1987, compared to the project target of 66 years. The infant mortality rate was about 54.2 per 1,000 live births in 1987, compared to the target of 56 per 1,000 live births. 1.35 Regarding facilities and personnel deployed, a 1985 DOH survey reveals the following: one MHC for every 27,458 as against the target of 1:20,000; one BHS for every 6,841, a little above the target of 1:5,000; one physician for every 6,453 population, a significant achievement as compared to the target of 1:20,000; one nurse for every 5,245 as against the target of 1:20,000; and one midwife for every 5,582 population compared to the target of 1:5,000. 1.36 While there were no changes in objectives during project implemen- tation, targets were changed based on the health and nutrition plan. For example, the infant mortality rate was changed from the original target of 56 deaths per 1,000 live births to 44.1 deaths per 1,000 live births by 1987 (1984-1987 Health Plan) and the original target of a 16% reduction in malnutrition among children below six years of age by 1987 was changed to 24.2Z in the same year (Objectives and Strategies of the Nutrition Program). 1.37 Variances between planned and actual results were therefore due to: (a) new thrusts, strategies and priorities of the health and population programs resulting in the development and implementation of additional and new activities, and (b) delay in the implementation of project activities. Project Sustainability 1.38 Sustainability of what the project started and accomplished can be considered from two perspecitives. At the program level, project objectives will be pursued further by the Government since they are part of its health development and family welfare objectives. At the project level, th3 benefits produced by the project as a result of deploying trained midwives to the BHSs, the availability and use of health equipment and facilities to diagnose and cure sick people, and the availability of family planning services and contraceptive supplies in the villages, among others, will be continued. In 1989, the government budgetary allocation for POPCOM and DOH was judged adequate to fund the agencies' PHC and family planning activities. 1.39 The success of the health program in providing much-needed health services to the population depends greatly on the availability of service providers and outlets like the BHSs and MRCs. The contribution of the project in constructing, equipping and furnishing these needed structures and deploy- ing trained midwives and nurses to staff them will help ensure the provision of an acceptable level of health services, medicine and medical advice. 1.40 The herbal processing plants (HPPs) will play an important role in the provision of low-cost drugs and medicine for ailments commonly occurring in rural areas, e.g., colds, cough, diarrhea, fever. A strong support system could be developed to sustain the flow of low-cost drugs and medicines through MHCs and BHSs. Provision of incentives for health volunteers and communities - - 58 - who are motivated to use low-cost drugs and medicines could be developed in support of the HPP activities. 1.41 In the case of POPCOM, the construction of warehouses in the regional centers will continue to meet the rural population's contraceptive require- ments; the availability of training facilities will be utilized to train new/ additional workers promoting health and family planning; and the availability of vehicles will facilitate the delivery of family planning services and commodities to far-flung areas. IDA Performance 1.42 The Association's main strength was its experienced and highly qualified project officers who worked with the implementing agencies during the project period. The project officers witnessed the changing thrusts of the health and family planning programs as the Chairman of the POPCOM Board of Commissioners, the Executive Director of the POPCOM Secretariat and the leadership of DOH changed over the years. In response, project monitoring activities doubled, and an average of two IDA missions per year visited the Philippines. These frequent visits and follow-up support facilitated the reprogramming and realignment of project funds, IDA's approval of contracts where required, the restructuring of the Government-IDA cost sharing arrangement, and the approval of a Special Account for the project. 1.43 Among the weaknesses observed weres (a) IDA's recommendation to change consultants for construction and IEC, which affected the smooth implementation of civil works and IEC activities; and (b) IDA's recommendation to hire a foreign consultant to prepare the PHN program plan when local consultants were available. 1.44 In observing the Association's supervision of the project, the Government noted the following lessons which may be helpful to IDA in future projects: (a) in supervising the project, the assigned project officer(s) should be retained, if possible, from the start of project implementation to its completion; (b) should there be a project extension, a new project officer could be assigned to replace the former one, but such replacement should have particip_ted in at least two supervision missions before assuming the position in order to ensure continuous/effective project monitoring and supervision; and (c) start-up activities should be closely monitored and supervised by the Association to reduce time, manpower and money wastage. - 59 - Borrower Performance 1.45 The strengths of DOH and POPCOM lie int their organizational structures which are centralized but flexible enough to make adjustments based on recommendation of the field offices; the presence of financial, reporting and monitoring systems that underwent several improvements to facilitate implementation of activities; and the common concern and interest of the POPCOM, DOH, NEDA, DBM and DOF officials involved to facilitate project completion. 1.46 The main weaknesses of the implementing agencies were: (a) their lack of coordination of activities like construction and purchase of equipment/ furniture, development of IEC materials and training of personnel using the materials, and conduct of training for community participation and during the pre-construction stage of BHSs; (b) the unclear system of prioritizing activities by some component coordinators, especially when the program component had several sources of funds and parallel or other activities that required simultaneous or coordinated implementation; (c) the practice of pooling funds from all financing sources for a specific program component and using such funds to implement project activities without introducing a system of monitoring how much was spent for an activity funded by a specific source; and (d) the changes in policies affecting project operations. 1.47 The performance of project management during implementation was poor, especially during the start-up period due to reasons mentioned earlier (para. 1.31). TheIr performance was fair by the latter part of 1982 and continued to improve so that by 1984-85 most of the civil works, procurement of furniture and equipment, and training had been completed (see corresponding tables). In spite of the slow start-up of project implementation, it is noteworthy that almost all of the major original targets were achieved in 1984 and 1985. The major concerns of project management from 1985 to 1988 were the additional new and realigned activities. 1.48 As planned, project administration was carried out by existing units and staff. Thus, the Chief of the Training Section in the National Family Planning Office became the DOH training component coordinator. The assignments given to national office personnel extended down to the field operation level where, at the regional, provincial and municipal levels, personnel (e.g., midwives, nurses, provincial health officers) had specific roles and functions related to project implementation. Consultant services, on the other hand, were tapped for civil works, IEC, and the MIS as necessary. 1.49 The following lessons were learned by the implementing agencies in the course of project preparation and implementation: (a) prior planning should be done for smooth project implementation. For example, a detailed five-year project plan of action should be completed to serve as a basis for annual work plans. (b) while activities under each component are implemented on a step-by- step basis, individual activities need to be coordinated. For example, training to prepare a community for the program should be - 60 - followed by mobilization of the community for construction of a BHS. Likewise, development and printing of a Family Health Guide should precede the training of those using the guide. In addition, timing of the delivery of furniture and equipment should be just prior to the completion of the related health structure, so that lengthy storage is not needed. (c) an ad hoc committee like the IAMCC provides a useful mechanism by which the implementing agencies can resolve operational and financial problems affecting the project. Project Relationship 1.50 Strengths of the IDA-Borrower performance revolved around the open- ness and flexibility of both parties in supporting and helping each other. For example, while the Government experienced peso devaluation resulting in the low drawdown of IDA funds, the Association was flexible enough to allow the Government to proceed with the implementation of pending additional activities. It also allowed a change in the percent of expenditures to be financed under the credit (see Table 1). The realignment of project activities and targets due to changes in the program priorities and directions was supported by the Association, which allowed the realignment of funds allocated by credit category. 1.51 The IDA supervision missions always consulted all other agencies involved in the project. For example, operational problems due to delayed release of funds or to excessive COA requirements were discussed and resolved by the mission, the implementing agencies and the relevant agencies. Consulting Services 1.52 Except for the consultant recommended by IDA staff to develop a PN program plan, consultants hired under the project were very useful. For example, the executive architects and the construction management consultants hired by POPCOM helped a great deal in designing and constructing POPCOM's regional offices and central office complex. The development of IEC materials like DOH's Family Health Guide and Household Teaching Manual benefited greatly from the participation of WHO and other consultants. The hiring of a full- time technical consultant and two researchers to assist the implementing agencies through the IAMCC helped facilitate project implementation by coordinating POPCOM and DOH activities with those of DBM, DOF, COA and the Association. Project Documentation and Data 1.53 Except for some changes in IEC, training, MIS and research activi- ties, the Staff Appraisal Report provided a useful guidance to the implementing agencies and IDA during project implementation. It was, however, regretable that changes in program policies and directions made some activities envisioned in the SAR non-implementable. - 61 - 1.54 Relevant data for PCR preparation were available, except for the pre- implementation period. It is therefore very important for an implementing agency to develop its capability to secure and keep records of what transpired during project identification, development and negotiations. 2. Institutional Development The Population Commission 2.1 Overall Assessment. A comparison of POPCOM's expected and actual accomplishments reveals that the project was originally designed to help develop POPCOM as a strong coordinating agency, but actual project activities were implemented within a general program framework, covering a broad range of needs prioritized year to year. Nevertheless, though implemented with variations from the appraisal estimate, the major categories of the project yielded substantial direct benefits for the POPCOM program. The POPCOM regional offices are now adequately housed and their facilities upgraded. Allocations for the Metro Manila and Southern Tagalog regional offices were combined to fund the construction of A building complex which now houses the POPCOM central office and the two regional offices. Training facilities were also provided to six regional offices. The acquisition of various types of vehicles gave high mobility to POPCOM personnel and improved the commodity distribution and delivery system. 2.2 During project implementation, POPCOM sought to adapt projects funded by other agencies, e.g., USAID, JICA and UNFPA, to complement the Second Population Project's objective of strengthening POPCOM's coordinating capabilities at all levels. Synchronization of activities and realigning of strategies were consequently carried out. In support of this objective, POPCOM created sectoral committees focused on the following areas: pre- schoolers, youth, pre-married couples of reproductive age, married couples of reproductive age, influential persons and professionals. These sectoral committees served as advisory bodies to POPCOM in formulating plans and programs and in identifying projects consistent with the new thrusts and strategies of the national population program. They also served as forums in resolving problems and issues related to population program operations. The sectoral committees were duplicated at the regional level to perform the same functions. One project identified to support the program is a research study to determine which herbal plants could be used as alternatives to foreign-made family planning contraceptives. 2.3 On the other hand, timing of the actual implementation of project activities was not coordinated as planned, and they consequently did not have the intended benefits. For example, the construction of facilities and purchase of equipment were not carried out by the target date when they were most needed. The progress of implementation suffered from rigid government procedures on procurement of equipment and frequent changes in management and personnel assignments, policy directions and priorities, all of which caused slippage in project execution. Thus, while inputs under the Second Population Project assisted POPCOM in concrete ways to coordinate population program implementation, there are still areas requiring further consideration. - 62 - 2.4 Achievements under the Individual Project Components. A major part of project training was intended to improve POPCOM's coordinating capabilities at all levels, from central headquarters to municipal structures, in order to facilitate collaborative planning, implementation, monitoring and evaluation of the program at all levels. As actually implemented, the training activities reinforced the information and motivational campaign for the family planning and population program by training and orienting 24,906 personnel. This included the program workers, volunteers and professional staff dealing with FP clientele. A total of 3,878 staff were trained in FP technology and cytology, 923 surgeons and other health professionals were trained in voluntary surgical sterilization (VSS), VSS assistance and counselling, and 1,525 workers were trained and oriented in natural family planning. 2.5 In line with the program's focus on youth, training in adolescent fertility management was provided to 2,768 personnel while an additional 787 personnel benefited from orientation sessions in the adolescent program activities. Further, training and orientation for the population education program were provided to 12,441 participants. 2.6 A majority of the training activities undertaken benefited partner agencies and volunteers; personnel of partner agencies in the population program, both government and non-government, received local and overseas fellowships and in-service training as well as financial, technical and commodity assistance for training activities. 2.7 Under the IEC component, materials, particularly print and broadcast, were produced by the regional offices and, especially, the central office. However, some key field materials for IEC like the Interpersonal Communication Skills (ICS) Package and the Family Health Guide were developed only after the original project closing date, with printing completed in the second semester of 1987. And by 1989, a substantial volume of these materials was still not distributed to end-users. Audio-visual (AV) support was a major element in the decentralized IEC strategy, but AV vans were not procured and regional audio-visual banks were not fully set up during the life of the project. However, selected video equipment was procured in 1987 and distributed to seven regions to complement the five regions covered by a JICA-supported project which received full audio-visual assistance. 2.8 Under the research component, 35 population studies and research projects were completed, which were utilized in project development, and evaluation and development of program guidelines. 2.9 Regarding civil works, the construction and upgrading of POPCOM's regional offices, warehouses and vehicle maintenance workshops and the procurement of equipment and vehicles were carried out during 1985-88, with many changes in the original plans. The upgrading of six regional office buildings in Regions 1, 2, 5, 6, 7 and 10 was finished by the end of CY 1987, although the Region 6 office was not completed until 1989. 2.10 While POPCOM was not able to purchase computer hardware within the project period to upgrade its MIS, it has nevertheless designed an effective and efficient mechanism for reviewing, processing and approving population - 63 - projects. It has developed a management information system to measure program performance vis-a-vis acceptors by method, logistics management, financial performance, etc. It has also established a system of measuring the performance of its regional and central offices, using expenditure and draw down reports from the Second Population Project as one of the parameters. The Department of Health 2.11 The project as originally designed included the testing and implementation of several primary health care schemes in 12 provinces, with activities geared towards the promotion of primary health care nationwide. As most of the targets were achieved by 1984-85, additional activities were developed and implemented as reflected in Table 7, with the full support of the Government. 2.12 The adoption of primary health care in the early 1980s as the corner- stone of the Health Development Program under the project responded to the growing concern that essential health services should be universally available to all individuals and families in the country. Primary health care was designed to extend the best possible but affordable health services to the greatest number of people, with particular emphasis on the rural and semi- rural communities. 2.13 With assistance under the project, progress has been made in making essential health services accessible to individuals and families in the communities despite problems and difficulties in implementation. A total of 37,827 barangays, 92Z of all 41,114 barangays, have been provided with PHC services. The areas still requiring service are either experiencing peace and order problems or are inaccessible to health workers due to difficult terrain and absence of any means of transportation. This significant outreach was partly achieved by gaining the active participation of NGOs in planning and implementing health programs at all levels. 2.14 Achievements under the Project. A total of 422,447 volunteer health workers received training under the project, which improved the ratio of barangay health workers (BHWs) to population, from the targeted one BHW for every 20 households to a 1:18 ratio. Overall, total health manpower increased by 32Z over the period 1980-88; increases were particularly noted in health personnel (physicians, nurses and midwives) whose numbers grew from 24,009 in 1979 to 31,580 in 1988. In addition, program staff and personnel, including field workers, developed skills and competency in project management, supervision, and implementation. The financial and managerial base of the health network was also improved to preserve and expand the PHC program and institutional development gains. 2.15 In support of community development, DOH has organized study groups, each group composed of 20 households as an effective strategy to impart practical know-how in dealing with common illnesses, household emergencies and preventive health care and family planning. This challenging approach to make every household participate in community health education is a mammoth undertaking to which the Department has committed itself. DOH's collaboration with the Department of Education, Culture and Sports (DECS) also paved the way - 64 - for the initial inclusion of PHC in college curricula and textbooks for high school and elementary school students. Moreover, its close working relation- ship with women's clubs resulted in the integration of PHC in all women's clubs' activities throughout the country. 2.16 Health facilities were increased by 4Z from 1,928 MHCs in 1979 to 2,003 in 1988, increasing population coverage by 18.5Z; and from 4,552 BHSs in 1979 to 5,460 in 1988 or an increase of 202, increasing population coverage by 4.132 compared with that of 1979. The MHCs also received the necessary equipment and furniture to improve the delivery of basic health and family planning services in the communities. Several Botika sa Barangay were also established in villages three kilometers away from an MHC, managed by a trained community resident, supervised by a BHW/midwife, and administered by the barangay PHC committee. 2.17 The production and distribution of IEC materials also increased, addressing the perennial lack or absence of IEC materials in the field. The IEC campaign was reinforced through the fielding of 12 audio-visual vans in 12 regions, excluding NCR, to serve the hard-to-reach island barangays. And in support of its training and community development efforts, DOH produced two important manualst a Household Teaching Manual, used as the "bible' for teaching/training nurses, midwives and BHWs; and a Family Health Guide, used by households as a basic reference book for health practices and family planning. 2.18 Current Issues and Remedies. Despite the measures adopted to facilitate PHC institution building and program improvement, problems have arisen which constrain program implementation. Of those barangays previously initiated into the PHC system, only about 682 were operational as of 1987. In some areas, the peace and order situation has hampered and, in some cases, stopped the provision of health services. Despite efforts to beef-up manpower, there is still a lack of health personnel, especially doctors, dentists. rses and midwives, in far-flung areas, and even government hospi# in dire need of more nurses. Ccommunity organizing skills are also g to deteriorate among health workers. And of the total number of Barangay established, only 422 were still operating in 1987. 2.15 ' ese problems and difficulties have been recognized, and measures and tegies are now being adopted to address them. These include the crea i% of the Community Health Services to institutionalize further the mult. sectoral collaboration among the Government, the communities and the non-government agencies. This is a positive development towards improving the - quality of health services for the people in rural and urban areas. - TAti1 L . ffi AJ1~ATIM BY CA'LtfMlMV MO YEAR OP REUir~ltG c r LIN 1 A1J,AI~ 143N EX P E N 1I TU t E . '0 (txpressed in Dollar ~quvalent) U e k i tå A N Ct; E) June 27, 1979 lt Aennr t 2nd Aendent 3rd Aäenumit jkute j, 19pp ist=n Ument 2na .rd htsej~*~ CAMlI~Y tOriginal) (July 13, 1982) April 1, 1985 Decenber 31, 197 (o]i inhdal) Jly 13, 1982 As l 1, 1906 1ax:nte. i, m u? 1. CIVIl. WRKS u,300,000 t, 200,000 50 5S 70, 701 a. by cnntract 4,100,000 4,100,000 b. by Force AccowIt 5,200,000 s,200,000 ELUI~34M IÉERIAIS 16 V81CIES 10.00,000 8,300,000 11,000,00 11,665,000 a. Directly 00,4 10t 1004 100 Imported of foriLje of foreigra ut fuoakiýja expenidituces exµad i tures exµ:sJ aure b. 31cally J1.1% 100% 100 SOU naiufactured of &a:gl of loca Lt åtla exµaNKi Lutes exquaditure:S expta.n-luses (ex-factoryJ (ex-tactoryl f" toturyl c. Prowured 656 USi fcally 00000'0' joolT^ an )0 <'<fl (TA) '(110 g amL I05 10C 000'0IZo 000'0~'S S '4T *fiil SaImi,lS V SWlVå UIJ#) KNIVUL, S SZSNi~i '13VLL 's 19L IOL IN %0C 000'099'9 o0'Onl'9 0'009'9 000'0099 WDI2-D~id i saammdQ1d 'mi o0'og9 000'o'Iz 000'00SZ' sat li^iilo 3SM 30; 9~ P9-1 q 1111001 9OMg %001 ooloIt oD,00?*c 00 oot ID' 903 SS S SrIzKrla 2 1V<SISSV T Sa3MiSS 'mIjtuIA c 000 '00C'I St WivvlrO r '(f l'pPU 9061 '1 it-tV ?3f1 'it Alnr (IInt&IrIo) L8l it I-opc-on 961 1 ildV 11861 'E AiTnr) (Iulf6T30) MMUva ownxl;*Inj p.1r 11"rlqvl.mI ix7 JIXIp»IV Jq[ tr,161 • sumr u~teauv pa luaupu~ui nu lugupamv m st 661 'L ~une i 1 3 11 v ti r .. 1 I (Iuehxf* jmllcu urj p~sdx91 n 1. 9 3 W 1 .J. i fl ti d X S ..l1) 14 iDm~fI fil1d Jt 7· id ' itl lAble 1, page 3 MOUIf CP IAN AICXIATICI I OF EX PENDITURES TO (Expressed in Dollar Spaivalent) BE FINANCED Jne 27, 1979 lot knendment 2nd Amemubent 3rd Anencnent June 27, 1979 1st Amenckrent 2nd Amerinent 3rd Amendnent CAISGORY (Originall (July 13, 1982) April 1, 19815 December 31, 1987 (Original) July 13,1982 Apr, 1 1, 1986 Deoewter 31,', 6. IMIO/ATIVE ACTIVITIES UNDER PARTS A (x) , & B (x) of the Project 1,100,000 1,100,000 800,000 65,000 50% 50% 70t 70% 7. Reconstruction of typhoM damaged BHS and HE 1,200,000 2,200,000 1,720,000 95% 95% 9!% 7. NALICATED 3,000,000 8. (kQallocated 1,800,000 TUM 40,000,000 40,000,000 40,000,000 34,400,000 TABLE 2: CREDIT DISBURSDENP CLWLATIVE DISBURSEMENT (US $) : ACTUAL % CAIEDAR : : SAR YEAR : APPRAISAL ESTIMATE : ACIWAL ES1TMATE : YEAR 1980 4,400,000 : 360,771.37 8.20 : 1 1981 : 13,400,000 : 2,399,505.06 : 17.90 : 2 1982 23,300,000 5 ,944,195.05 25.50 3 1983 31,800,000 : 11,835,973.03 : 37.22 : 4 1984 37,400,000 14,383,405.29 : 38.46 5 1985 : 40,000,000 : 19,345,034.51 : 48.36 : 6 1986 22,982,981.35 57.46 7 . 2/' 1987 : 34,400,000 : 24,805,018.08 : 72.11 : 8 1988 : 26,730,759.841 1 77.70 9 * 0' 1989 : : .: : o 1989: 32,278,419.60 : 93.83 10 -/Original Credit Closing Date: June 30, 1985 2/Revised IDA Credit is $34,400,000.00 3/US $5,547,839.75 additional avaiment as of April 25, 1989. 4/US $98,337.89 was not applied for availment by POPOOM. Note: 1. The amount of $96,967.07 (DOH) was not availed of. 2. The reduced amount of $34,400,000 was further decreased to $32,223,202 as a result of the Association's cancellation of $2,176,768 effective April 13, 1989. 3. The difference of $55,217.60 between the estinated actual disburserents and adjusted credit made available to the Project maybe due to conversion rate. .8 w qu 1 -- -- - - - - . . - - -= - . - -' - - - - - %& -- -~ - - -- --- - -- -- - . .. .. .. .. .. .. .. .. .. .. .... øg a ~ ~ ~ ~~B ...... ....... ~~es. • - 69 - 0.1 TalaIe 1,* je2- i»L:23%.T1flI 11t>2C1DRS * A C T Ui A 1. :___ Ali)ITIttA. A . I A _ .: : GI<At 'li'Ai. PER AflHAISM. HEPOR:(SAR): 8-84 : PERENP":''85-'Ou PSCNI : 100AL :PEICD1Ir : TIVITL:S '80-T % : 'US-38: :1-: 7.8 :s*llt8on686 of lecra8 * * * * 7. jiasyLteIuLtuuA 6~ le .ba P<i ce 8 * 8 * * Si:K) t'ij 3 t T AlU 4: POPCOM CIVIL WORKS Implementation Actual Additional Variations 1980-1984 1985-1988 1989 % of Indicators Per 1980-1984 Activities % of % of Accomplibi Appraisal Report (SAR) Accomplish- Accomplish- ment m11ent anent Construction of 7 5 Regional 90% 100% POPCOM Regional Offices (Regions Offices (NCR, 3, 4, 3,8,9, 11 & 12) 8,9, 11 and 12) Construction of 90% 100% a complex build- ing for NCR, 4 & Central Office Construction of - 100% 6 training faci- lities Construction of 13 11 Regional Ware- 80% 100% Regional Warehouses houses & Regional & 13 Regional Vehicle Vehicle Maintenance Maintenance Work- Workshops shops Implementation Actual AdditionAl Variations % of Indicators Per 1980-1984 Aciivities % of % of Accomplish Appraisal Report (SAR) Accomplish- Accomplish- Meil mett ei - -- - ------------------ 98 12j 1- - Central Office H(j% 100%. - Complex with NCR & KPO 4 Warehouse & V'hicle Main- tenance Work- shops Perimeter fence, 100% window grill, guard house, flag pole and windom screen (Region XI) TABIE 5: DOH TRMINING IMPLEMNTATIM IMICAA C T U A L A C T II A L PER APPRAISAL REPORT (SAR) '80-'84 : '85-'88 :: :ITIOL '80-MA4IVTiS-'0: 8 A. MASER TRAINING PROGRAM 1. International Fellow- : 8 : 53 : : : 1. 47 local fellowshaii for 47 100 ships for 15 persons : (1-3 mos) : : : 2 weeks (4 amnths) 2. National Refresher : Not Conducted Course (100 persons for 5 sessions at 1I : week each 3. Joint M0H/POF00M Not Cond6cted Refresher Seminars/ Coordinating Temn 4. W)rkshop on Operation : Not conducted of MIS H. TRAINING OF TRAINERS (8891' 1012 214 1. National : 48 persons : 2. Regional :243 persons : 3. Provincial:550 persons : (1 session for 6 weeks : each) so 4. Planning Supevision of : Comunity Health : Services and MIS 48 3/3 weeks, sessidns) : 1/ Per - IAMDC Report. A C T U A L A C T (1 A L IMPtEMMENATTCN INDICAMRS .AD.DI'.olTIONAL AOTIVITItES . PER APPRAISAL REPORT (SAR) : 80-*84 : % : '85-'88 : 8 : : *B( '84 : : 115 '88; j C. IIICIPALBARANGAY PEICEPORS/FACILITAORS :: 1,533 (1/6 wks, ession) 633 41% D. WORKSIOP ON PHC (6,940) :465687 6710 1. Regional/Provincial 10036 Agency representatives 300 (1/1 %k. session) 2. Khnicipal Trainers : 37301 2,570 (1/2 Aks. eession): . . : 3. Central Agency (include4 in No. 11 Representatives, 20 . . (1/1 day session) .2. 4. Basic Course for 4,050 :418,350 2. Sarikayd Wrkers : a 882 :100: tlfWs (1/8 4ks. session) a : : 3. Botika sa barangay Aides : 1615 :100: E. WORKSHOP ON HEAUI NUrRITION AND F PROGRAM 192 persons (Central, 8,285 4,315 Regional Provincial/City levels) F. HEAL1 EUCATORS CN IEC 86 54 HAS DEVELOPMEN 160 persons (1/6 As.) : : : : : Training of Supervisors. IMPLEM'NTATICH INDICATORS A C T U A L A t' T ( It 1. PER APPRAISPL REPORT (SAR) :(IVITiI-I' : '80-*84 : % : '85-'88 : % : "i)- 'l : a : '5 ' G. TRAINING EVAJIATION: WORKSHOP (84 persans 686 816.7 : (4/1 vkJ iI. W0jWSII0P ON I.GIbrICS 267 persons (Central, a Not Cooducted: regional, and provincial : : supply officer 5/1 wK sessions) I. CCNITNUING EDMCATIOI N FOR RURAL SANITARY INSPECIORS (100)8 '8, 285 *767* J. FAMILY PLANNING COURSES FOR ShRVICE PRWJIIERS (13,525) 2,507 : 18 1. Basic Course for . midwives and nurses, . 1353 (1/4 vdks session) 2. Skills Training : 1,920 persons (1/6 wks : session) 3. infresher Course (10253): IPIEMENATIm IINDCAmiRS A C T U A L A U ' O A 1. PER APPRAISAL REPORT (SAP) , ADDITUNAI. AC'T1VITJ:S 80-84 b : 85-'88 b . 80-'84 :5-H. * K. ORKSHOPW PUIELEMER : ~ ~ APP~C 141,105) : 55,445 135 4. Developienöl, revisumt : Acc(1i1shed per procuctionk of VIBAlues, IAf1I' Ibport 1. Health Staff frmn : nanuals alnd traiinig various levels, 65 : syllabi persons 5. Workshop Ior Pv_övism:idl 166 2. Evaluation, 40 persons statt J. Meetings with Purok Leaders, 41,000 persons: L. BARANGAY NURITICH Not conucted SC[1ARS, 10910 persons (I/i day session) 6. Refreslier couse tur 467 field workers 7. Skills Tialrng HO 8. Medical Black-Up Trajning 583 9. Iraining of Raral lealtii Al l Uese det Ivm ties 1: u Midwives and IPIK) Stafft Cacuajp ist:sì la.-tween on 5 ipact Progxjrams 1985-1938 * . 10. Evaluation ofe.idiing Conltt by p pivute, Actvities organ i iZAtici å1d impletim* ni* **lmjimp * ** '5-: oni fimdiistjs) TABIE 5a: SLWRY OF ItAINIM PiORAM UNIER PUP II (Per AIC Associates Eva WndL io)* : : : IMPLIMtP I(I: IMPIEENWATION INDICAIOM : TARWP :ACIUAL. : INDTCA'JnRS TAICET ACT1JA1L A. HEALII PERSClNNEL B. NCN-HEAlilli PIUt(43. 1. Training of Trainers : 1,013 : 2,224 : 214 ; 1. P1C VAMkshops OL 2. Training or Preceptors/ Agency 1"nesuti(tive still 0, 0s 1 ,1 45 Facilitators a 1,533 : 633 : 41 3. Trainig baluation brkanop 3 * :r btatf DeveiLopInt 124 : 686-. 553 : SariKay'l Va'ku1 H 4. logistic Mnagement trkshop 267 :Not conducted 0 : otika sa baacuiLpy 1,615 ::Conducted : :Aie 5. PIC warxshop : 2,591 ; 37, 01-: 1, 4 39 : 6. Continuing Olucation for : Itiral Sanitary Inspectors : 1,080 : 8,285N 767 2. Vbkbtx4[ ol 1ok- 7. worKshop On healtn, nutri- leader A14roacs 211,60t) 55,44 269 tion and FP Program Directions : 192 : 747-: 366 : 8. Healtn FAcators on IEC : : : Hbterials Develoient a 160 a 86 54 : . 9. FP Courses for Service Providers a 13,525 : 2,507 18 10. JOIlfW POCO44OH Wrkshop : sNot : an Coordination 3 20 :Conducted : 0 11. MIS Operation Nbrkshop 912 :Not : 0 a :Conducted : SUB-'10mL 21,417 52,469 245% 24u9-6 '486,928 1,951 " l A . .5 9 ** 3 3 . * 3 * -.Cowmtiaeu Ifealth & Nwka- a . * :11eaUt1PariciauLs PIL-2L ;46iUA/84 3/ Planning anc fvaluation workshops *lhe Evaluation of 1oqmtation Project 11 Traiiiin Procjr,mmi- iFes 1/ Includes training on CO ano IC a ngujeat conditei by a prvaLe researcP n and ICiiictio cnitiagemy 5/ PIC Management for otner Health Personnel (Alf Associates) fruit lxcaidwr 29, 1986 to (XACljM 29, 1987, i Training of Supervisors covering 12 regions, 37 provinces, 610 micilmliLies 7/ Intra Sectoral workshops and 9,280 respondents, represeating PP 11 tining dcLiies 1i Basic Course for Bis from 1980 to Septtsiber 30, 1987. 91 Workcsnnp tor OPHOC Mbers TABLE 6: POPCOM TRAINING IMPIEMENrATION INDICATORS PORC Actual PJ711A. 1 IMsiMN imll1-3) PER APPRAISAL REPORT (SAR) 1980-1984 1)111) 19116 1U.3l jriginal 191 0- 19811 1. POPUIATION EI ATION PIMGRAM Masters Trainers 1. Pre-Mrriage Counselling 7,73658 2,4 10,775 a. International fellowships 2. Value Inculcation for 30 lit 1-3b b. Joint POPOOM/DOH Pre-Schoolers Refresher a. Training of Day Care 997 90 Worksnop for POPCCMWorkers Worksnope fo PoalCC b. Training of SW on 54 Executives on Goal Setting/ NPFAs Team Building 3. Training of Day Care 21 20 Workshops for POPCOM Vbrkers on Value Regional and Divisional Staff Inculcation (NCR 3) on Goal Setting/Team Building 4. Training of Trainors for Is 15 PMC (3) Workshop for National. 5. Expansion of FP Outreach 254 254 Population Program Coordinating throign Day Care Workers 14) Team on Goal Setting/Team 6. Training of Barangay High 100 100 Building nunber in parenthesis representsOCOM Regional Offices. -rAlit.[- 6, pacjt 2 IMPrlrrIN -mTCmoRs POPCOM Actual* Actual Number Trained PER APPRAISAL REPORP (SAR) 1980-1984 1985 1986 Total (Original Extension Period) 1980-1986 Duration) School Teachers on POPED (12) Workshop for National Popula- tion Training Coordinating Team II. ADOLESCENT FERTILITY on Staff Level PROGRAM Workshop for Joint POPCOM/ 1. Adolescent Fertility 312 1,626 1,938 DOH Training Coordinating Training Team 2. PASE/POPDOSY/FP for 58 58 OSY Workshop for National 3. Integration of FP Con- ill 59 170 IEC Coordinating Team cept in Guidance and Peer Counselling Workshop for National 4. Orientation of Kaba- 100 100 Population Service Delivery taang ARBA on Popu- Coordinating Team lation Program 5. AFP for High School 421 421 Workshop for National Guidance Counselors Population Research and (2, 11 & 12) Evaluation Coordinating 6. School Dormitory 40 40 Team AF related Inform- ation & Service TAt.l o, pdsge . Pn'IDEriuIa alfrICroM POPCOM Actual Actual Nulmer Trained PER APPRAISAL REPORP (SARI 1980-1984 1985 1986 Total (Original fixtension Period) 1980-1986 Duration) Workshop for Regional Program (7) Population Program 7. Expansion of AF for 37 S/ Coordinating Team WYC of MOLE (12) Workshop for Regional 8. Utilizing In-School 32 32 Population Training Adolescent as Dis- Coordinating Team cussion Facilitators in Adolescent Sex- Workshop for Regional uality Rap Session (8) Population IEC Coor- 9. AFP for Anak Bukid 317 317 dinating Team Agrarian Reform Beneficiaaaries (5) Workshop for Regional 10. Training of Youth 130 130o Population Service Leaders/Workers Delivery Coordinating as Venues for Coun- Team selling on Sexuality/ Fertility related issues Workshop for Regional of adolescent (12) Population Research and 11. AFP for ISY 128 128 Evaluation Coordinating 12. AFP for OSY 184 184 Team TAHI.*' 6, patje -1 ... IMPIrrATIN NIMIGAONS POPCOM Actual Actual Number Trained PER APPRAISAL MFORP (SAR) 1980-1984 1985 1986 ltal (Original Extension Period) 1980-1986 Duration) III. FAMILY PLANNING Workshop for Pro- PROGRAM vincial (including Metro Manila Popu- .1. Basic FP Course for MDs 619 266 885 lation Program Coor- RNs and RMs dinating Team 2. Basic FP Training (12, 4, 845 845 6,7,9, 10, 11 & 12) Workshop for Municipal 3. Comprehensive FP 112 266 338 Population Program Coor- Course for RNs & RMs dinating Team 4. Comprehensive FP (2, 4, 178 178 7, 11, 12 & 6) Workshop for Media 5. VSS Training 322 23 345 a Executives 6. VSS Assistance 246 27 273 7. VSS/VCS Assistance 52 52 Workshops on FP integ- Training (CO) ration for key media 8. Cytology 96 30 126 executives 9. Exfoliative Cytology 21 21 Training (CO) Seminar/Workshop on 10. VSC Counselling 244 9 253 on Voluntary sterilization MDs for medical/nursing staff 11. Training for Back-Ups 46 14 60 TABIE 6, ij.,e 5 IMPLFEVIAPICR *!DICATORS POPCOM Actual Actual Number Trained PER APPRAIAL REPORT (SAR) 1980-1984 1985 1986 Total (Original Extension Period) 1980-1986 Duration) 12. Family Planning 1,283 193 1,476 Refresher Course Workshop on Records 13. Refresher Course on 9b 96 Management for POPCOM/ FP Technology (2,4) PA Staff 14. FP for POPED Teachers 1,494 1,494 15. FP for Program Per- 444 444 Logistics Management sonnel/PAs Seminar for POPCOM/PA 16. Natural FP Training 1,126 156 1,282 Staff 17. NFP Method Training 111 I for Clinic Personnel O0 Administrative Manage- (NCR & 2) ment for POPCOM/PA Staff 18. NFP Training for KARBA 29 29 (2) Financial Management Seminar 19. Seminar/Workshop on 999 999 for POPCOM/PA Staff FP and Motivation 20. FP for KBP Members 239 49 288 Modern Disbursement Pro- 21. NGO 148 148 cedures for POPCOM/PA Staff 22. FP for Out of School 10,859 10,859 Youth Tiil.* 6, pay,: 6 POPCOM Actual Actual Number Trained PLEMENPATIO4 INDICATORS 1980-1984 1985 1986 Total PER APPRAISAL REPORT (SAR) (Original Extension Period) 1980-1986 Duration) - ------ - -- -- - ------------------------------------------------------------------------------------------------- Accounting for Non-Accountants 23. Motivational Skills on 239 '19 288 Delayed Marriage for Vehicle & Equipment Maintenance KB Leaders 24. Special Population 65 15) 215 Refresher Course on Vehicle Program for Hospitality & Maintenance Girls 25. Training of Contact 166 166 Specialized Training on Per- Leaders in integrating sonnel Planning & Staff FP.to Extension Activities 26. Family Life Enrichment 30 30 Marital/Pre-Marital counsel- Program for Agrarian ling for selected Field Person- Reform Beneficiaries nel of PDs 27. PBSP - Family Welfare Pr3gram Skills Training on Production a. Community Organiza- 91 91 of LEC materials: Print tion Volunteers b. Barefoot Technicians 119 119 Minilap Training for Physicians c. Couple Facilitators 134 134 of PA's d. FWP Progran Plan- 21 21 ning & Systems TALE 6, p&it: 7 POPCOM Actual Actual Number Trained IPIBEOFATION INDICA'lMRS 1980-1984 1985 1986 Total PER APPAISAL REPORT (SAR) (Original Extension Period) 1980-1986 Duration) Sterilization Assistance Train- Development Work- ing for Nurses and MI' iwives shop Seminar of PAs e. Technical Training 13 13 Course Vasectomy Training for physicians f. Training on Basic 16 16 from PA's Research Project Monitoring and Cytology Training & Lab Procedures Evaluation for Lab Technicians of PA's g. Team Building and 5 5 Program Develop- Refresher Course on FP Techniques ment for FWP Staff and Concepts h. Basic CO for Antique 10 * 10 1. Annual Assessment & 22 22 Workshop on Field Operations Planning Workshop Monitoring Systems for Regional j. Upgrading Technical 15 Is Population Staff Training Course k. Basic Community 16 16 Workshop on FOMS for Central/ Organization Training .MAts 6, pagu 8 POPCOM Actual Actual Number Trained DWIkMIEATION INDICAIRS 1980-1984 1985 1986 Total PER APPRAISAL REPOR (SAR) (Original Extension Period) 1980-1986 Duration) Provincial/District Population 28. PP Volunteer/Motivator 25 25 Officers Training for Officers of Family Circles Clubs (3) Workshop on FOMS for 29. Training of Hilots as 160 160 FTOW's Motivators in FP (3) 30. Expanding FP Static 100 10(K) Diploma Courses in IEC Centers to Barangay Health Stations (8) Supervision of Services- 31. Mobilizing School Clinics 23 23 Follow-up of Training as FP Service Centers (8) 32. Caceres Christian Family 103 103 Life & Welfare Program: Oneness of Husband & Wife (5) 33. FP Motivators Seminar 240 240 Workshop for Kababaihang ARBA (10) 34. Training of Elderly Volun- 96 96 teers as Motivators in FP (7 TABE b, page 9 ... POPCOM Actual Actual Number Trained IMPIENPATIGI INDICAORS 1980-1984 1985 1986 Total PER APPRAISM REPORT (SAR) (Original Extension Period) 1980-1986 Duration) - --- ----- --------- - -------- --------------------------------------------- 35. Family Life Enrichment 30 31) Profram for Agrarian Re- form Beneficiaries (5) 36. Developing Volunteers 78 78 Health Workers as FP Motivators (10) IV. MANPOWER DEVELOPMENT PROGRAM 1. Staff Development for 400 332 732 1 10 POPCOM/PA.,. Workers a. Project Development 268 159 427 Course b. POPDEV 987 455 1,442 c. RPO Staff Dev't/HRD 352 193 545 d. POPDEV Training (1) 41 41 e. POPDEV Orientation 20 20 for PAs (2) 2. Training on Finance and 851 851 Financial Management TABILE 6, page 10 POPCOM Acizual Actual Number Trained IMPIUBFPATION INDICAORS 1980-1984 1985 1986 Total PER APPRAISAL REPORP (SAR) (Original Extension Period) 1980-198b Duration) 3. Supervisory Management 95 95 Training 4. Research Utilization Work- 80 80 shop 5. Trainers Training 95 95 6. Skills Training (FTOWs) 5,722 363 6,085 7. Training and Research 269 461 730 8. Skills Training on Pro- 69 883 952 ject Management 9. Skills Training on Para- 14 18 32 sitology for Medical Staff & Paramedics 10. Fellowship 132 22 152 11. Training of Development 251 254 Theater for OSY 12. Skills Enhancement 132 132 Training for MSSD Workers 13. Development of low cost 47 47 94 IEC materials 14. Refresher Course on the 125 125 Phil. Population Program Policies (CO) TA13TE 6, page 11 POPCOM Actual Actual Number Trained IIMLEMPMATIGI IDICAlIRS 1980-1984 1985 1986 Total PE APPRAISAL MOM (SAR) (Original Extension Period) 1980-1986 Duration) - ------------------------------------------------------- 15. Fellowships (CO) 2 2 16. Skills Training for FTOWs 260 260 (NCR, 2,3,4,7,8,9, 12) 17. AMF Population Project 19 19 Management (5) 18. Team Building Workshop 334 334 on MIS (2) 19. Project Development and 50 50 Screening for RPOs/PAs (1, 2 & 6) 20. Staff Development (NCR, 118 118 1, 2 & 3) 21. Harnessing the Elderlies (6) 101 101 1 22. Project Monitoring Skills 77 77 Training (CO, 1, 11 & 12) 23. Building Administration 35 35 Seminar (CO) TAHE 6, page 12 POPCOM Actual Actual Number Trained IMPLEMEITATI(I TNDICA'IOPS 1980-1984 1985 1986 Total PER APPRAISAL REPORT (SAR) (Original Extension Period) 1980-1986 Duration) V. POPULATION INEQRMATION MANAGEM ENT& DISSEMINA- TION PROGRAM 1. Task Force Meetings/ Coordination Workshops a. Coordinating Work- 25,082 1,990 27,072 shop/Task Force Meetings b. RPPCT/CPPCT/ 2,116 5,207 7,323 MPPCT/ROMC c. Evaluation and 143 143 Planning Workshops 2. PPP Orientation for 127 127 Pastors and Ministers 3. Orientation Workshop 164 66 230 for Top Management & Union Leaders 4. Orientation/Re-Orient- 7,969 2,395 10,364 ation of LG Executives & Staff & PAs Heads TABTL*E 6, pge 1 3 5. Population Information 24 12 36 Network System (POPINS) 6. bMPA 1,660 1,660 7. Population Service Corps 20 20 8. Consultative Meetings w/ 280 280 Field Workers of Refering Agencies (3) 9. SDCC & MIS Orientation (5) 370 370 10. Task Force Meetings (1, 3, 577 577 and 4) 11. RPPCT/CPPCT/MPPCT/ 6,335 6,335 ROMC (1, 2,5,7 & 10) 67 67 as FP influentials (10) 13. Orientation of LCR on 200 200 PMC (3) 14. Operations Review/. 75 75 Planning Workshop of CT/CIT (11) 15. LG Orientation on PPP (11) 241 241 16. Local Gov't Orientatibn' 1,066 1,066 (1, 3,4, 8, 10, 11, 12 & NCR) 17. Orientation Seminar of 105 105 Church Lay Leaders to FP Concept (1) 1,660 1,660 TABLE 79 PRIMARY HEALTN CARE IMPLENENTATION INDICATORS A C T U A L ACTUAL PER APPRAISAL REPUIfd (SAR) . ADDITIONAL. ACTIVITIES . s 80-'84 s % a *85-*88 % :8-*84 % '85-'88 a 1. Acceptance and Ehforcement s Done a a 1. Evaluation of 111C Completed in 1983 of Primary Health Care a a a a Impleanentation by IP-1I :: Scheme by the Regional : a a Health Directors - 12 Regioh a 2. Training on Effective :completed in 1983 12 Regions a : Management (UP & PRHIN) a 2. Selection of a province : Done a 3 3. Documentation of 11O11 1 habe I : a Phase li; in each Region. : : a Experience in Pld( Completed: GCompleted: 3 3 a : : : 1985 : : 1985 3. Acceptance of the Primary : Done 3 3 3 S 4. Ranking of barangay :Coinpleted: : Health Care Scheme by the : a : by level of Development ;in 1984 : Selected Provincial Health a s a a Officers-12 PHOs * 3 3 3 3 5. Support and Maintenance s Support and maintenance a 3 a 3 : to barangays on the 13t a provided: 4. Social Preparation of a Accomplished in 1984 a a and 2nd levels of Barangays In the 100 : a a Development Municipalities a : a : a : a a 6. Support for Integration :Provided 5. Setting up of Barangay 4 4954 a 122%: a of PHC Hanagefnt of i n 198'a Development Councils in a M a 1011 field unite at the : these municipalities 3 3 3 District level : : (4,050 municipalities) 3 3 3 3 : a : S 3 a : 7. MOI-UPLB Medicinal : : Completed: 6. Communty Selection of a 3 4,954 3 122%: Pl6nt Production and :In 1985 Barangay Kealth Workers a a : a : Propagation Project : a * 3 3 a a 3a : a INPLINENTATION INDICATORS I A C T U A L ADDITICHAI ACT1%IT1k;S : A C T U A L PER APPRAISAL' REPORT (SAR) a-80-*8' ; % : ,-'88 ; . 8 080-084s % s 185-88 a %a8 3 3 3 3 3 * . 8S 3 3 a 7. Identification of type of a a a 8. Training on Herbal :Completed; community resource I I a Medicine (Regions II, sin 198to a project suitable for :I a 3 a 3 XII, VIII) a comunity I 3 3 I 1 s a : a a 9. Preparatioto for the :Completed; a a. Establishment of a 6760 100%*s a establishment of Herbal sin 1984 : 2 3 Additional BSPOs - a a 1 t Processing Plant 6760 1 - I I : a a 1 3 2 a 10. MOIl-POPCOM Tech. Ga ;Completedi b. Development of a I Accom- I I a t Collaboration on the sIn 1985 : Herbal Medicine a plished I a I I preparation of Family Manual a in 1983 1 a a s Health Guide : 3 3 3 a s 11. Monitoring/Strengthening a : :Strengthe- 3 a a a a a of BSD's aed inactive: a a 3 a s a : and nion- s 3 3 3 a a : a afrunctional 3 3 8 3 aa :BSB' 3 S 3 £ 3 3 3 2 3 3 3 2 5 8 3 * 3 5 a 2 3 2 8 3 3 S 3 3 3 3 3 3 3 3 3 3 2 a 3 3 S 3 3 3 : 2 3 3 3 3 3 8 ; : 3 - 93 - lhB 8: PCDS FUlti2UM, EQUIENT AND VEHES IMPMENERTIO 3DICAMSS PCPC4M ML mEmR PR APPRAIAL CCMED 1. PIOUREEN AND DLIVERY a. Euiipmt and 33 Aircmxditime 1987 Furna.ture far 28 Edhausm gm Centra.L Office, Miniblinds NCR and RPO IV 6 Electric 1an Offices 2 single Side Band 3 COpact Industries AAVR Various Kitnen EqUspmnt Tables and Chair for Kit=n 1 Jefrigerator/Freezer 60 Plant Ba Dvivder 25 Sunk bed with mateK tom 22 Stool 30 Executive DeK 38 Executive Chair 482 Cleracal Chair 72 Clerical Desk 131 Visitors Cnair 19 Sofa set 20 Cnference table/aesm 32 Conference chair 10 Audio Visual Table 7 Caputer Desk b. CO Warehouse Cancelled Fumiture c. CC Vehicle maintenance Wrkshop Furniture Ca-:elled d. CO Warehouse Cancelled howver, POPCCM purchased 12 Heavy Daty Cart 12 Heavy Dwty Hand Tuck 1 Filluag cabinet 1 Intero 1 Aizmn .L Emnaust Fan 94 TBILE 8, page 2 ZMLaEA CN NDICARS 9PC4 PTUAL EM PER APPRAISAL CCMPEE 1 Strapping achine 75 heavy Duty retal shelves e. CO Vehicle Cancelled Mintenance Workshop Equipmant f. CO Vehicle 1 Isuzu Truck 1 Nissan, Micro Bus 12 Mitsubishi, Pajero 24 Nissan, Pick-p g. CO Audio-visual 8 Color Video Camera sEupent 8 Video Cnnecting Cables 8 Color Video Projector 8 Video Cassette Recorder h. CO Nine (9) Cancelled Large Boats and Twelve (12) Small Boats i. Bquipnt and 26 Executive DesK Furnt:ure for 35 Executive Chair Seven (7) RPOs 88 Cler=cal Desk 189 Clerical Chair 340 Otner tables tconference, dining, coffee, center, corner, worK, study, etc.) 17 Sofa set 12 Index Card Cabinet 3 Mnual Typewriter 5 Electric Typewriter 13 Calculator ―戸”－【／・‘& VMS 10; POFCCH-INFaMTICN/WUCATION/CMMI[CATLCN - ---- - - - - -- - - ---------------------------------------------------------------------------------------------------------------------- --- --- IMIDGM TICN POPCOM Target Actual Actual 1,01al Actual its % MICKIK". PER 1980-1984 1985-1988 1980-1988 ot Appraisdi - - - ---- - -- - -------------- ----------- - ---------- - ------------------------------------------------------------ -- - -- ---- A. Radio 4,940 2 types iadio 15,340 broadcasts 22,960 broadcasts 38,300 broadcasts 775-30% segments of programs at radio pro- 1,560 masters grams (49,000 and 20,480 copies copies) each) 450 radio 450 situational 1,392 spots/ 6,278 spots/ 7,670 spols/ spots/iingles: spots and spots/jingles jingles (84,936 jingles (54,538 jingles (139,474 1,71W.44% jingles airings) airings) airings) afirings: (7,W copies) 1,859-65% 60 bulletins 60 bulletins 48 bulletins 48 bidlelins 80% for radio (30,M copies) broadcasters (30,000 copies) 50 issues of 470 issues of 3 40 newsletters 584,298 copies 40 newsletters newsletter: 2 newsletters newsletters (556,123 copies) of newsletters/ (1,140,421 copies) 80% (400,000 (2,062,W copies official publication a)pies: copies) for 13 regions) rwBIE 1O, page 2 IPIDITATICN POPCOM Target Actual Actual Total Actual as % INDICAORS PER 1980-1984 1985-1988 1980-1988 of Appraisal 70 comic 18 comic books 56 comic books 11,319,102 copies 56 comic books comic books: books (18,000,000 copies) (10,722,50 copies) of comic books (22,041,662 copies) 80% (34,700,000 copies: copies) 65.52% 36 leaflets and 7 brochures and 44 brochures 6,436,070 copies 44 brocures brochures: brochures leaflets (4,655,000 (5,589,118 copies) of brochures/ (12,025,188 copies) 122.22 % (7,088,000 copies) leaflets copies: copies) 169.66% 260 posters , 4 types of posters 153 posters 1,947,488 copies 153 posters - posters: (923,000 (2,000,000 copies) (1,244,020 copies) of posters (3,191,508 copies) 58.84% copies) copies: 345.78% 5 calendars 5 calendars 12 calendars 1,819,524 copies 12 calendars calendars: (4,000,000 (5,000,000 copies) (960,620 copies) of calendars (2,780,144 copies) 240% copies) copies: 69.50% 4 manuals 7 manuals 72 manuals 511,612 copies of 72 manuals manuals: (96,000 copies) (103,000 copies) (471,426 copies) manuals (983,038 copies) 1,800% copies 1,024% TiBLE 10, page 3 IPpL*MTIN POPCOM Target Actual Actual Total Actual as % MIC RS.:PER 1980-1984 1985-1988 1980-1988 of Appraisal A PAIS-B . .. -.. --. --.-- . - . --.-.-... ----..- --.. . ---------.-. -------- 60 press 60 full-page ads advertise- ments to integrate population content into: 24 comic 25 novels integ- 36 novels/stories 36 novels/stories 150% magazines rated in popular comics publica- tions I 48 feature 60 feature releases 75 newspapers/ 75 newspapers/ 156.25% articles . on population & magazine ads magazine socio-economic dimensions C. Audio-Visqal Support 116 sound- * 25 types sound- 29 sound-slide 363 sound-slide 29 sound-slide sound-slide sets: sets (1,740 slide present- presentations copies sets (1,085 copies' 25% copies) ations (722 copies) copies; 62.36% TA11E 10, page 4 IIMl'ATION POPCOM Target Actual Actual Total Actual as % INIC;TO,S PER 1980-1984 1985-1988 19811-1988 of Appraisal APPPAISAL REPORT ------------------------ ---- 26 flipcharts 2 types flipcharts 7 flipcharts 51,840 copies of 7 flipcharts Ilipcharts: (5,265 copies) (22,000 copies) (38,805 copies) flipcharts (90,645 copies) 26-92% copies: 1,721.65% 12 training 11 training films films (2,130 (429 copies) copies 8 public edu- 8 motivation/ 7 films (62 prints) 351 prints of films 7 films (513 films: cation films education films prints) 87.50% (1,520 prints) (1,040 prints) prints: 33.75% 2 feature films 2 co-productions 4 feature films 3,147 copies of 4 feature films films: w/ integrated of full-length (147 copies) feature film (3,294 copies) 200% population theatrical films content 3 entertain- replication of I replication.of 4 - replication of 4 films: ment-type full-length film full-length films full-length films 133.33% fi!mc (390 (130 prints) (147 prints) (147 prints) prints: prints)' 37.69% TAilk 10, pay: 5 IPa*wimtcl FOPCOM Target Actual Actual Total Actual as % DIDICA1IS PER 1980-1984 1985-1988 1980-1988 of Appr4isal APPRAISAL. EXORT 16 film spots 16 film spots 13 film spots 3,936 copies of 13 film spots films: (8,000 copies) (80 copies) (1,210 copies) film spots (5,146 copies) 81.25% copies: 64.32% 210 cine slides 210 cine slides D. Community Relations 59,000 sign- 58,940 sign- 74,735 BSPO 74,735 IISPO 126.66% boards boards (OSP, signboards signboards DPO, MPO) 380 plaques 1,380 merit awards 10 grants-in- aid E Special Projects (Indigenous) repertoires 520 folk media 441 folk media 396 folk media 837 folk media 268.26% TABIE 10, page 6 imsm winvinm POPCOM Target Actual Actual Total Actual as % IDICV7OM PER 1980-1984 1985-1988 1980-1988 of Appraisal ---------------------------------------- ---------- of 312 folk presentations presentations presentations presentations media groups repertoires 650 rural theater of 468 rural presentations theater groups 5,200 blackboard newspapers F. Innvayliti9jacts regional exhibits Population Quiz Population Quiz Population Quiz and contests Show (5 National, Show (1 National, Show (6 National, 65 regional) 13 regional) 78 regional) 3 coloring and 47 contests on FP 3 coloring ant oratorical contests integration oratorical contests, 47 contests on FP integration 47 contests on FP integration regional print 1,280,182 pieces of 300 rubber stamps 1,280,482 pieces of gimmicks and print promotional promotional items TALE 10, paye 7.. IMPMITATION - POPCOM Target Actual Actual Total Actual as % INDICATOFS PER 1980-1984 1985-1988 1980-1988 of Appraisal Ar L4MnT .. .........-- - --- ------------------------------------------------------------------------------------ other novelties items & handouts/ and novelties giveaways 16 popular integration of 13 popular songs - 13 popular songs 81.25% songs with population and integrated family planning population messages into content popular songs 9,410 pre- 9,410 pre- marriage kits; marriage kits; 7,106 billboards; 7,106 billboards; 5 tours of schools; 5 tours of schools; 26,178 youths 26,178 youths oriented on oriented on POPED POPED TABLE 11: DO-INFOLRMTICN/EDUCATICNOOMMUNICATION IMLEMEUMICN DIMICNWS :ACTUAL PEICEN : ACIJAL PECNT: PER (SAR) 1980-1984 *E4 1985-1987 1. Advisory Services and Fellow- : : : : Production cid: ships : : repl icaUon : * a of JBC nute- a. Consultants JEC we 30 an-nonths of local and 4 100 rials were international consultants !:itU+4?d IeLvA±ei' : : 1985 and 1988 . b. Fellowships 4 :125 : : as per Wtld : 4 fellowships for B i : iank advice to: maternational training c : i.citraLe ONII the Mic. : 2. Design and Developrent of : related Prototypes or Master Copies : : : acivities of IEBC Materials a. 3,120 segments or radio :3,120 100 Distributed to selected radio programs stations nationwide b. 10 theme songs 10 :100 c. 240 spot announcements 240 100 d. 4 training film : 4 100 e. 30 sounc slide sets 30 100 ** * * TmIE II, paye 2 AC'IJA4PBEiE . AMIAL 1 Il': DMPIEMWATICI IDICAORS : PERL (.SAR) a HS1980-1984 REMARKS 1985-1987R PER (SPLR) 3. Production/Riplication of 18 aw Mterials 3 a. 4 training films (460 copies)3 224 45 Out of 460 copies proposwd only 224 were targettea for *k Iplementation b. 30 sound slide sets 27 : 90 : Out of 4,600 proposed only (4,800 copies) : sets a : 840 %ere targetted for ' 840 inaplementation copies: a : c. 240 tapes of radio spots :120,000 5000 2,400 proposed no. of copies (2,400 copies) a revised to 120,000 for a ; Juplementation d. I entertainment type film 100 100 100 copies e. 3 coaic books (8 4 copies) t50,000 6 3 t. 4 posters (340,000 copies) 140,000 41 nut of A40,00u copies as', * proposed only 100,000 was targetted for irpleentation and 140,061...w. achieved. g. 3 booklets-(7.6 N copies) 1.5M 20 3 h. 1 flipchart (15,000 copiesi 320,000: 50 Wut of 15,000 copies as Laposed t it %as -revised to 40,0ul for a : a apleuntation and only 3 3 3 *0,000 was achieved T~ABLEk , W9ye 3 IMPDNATIMI DIDIMClORS ACRL PMEIEf ACitIA. PE1t.' PER ISAR) 1980-1984 REMAWS 1985-1987 KMARKS Additional Activities a a : 1. Design and Cevelopment of a As 100 16 j%ngles, 3 stickers, aid*-* 1 flipcnarts, leaflets (24 3 Cated; subject areas), 10 posters, 12 canics, 15 docauntary film, 20 print ads, 5 manuals, .. ~ cinea plugs, 5 brochures, 2. Production of 1W Materials t a a. 500/tape jingles s 320 64: b. 600 cinema plugs b 600 100: c. 750,000 stickers 830,000 111 d1. 9,000,000 leaflets a 1.8M 2 20 e. SM ini-brochures 1.5M 30 f. 955 documentarytis a 55: 6 g. 204 print ads 74 36 h. TV Epoa re 9230,400 . : TABLE II, page 9 ... IMPLEENMlRY IDICAIORS :ACTLUAL PERCENF :A'l1AL PEICENw PER (SAR) : 1980-1984 : REMARKS : 1985-1987 : *2ARKS 3. Production of Household r.28,000 5.6 ;q5,000: 9% materials for the Teaching Mnual (500,000) a . : . : . : remiaining cupies : . : : : are Leady. Prin- a : . : : : . ting problans re: a : : : capacity of IC : a : : : : : printing machines. : S : . : Continuing activity; 4. Womens Club Involvement in *Partnetship *Partnetship wasucgawiizd in 73 IBC for PIC (42,091 groups) was or4anized provii&4s and 39 cities as of 1988. in 27 provin-' Contin6ing actiWty for the groups * "ces in 1984 v1so arA still ative. S. MH-MUCS Partnership :Signing of a :537 districts Continuing activity: :Contracts a ;nationwide : * a;participated. 6. Family Health Guide Not LkAertakeh betweeh . :1980-0984 a aa a. Prototype 18194 1 - 1 *Designed in 1986 : :. : . :and bidde in : : a : 19U8 b. Production . 2M 2M" Coapleted in 1988 7. Media Update Conducted in a Participated by ;1985 : : radio inen, 1ibliihers : and school oryan : : : eitors. TABIR 12: .'POPCOI AND DI RESPARCII SiDIES A. Pacal4 SamouEs ~PROPOSED- S'fJDIES' PPR PPSMD- (SR) POPCOM Actual Purpose Status impact Review of Regional A Comparative Analysis of - To determine to what completed Policy to procure Population Policies Three Different Dose Combi- extent the family plan- 1987 low dose pills nation of Oral Contraceptives ing program ha's con- beginning 1984 A Study on the tributed to the reduc- was dWo indicators of pro- ion of population gram performancc growth; to recommend measures for impro- A Study on the im- ving the farhily plan- pact of family planning ing program on population growth AStudy on the Econarniic - develop an index based completed -P L pIir -t iojized .The influence of the Cost of children: A Corpo- on a set of indicator 1987 Uia rwaj to cii.,L ical religion-moral' beliefs rate & a Local Government that will determine the 4 t ta t- . in family planning Strategy in Region XII Jevel of success of the lowlatiors XLuLli rate decision FP program; to recom- particularly Uie advantages mend which indicator/s Oi SlIkill fdflilly SiiZe Male specific IEC should be used for effect- strategies ive evaluation of program performance Study on the causes and extent of pre- An Evaluation Study of completed marital conception DSS Os POPDOSY 1986 BIE 2,page 2 PhP. a SMESAJ POPCOM Actual Purpose Status Impact Studies on cost effectiveness of various contraceptive - A Survey on the KAP of to develop an index completed - sicy showed that methods FP among population based on a set of idi- 1986 govt instrumentalities program professionals cators thaE will deter- can serve te purpose Condom marketing in Region XII mine the level of of 1O1COM. favorable research program: success of the FP pro- attitude and support to Phase 1I gram; to recommend lte program can be which indicator/s sustained l6rough lte Pilot project on should be used for formulation of A scheme integrating family effective evaluation involving govt emplo- planning into the of program perform- yees in popilalion-re- ISA (Farmers' ance lated endeavors w/o Cooperatives) necessarily eating up programs their time in office and that there shuould be a Pilot program offer- series of training prograu ing benefits for family which woild be designea planning to employees to make them more effet- of rural-baed indust- ive program impereallinr ries imiE 12, pvqe 3.. M MARAVAL A POPCOM Actual Purpose Status Impact Development on base- line information and An Evaluation of the Effects - to develop an index completed Project showed that value an evaluation of the of the Value Inculcation based on a set of in- 1986 inculcation siraiegies are not program IEC report. strategies on the Value dicators that will de- effeciive in firming up te Development of Pre- termine the level of children concept on the A Study that will School Children in Day success of the FP pro- small family size. focus on Method Care Centers Ages 3-6 gram; to determine preference by varying to what extent the FP types of clientele program has contri- buted to lte reduction of population growth; to Identify other factors and their contributions to the growth rate Strengthening the Phil. this study will produce completed POPIN hopes to extend it Population Information a data bank of basic info 1983 network services to lte Network: A'Pilot Project on TEC needs, which will grassrowt level throtigh the serve as a basis for ide- establishment of POPIN tifying planning and centers at te provincial evaluating future IEC and barangay levels in activities addition to its institution- alization a.d computer- zation.  TAl-; 12, page 4 l POPCOM Actual Purpose Status Impact PUt APPaA;l I(SARI Assessment of the Phil. completed - tiiainhes wea *ti in Family Planning Com- 1986 strenOLIihlj t.- V ponent of the Nursing cknest. of JC Slurti-.i Curriculum curr ain. A Study on the Role of completed -Aie Stiy ujitatitJ Filipino Elderly on Popu- intuntL dixi puoIi*% lation Matters otioan for tfjrogra plaWt'Xi to U...dfl inl evulyiiks acLiVILies LdsL VAIIJ ialneb zupA)rt t:u e-10cly. An'Assessment of Dula- - the study will produce completed - ang Tinig ng Tundo a data bank of basic 1985 information on IEC PFAPM STUJDIES POPCOM Actual Purpose Status Impact PER APPRAISAL (SAR) needs which will serve as. basis for identifying, planning and evaluating future IEC activities - A KAPS survey of pro- completed gram professionals. 1985 - Enhancing Program Data completed - aecoIalatiouw Assessment & Utilization 1985 used for training of REC in assessina, presentirg, utilizing aa interEpzeting Pisilarusle nttd thst alxd - be usenda tar plattminK/targel tiet"Jlniate "-IE2L ig; - The impact of training completed on services 1985 TAX 12. jage 6 PRPO0SMflMMICPOPCOM Actual Purpose Status Impact - Family Size & Family - to develop an index completed Welfare: Effects of based on a set of indi- 1984 Actual and Perceived cators that will deter- Relationships mine the level of success of the family planning program; to recommend which indicator/s should be used for effective eva- luation of program per- formance - Establishing Evaluation completed - Finings were utili"ses in Indicators on the Popu- 1984 evaluatihj tw KAP ot lation KAPs of Second- seNV.ar soMe teder ary School Teachers and Students in the Phil. L TAulE 12, page 7 F APPAISAL MPOPCOM Actual Purpose Status Impact - fopulation Related Re- completed - searches on Sectoral 1984 Groups: A Review on Findings and Policy Implications - Religious Beliefs, - To determine whether completed - Fertility Control or not these religio- 1985 Policies & Pamily moral beliefs do actual- Planning Behavior ly influence FP behavior to compare the religio- moral belief of people with the official posi- tion of their respect- ive religion; to deter- mine the relationship of the official position of various religions TABIlE 12, page 0 PRAPOS SMIS. POPCOM Actual Purpose Status Impact on population and the formulation of the population policy - Employee Benefits for - This study will test completed FP in Rural-Based the concept in four 1984 industries rural-based indus- tries in Visayas & Mindanao. It is expected that these results will help to persuade other rural- based industries to participate in the program. - An Evaluation of the Pre- completed Marriage Counselling 1983 Program TABLE 12, WOO~i. - ------------------------------------------------------------------ PP APPIUSM (M) POPCOM Actual Purpose Status hipact PER NFlmlSM. (SMO) - An Assessment of the - Develop an index completed Finuhings were utilize Metro Manila Outreach based on a set of 1984 in Lie developftlnL Project indicators that will or pr&o Is thati the evelpruss>e IP practie determine [he level in (ULL.d Wo1W of success of the FP are. program - A Research Program for - To determine the completed the Commercial Contra- cost-effectiveness 1983 ceptive Market of various contra- ceptive methods; to recommend po- licies that would generally promote the use of the most cost effective method - Commercial Contraceptive - To determine the cost completed - Findinqs were used Industry Study effectiveness of various 1983 in developing rehoy;pulicies to sustaim contraceptive methods; involvenent of to recommend policies ene connercal sector in niarketUag conruaceptives. TlE12, page JO.. POPCOM Actual Purpose Status Impact PER APPAISAL -(SAlm) that would generally promote the use of the most cost effective method - Assessment of the Third - The study will produce completed neccusetumm2 was National and Regional a data bank information 1984 used to jaiawe Lth Population Quiz Shows in IEC needs which will uiakd and reaSamial serve as a basis for iden- potulation quiz slw. tifying, planning and evaluating future IEC needs. - Essay on the Economic Per- completed - tility Population Growth 1984 and Public Intervention in a Developing Country: The Philippines - A Systems Evaluation - This study will pro- completed of POPCOM Decentralized duce a data bank of 1981 IEC Strategy In Regions 3 basic Information on and 5 IEC needs which will serve as the basis for Identifying, planning and evaluating future IEC needs Delivery TABI.E 12, pd(je 12 Mf IL MDJFt4 POPCOM Actual Purpose Status Impact PMt APPRAISRL (ShR)ap - Masculinity/Pemininity - This study will test completed Concepts and their bear- alternative IEC cor- 1982 ing on the National Popu- binahion of approaches lation Program: Phase Rf to reach tle male Fil- Evaluation pino with Fl messages; to develop and pilot within an 18 month period, three (3) IEC approaches, i.e. mass media, sports and inter- personal designed to reach the Filipino male; support the above- mentioned approaches through the use of existing male oriented IEC materials as well as additional materials to be developed and tested for the purpose of the project - Guidelines for Planning, - This study will pro- completed Implementing and duce a data bank of 1985 iABIE lU, lege 13 PUMW SEC S7IES POPCOM Actual Purpose Status Impact P APPRAsaL -SAR Evaluating Population IEC basic information on Training Programs IEC needs which will serve as a basis for iden- tifying, planning and evaluating future IEC activities - Barangay Integrated completed Worker: A Pilot Project 1985 of the Provincial Governor of Camarines Sir 'IMIZ 12, page 14 POPCOM Actual Purpose Status Impact M AP L aISAlth.d - ISA sa Pagplano ng Pamilya - This study will deve- completed lop and test a scheme 1984 that would serve as a model for integrating population/FP com- ponents into ISA pro- grams I I - KASAMBUHAY Youth complted Peer-Hlping ftooO 1984 TABAE 12, page 15 PW q e POPCOM Actual Purpose Status Impact - 1985 Baseline Service completed - Corps. (PSC) Baseline 1985 Survey I - A Study on the Values - The study will pro- completed Related to Population duice a data bank of 1987 and Fertility/Sexuality basic information Issues among Adolescent on IEC needs which Muslims In Region XII will serve as the basis for Identifying, planning and evalua- ting future IEC activities TABIE 12, page 16 P =. POPCOM Actual Purpose Status Impact - An Information and completed Counselling Program on 1985 Sexuality for the Young Workers at the Bataan EPZ - An Evaluation of the completed POPCOM-JICA Integrated 1985 FP and MCH Project in the Philippines - Integrated Research on In- on-going digenous Medicinal Plants for FP B. 0011 STUDIES TABIE 12, page 17 PFPOSED SIDIES DOH ACIAL PURPOSE SATUS IMPACT PER APPRAISAL (SAR) - Organization Mhnagement coipleted Effectiveness System (0MES) in 1984 - Documentation of MoH - To conduct records ecmpleted Experience in PIE review and validate in 1984 (Phases I &'II) the same - To produce P1C slide-tape presenta- tion for briefing purposes. - 0detemie, future studies on PIC - Operations Evaluation Carpleted of Primary Health Care in 1984 - Evaluation of PHC Pilot coupl eted Provinces in 1984 - Medicinal Plant Production Cc%jeted Study in 19b4 - Dosage Formulation Study ocmpleted in 1984 - 125 - .%~T Op4 . F Republic of the Philippines SAN LAZAROnOMOUuNO z Departmenpf H RIZAL AVHNUt.hSTA. CRUZ fth MANILA. PHILIPPINES OFFICE OF THE SECRETARY TEL.NO.71140*0 December 21, 1990 Mr. Graham Donaldson, Chief Agriculture, Infrastructure and Human Resources Division Operations Evaluation Department The World Bank 1818 H. Street, N. W. Washington, D.C. 20433 U.S.A. Dear Mr. Donaldson: Re: PHILIPPINES - Second Population Project Credit 923 - PH Draft Project Performance Audit Report We are sending to you our comments on the draft PPAR for the Philippine Population Project II. The consolidated comments are from the Department of Health and the NEDA. Very truly yours, RHAI M.'GAIW Undersecr6tary of Health for Management Services - 126 COMMENTS (Main Text) 1. The statement that the availability of information on which to base project assessment is poor (page 5, 2.02) may not be true considering that periodic reports were sent to the Bank regularly by the implementing agencies. Moreover , project files are maintained by both agencies and are usually made available upon request. 2. The IAMCC proved to be effective in facilitating the activities of disbursment of funds for the first population project. Thus, it was again created for the second project primarily to expedite activities and disbursement, but not because there was an " untidy arrangement between POPCOM and DOH which led to turf battles (page 10, 2.07). 3. According to the PPAR (page 12, 2.11), no documentation exists to explain World Bank's agreement to implement PHC nationwide. The PHC approach, however, was adopted ( with bank's approval) primarily to improve. and expand DOH's ser- vice delivery capability to rural and underserved areas. This was even recognized as the most important impact of the Second Population Project (see PCR, 6.07). 4. As to the doubts regarding the effectiveness and shelf life of herbal tablets, it should be noted that these tablets were clinically tested by the UP College of Pharmacology, NSTA and the Bureau of Food and Drugs. With regard to the feasibility study, a copy on file at the DOH and this could have been borrowed by the Audit Mission if it was needed. - 127 - 5. The changes in the studies undertaken may not have been introduced just to accommodate PHC. In fact, out of forty one studies, only around 6-8 were directly related to PHC. It should also be noted that such changes were made in order to address the present needs of the sector and prior to such changes, the Bank's approval was also sought. 6. On miscellaneous purchases, (page 13, 2.15) the production of toys for pre-schoolers was not at all included in the project. It should also be noted that the Radiation Healta Office has been established in June 6, 1974, long before the project started and that no equipment was purchased for this office. 7. On the statement that "the net effect is a project more like a fund into which POPCOM and DOH could dip for pet projects and activities..." (p. 14, 2.16), this may be unfair to the implementing agencies considering that whatever changes or additional activities to be undertaken were based on the plans and priorities at that time and that the Bank's approval has always been sought everytime a change was made. 8. While it is true that there were changes in the production of IEC materials as originally planned, it should also be noted that the development of IEC materials for FP was not altogether disregarded. The following developments on IEC should be noted: a) In 1983, there was a six month campaign countrywide for general awareness of the target population on PHC - 128 - integrated messages on family planning. MCH, nutriiion, etc. Tri-media was utilized, e.g. print=posters on FP and MCH were distributed; radio-spots which included MCH toned to child spacing and nutrition and TV plugs on MCH, nutrition, family planning immunization and breastfeeding. b) In 1984, an agreement with the Department of Education, Culture and Sports and with women's clubs was made. A countrywide approach in the delivery of messages on MCH and family planning, among others, was adopted. It was also during this year that the Household Teaching Manual (HHTM) was developed and pre-tested. c) Between 1984-1985, a change in the production of some IEC materials was considered and approved to conform with the new IEC thrusts of the DOH to massively educate households and this is were the HTM and Family Health Guide (FHG) came in. d) The HHTM and FHG is at present being evaluated by the UP College of Public Health. Lastly, mere development, production and distribution of IEC materials is not enough. It is necessary to consider the process by which utilization and action is fa7ilitated, thus, the origi- nal concept on IEC was linked with the PHC approach. 9. Regarding the statement that the training of supervisors was neg- lected, this may not be so considering that training for the supervisors was conducted between 1980-1984, although such train- ing also included health and nutrition matters. - 129 - 10. On 2.26, i.e. the new chairman was opposed to the promotion of FP on religious grounds and effectively blocked all efforts of POPCOM to implement the program. In fairness to the person concerned, it should be noted that he resigned as the chairman of the POPCOM Board so as not to interfere with the Board's decisions. 11. It should also be noted that when it comes to family planning services, the cafeteria approach has been espoused ever since. The Catholic Church prohibits the promotion of artificial methods, thus, the claim that the church withdrew from the Board because POPCOM failed to promote natural as well as artificial means of FP (page 21, 2.26) is not true. 12. On 2.27, the previous administration did not withdraw its support for the population program just to appease the church. Also, there is an existing Memorandum of Agreement between POPCOM and DOH for the use of POPCOM's facilities for family planning. POPCOM is now in charge of the Integ- rated Population and Development Program which is generally improving its efforts in achieving consistency of plans, policies and programs by systematically incorporating popu- lation concerns into the wider spectrum of development efforts. Specifically, it aims to integrate population concerns in development plans, policies and programs at the national, regional and local levels and to support and implement projects and test innovative approaches that demonstrate the impact of population-related factors on development projects. - 130 - 13. It is believed that to a certain extent the project also contributed in the estimated decline in fertility levels from 4.51 in 1983 to 3.95 in 1989. It is, however, un- fortunate that in the absence of an appropriate method- ology, it is difficult to determine the specific contri- bution of the project (i.e. how much of the decline is due to the activities of Population Project II). 14. On logistics, it should be noted that logistic and equip- ment needs of the project were bidded as scheduled. Delays in the delivery of items were due to problems encountered by the contractors with their principal suppliers, delays in the opening of L/C and confirmation by the Bank. Moreover, items were shipped to end-users in accordance with the dis- tribution list furnished to the Procurement and Logistics Services (PLS). 15. It has also been noted that the PPAR's discussion on training (page 18, parag. 2.22) is inaccurate and incomplete and out of context of the cited portion of the PCR. The following should be noted regarding the implementation of POP II trai- ning activities: 1979 - Evaluation of the implementation of the RHCDS revealed that coverage increased from 35% (in 1974) to 67%. Although there was a marked increase, Management felt that this can still be improved with the PHC Strategy. Thus, the training of 100 RHPs and piloting in one province per region (12 regions). - 131 - - LOI No. 949 which was passed and approved in late 1979 supports the nationwide implementation of the strategy (even be- fore the result of the pilot testing.) This started with the orientation and training of all RHM's on the PHC approach so they can in turn disseminate the con- cept of PHC to their constituents, as part of the social preparation activities. The social preparation was staggered for a period of three (3) years where each Midwife initiated two (2) barangays per year until all the barangays in her catchment area are covered/oriented on PHC. Training of all Midwives on Community Organization. After this training, the RHM organized and trained members of the Barangay PHC Committee (BPHCC) in PHC initiated areas on Organization Manage- ment Effectiveness System (OMES) Re- gional, Provincial and Municipal health personnel were also trained on OMES and organized/trained the members of the Re- gional, Provincial and Municipal PHC Committees. - 132 - Concurrent with this was the recruitment and selection of BHW (based on the results of the "Sarikaya" project con- ducted by the (NFPO) an&d training on the 5-program thrusts of which F.P. is in- cluded. 1983 - As a result of a study on the Botica Sa Barangay (BSB) where it was found that the person incharge do not have formal training and lack skills in the business aspect of running the BSB, BSB Aides from still ac- tive/viable BSB's were given training. Also, a tool for monitoring the level of implementation of the PHC Strategy was de- veloped and used. 1984 - This monitoring instrument was revised this year and supervisors/coordinators were trained to use this during the consultative workshops conducted during the year. BHW were trained all over the country to achieve the targetted ratio of 1 BHW to 20 Households (HH). 1985 to- - RHU and Provincial Staff continue training present BHW to replace those who drop out. 16. The statement on the 0 of midwives trained under POP I is inaccurate (page 2, parag. 1.05 and 1.06). There were more than 5,000 RHM hired and trained under POP I. - 133 - 17. On page 14 and 15 parag. 2.17, it should be noted that F.P. is a thrust of the DOH and a part of the MCH program. 18. It should also be noted that the reason why in the end, 20% of the original credit has to be cancelled was the fact that there was a successive devaluation of the peso against the dollar and this resulted in low drawdowns in terms of US dollars (page 15 parag. 2.15). 19. What was stated in page 18 parag. 2.22 regarding integ- rated training programs is not entirely correct. The RHMs were trained on stool and sputum collection and the training of BHWs include practicum/hands on. Since no in-depth evaluation was done, the statement may lack suf- ficient basis. 20. It is the impression that the PPAR seems to be written with a bias against PHC. It seems that there is a pre- conceived notion that the PHC strategy is not workable and as such any project that adopts it as a strategy will somehow be a failure. This attitude is compounded by an apparent lack of understanding of PHC. For instance, PHC was referred to either as a "service" (PHRD-Country De- partment II p. 74 parag. 213), or as a "program" (PHRD- Country Department II p. 39 parag. 6.06) instead of as a strategy or approach adopted to contribute to the improve- ment of the delivery of basic health services including F.P. 21. The DOH furnished the Bank copies of Annual Audit reports. - 134 - 22. On abbreviations and acronyms, the Department of Health was formerly Ministry of Health and not Ministry of Finance. 23. The credit was approved in June 5, 1979 and not June 6, 1979 as indicated in the Preface.