Philippines - Women's Health and Safe Motherhood Project

Document of The World Bank Report No.13566-PH STAFF APPRAISAL REPORT PHILLIPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT JANUARY 27, 1995 Human Resources Operations Division Country Department I East Asia and Pacific Regional Office CURRENCY EQUIVALENTS Currency Unit - Philippine Peso (P) US$1.00 - 928.0 (as of June 1994) ABBREVIATIONS ADB - Asian Development Bank AIDAB - Australian International Development Assistance Bureau BMI - Body Mass Index CAS - Country Assistance Strategy CHCA - Comprehensive Health Care Agreement DOH - Department of Health DHS - Demographic and Health Survey EC - European Commission ICB - International Competitive Bidding IEC - Information, Education and Communication KfW - Kreditanstalt far Wiederaufbau of Germany LCB - Local Competitive Bidding LGU - Local Government Unit LIB - Limited International Bidding MCH - Maternal and Child Health NGO - Non-governmental Organization OSC - Office of Special Concerns PHC - Primary Health Care PIA - Project Implementation Agreement PMO - Project Management Office POPCOM - Population Commission PPAR - Project Performance Audit Report RTI - Reproductive Tract Infection SOE - Statement of Expenditures STD - Sexually-Transmitted Disease UNFPA - United Nations Population Fund UNICEF - United Nations Children's Fund USAID - United States Agency for International Development FISCAL YEAR January 1 - December 31 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Table of Contents Page No. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv LOAN AND PROJECT SUMMARY . . . . . . . . . . . . . . . . . . . . . . v I. THE SECTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 A. Background . . . . . . . . . . . . . . . . . . . . . . . . 1 Country Background . . . . . . . . . . . . . . . . . . . 1 Sector Background . . . . . . . . . . . . . . . . . . . . 1 B. Issues in Women's Health . . . . . . . . . . . . . . . . . 3 Under-investment in Women's Health . . . . . . . . . . . 3 Limited Availability of Women's Health Services . . . . . 3 Institutional Issues . . . . . . . . . . . . . . . . . . 6 C. Strategy for Sector Development . . . . . . . . . . . . . . 7 Country Development Goals and Strategies . . . . . . . . 7 Health Sector Strategy and the Implications of Devolution 8 Bank Experience and Strategy . . . . . . . . . . . . . . 9 II. THE PROJECT . . . . . . . . . . . . . . . . . . . . . . . . . . 11 A. Objectives and Scope . . . . . . . . . . . . . . . . . . . 11 B. Project Description . . . . . . . . . . . . . . . . . . . . 12 Component I: Service Delivery . . . . . . . . . . . . . 12 Maternal Care . . . . . . . . . . . . . . . . . . . . . 12 Family Planning . . . . . . . . . . . . . . . . . . . . 13 Diagnosis and Treatment of RTIs/STDs . . . . . . . . . 13 Detection and Treatment of Cervical Cancer . . . . . . 14 Life Cycle Approach . . . . . . . . . . . . . . . . . . 14 This report is based on the findings of an appraisal mission to the Philippines conducted jointly in June 1994 with the project's four cofinanciers (the Asian Development Bank, the Australian International Development Assistance Bureau, the European Commission and Kreditanstalt fur Wiederaufbau of Germany). The World Bank mission comprised S. Scheyer, M. Dalupan, R. Lakshminarayanan, J. Martins, C. Verzosa, R. Ng, C. Hsu, P. Prangkham, V. Vijayaverl and M. El-Erian. C. Fogle and R. Heaver contributed to the preparation of the project. The contributions of the following consultants funded under a Japanese Grant for Project Preparation are also acknowledged: M. Clark, R. Gutteridge, H. Khajepour, B. Alano, R. Libatique, M. Taguiwalo, M. Enache and R. Capul. Peer reviewers for the project were A. Tinker (PHN), B. Duza (SA2PH) and M. Mac Donald (ASTHR). The report was cleared by Messrs. J. Shivakumar (Chief, EA1HR) and C. E. Madavo (Director, EAl). - ii - Page No. II. THE PROJECT (cont.) Component II: Institutional Development . . . . . . . . 16 Information, Education and Communication . . . . . . . 16 Training . . . . . . . . . . . . . . . . . . . . . . . 16 Logistics . . . . . . . . . . . . . . . . . . . . . . . 17 Project Management . . . . . . . . . . . . . . . . . . 18 Component III: Community Partnerships . . . . . . . . . 18 Component IV: Policy and Operations Research . . . . . . 19 Technical Assistance Summary . . . . . . . . . . . . . . 19 III. PROJECT COSTS, FINANCING, PROCUREMENT AND DISBURSEMENTS . . . . 20 A. Cost Estimates . . . . . . . . . . . . . . . . . . . . . . 20 B. Financing . . . . . . . . . . . . . . . . . . . . . . . . . 22 C. Procurement . . . . . . . . . . . . . . . . . . . . . . . . 23 D. Disbursements . . . . . . . . . . . . . . . . . . . . . . . 26 IV. PROJECT MANAGEMENT AND IMPLEMENTATION . . . . . . . . . . . . . 28 A. Organization . . . . . . . . . . . . . . . . . . . . . . . 28 B. Project Implementation Under Devolution . . . . . . . . . . 29 CHCAs and PIAs . . . . . . . . . . . . . . . . . . . . . 30 Resource Allocation and Cost-Sharing . . . . . . . . . . 30 C. Accounts and Auditing . . . . . . . . . . . . . . . . . . . 32 D. Progress Reviews and Reporting . . . . . . . . . . . . . . 33 E. Project Evaluation . . . . . . . . . . . . . . . . . . . . 33 V. PROJECT BENEFITS, RISKS AND IMPACT . . . . . . . . . . . . . . . 33 A . Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 33 B . Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 C . Impact . . . . . . . . . . . . . . . . . . . . . . . . . . 34 D. Sustainability . . . . . . . . . . . . . . . . . . . . . . 35 VI. AGREEMENTS REACHED AND RECOMMENDATION . . . . . . . . . . . . . 35 TEXT TABLES Table 3.1: Summary of Project Costs by Component . . . . . . . 20 Table 3.2: Summary of Project Costs by Category of Expenditure 21 Table 3.3: Financing Plan . . . . . . . . . . . . . . . . . . . 23 Table 3.4: Project Costs by Procurement Arrangements . . . . . 24 Table 3.5: Disbursement Categories . . . . . . . . . . . . . . 27 - iii - Page No. LIST OF ANNEXES . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1: Public Investment Strategy and Plan for the Health Sector 39 2: List of Provinces Targeted for Intensive Coverage by the Maternal Care, RTIs/STDs and Cervical Cancer Sub-components 45 3: Maternal Care Sub-component . . . . . . . . . . . . . . . . 46 4: List of Drugs, Reagents and Medical Supplies for Other Women's Health Service . . . . . . . . . . . . . . . . . . 54 5: Information, Education and Communication Sub-component . . 56 6: Description of Training for Health Care Workers . . . . . . 58 7: Public Financing of Health in the Post-Devolution Era . . . 67 8: Decision Support Models for Central-Local Financing of Public Investments in Health: Conceptual Framework and Application . . . . . . . . . . . . . . . . . . . . . . 73 9: Project Management and Implementation Arrangements . . . . 79 10: Implementation Schedule . . . . . . . . . . .. . . . . . . 87 11: Project Monitoring Indicators . . . . . . . . . . . . . . . 97 12: Costs by Component, Category of Expenditure, Project Year and Cofinancier . . . . . . . . . . . . . . . . . . . . . . 107 13: Procurement Plan . . . . . . . . . . . . . . . . . . . . . 114 14: Disbursement Schedule and Profile . . . . . . . . . . . . . 115 15: Supervision Plan . . . . . . . . . . . . . . . . . . . . . 116 16: Selected Documents Available in the Project File . . . . . 118 MAP SECTION IBRD 26586 - iv - DEFINITIONS Contraceptive Prevalence Rate The percentage of married women of reproductive age (15 to 45 years) who are using a modern method of contraception at any time Incidence Rate Number of new cases of a specific disease during a given year divided by the estimated population at mid-year times 1000 Infant Mortality Rate Annual number of deaths of infants under one year per 1,000 live births during the same year Lifetime Risk of Death Cumulative risk of death from motherhood (calculated as 1 - (1-MMRatio) TFR); indicates risks associated with each pregnancy and number of times a woman becomes pregnant Low Birth Weight Infant weight at birth less than 2,500 grams; may be associated with either pre-term (less than 37 weeks gestation) or full-term (38 weeks or more) but small for dates of gestation Maternal Mortality Rate Number of maternal deaths per 100,000 women of reproductive age attributable to pregnancy, childbearing or puerperal complications (i.e., within six weeks following childbirth) Maternal Mortality Ratio Number of maternal deaths per 100,000 births (MMRatio) attributable to pregnancy, childbearing or puerperal complications (i.e., within six weeks following childbirth) Morbidity Any departure, subjective or objective, from a state of physiological or psychological well- being; in this sense, sickness, illness, and morbid conditions are synonymous Prevalence Rate The number of cases present at a given time divided by the estimated population at the same time times 1000 Risk A probability that an unfavorable outcome related to morbidity or mortality will occur within a stated period of time or age Total Fertility Rate (TFR) The average number of live children that would be born per woman if she were to live to the end of her childbearing years and bear children according to a given set of age-specific fertility rates; serves as an estimate of the average number of children per family PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT LOAN AND PROJECT SUMMARY Borrower: Republic of the Philippines Guarantor: Not applicable Implementing Agency: Department of Health Beneficiary: Not applicable Poverty: Program of Targeted Interventions Amount: US$18.0 million equivalent Terms: Repayable over 20 years, including five years of grace, at the standard variable interest rate Commitment Fee: 0.75% on undisbursed Loan balances, beginning 60 days after signing, less any waiver Onlending Terms: Not applicable Financing Plan: See para. 3.6 Net Present Value: Not applicable MaR: IBRD 26586 9 e PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT I. THE SECTOR A. Background Country Background 1.1 At the beginning of the 1970s, incomes in the Philippines were at levels similar to those in Korea, Indonesia and Malaysia. During the 1980s, these countries grew at an average of over six percent per year, compared to the Philippines' rate of less than one percent. Poverty reduction in the Philippines lagged because of the slow growth; moreover, the growth was concentrated in the higher-wage formal sector protected by minimum wage legislation and did not benefit the majority of the population that worked in the agriculture and informal sectors. Slow economic growth, combined with the effects of political crises and natural disasters, left the Philippines in 1992 with a real per capita income 7.2% lower than in 1980. 1.2 Similarly, while health, nutrition and fertility conditions in the Philippines have improved over the past two decades, progress has occurred at a slower pace than in most East Asian countries, due to the country's sluggish growth and lower levels of investment in health. The infant mortality rate, for example, was comparable to the rates in China and Thailand in the 1970s, but is now twice as high as in these two countries. The incidence of communicable diseases, notably tuberculosis, is also considerably worse in the Philippines than in countries of comparable socio-economic status. High rates of fertility, linked to a weak commitment to family planning programs, have contributed both to slow per capita economic growth and to increased mortality, morbidity and malnutrition rates among women and young children. 1.3 The Philippine economy has improved in the past two years, with growth rates estimated at 2.4% and 5% for 1993 and 1994, respectively. Prospects are favorable that this recovery, led by rises in domestic demand, net exports and foreign direct investment, will continue into the near future. The need remains, however, to channel the country's macroeconomic gains into programs that support the Government's human resource development and poverty alleviation objectives, and translate into measurable improvements in the health status of the population. Sector Background 1.4 The Department of Health (DOH) has been the main health policy- making and implementing agency of the Government. DOH policies have undergone significant shifts in the last decade. In the early 1980s, the Government initiated a community-based primary health care (PHC) program to improve the outreach of health services to the poor, with particular focus on maternal and child health (MCH). The PHC program, which reached near national coverage by 1985, involved strengthening the para-medical midwife cadre to a coverage of about one per 10,000 population, and recruiting volunteer barangay (i.e., village) health workers at a target ratio of one for every 20 households. - 2 - Simultaneously, the vertical structure of disease control programs was largely dismantled in the expectation that they would be integrated into the PHC program. 1.5 The PHC strategy had mixed results. Outreach and community involvement grew rapidly, but the technical integrity of the preventive programs quickly deteriorated, leading to significant increases in cases of malaria and tuberculosis, among others. It was recognized that the technical complexity of the disease control programs--with their specialized training, task scheduling and equipment needs--fit poorly into the PHC structure. Vertical logistic and technical supervision systems for the disease control and immunization programs were thus reinstalled in 1987. 1.6 Health workers at the periphery, including midwives and barangay health workers, were also unable to meet the growing demands placed on them by the PHC strategy, both in terms of health service delivery and community mobilization. Their original focus on providing maternal care and support to the expanding child health program was undermined by having to handle a multiplicity of clients and interventions. In response, the DOH introduced in the late 1980s a targeted area-based planning process in which communities, health workers and non-governmental organizations (NGOs) worked in partnership to identify the highest risk communities and families in their area and concentrate resources on them. Successive Governments also increased the numbers of midwives to the present midwife to population ratio of 1:5,000. 1.7 Area-based planning was part of the broader health sector strategy adopted in 1987 by the Aquino Government. This Administration increased resource allocations to the health sector from 2.7% to 3.0% of public expenditures, succeeded in raising immunization coverage from 23% to 80%, improved performance in diarrheal disease control, and launched a program for control of acute respiratory infections. In order to use limited resources more cost-effectively, the Government also revised its resource allocations to community health so as to minimize regional disparities and focus resources on those most in need. 1.8 The Ramos Government, which took office in 1992, has broadly endorsed the strategies of the previous Administration, and proposes to consolidate and build on them. However, it faces a new challenge as a result of the devolution mandated by the 1991 Local Government Code, which shifted the budget for and management of health services from the DOH to the local governments of 75 provinces, 60 chartered cities and about 1,500 municipalities. Correspondingly, the new role of the DOH is to provide policy, technical and financial support towards the achievement of national public health objectives. 1.9 To provide continuity to national public health programs under a devolved system, the Government approved in July 1994 a ten-year Public Investment Plan for the health sector, Investing in Equity in Health. The Plan provides a sound basis for supporting investments in health. It outlines a strategy for resource mobilization and utilization which aims to support and encourage local governments to sustain and expand six priority health programs. These priorities are: women's health and safe motherhood, child survival and development, control of prevalent diseases, health service capacity improvement, environmental health, and national health insurance. The proposed project would support the first program. - 3 - B. Issues in Women's Health 1.10 More than one-third of the global burden of disease for women ages 15-44 and over one-fifth of that for women ages 45-59 are caused by conditions that afflict women exclusively (e.g., obstetric complications and cervical cancer) or predominantly (e.g., anemia and sexually-transmitted diseases). The Program of Action of the September 1994 International Conference on Population and Development in Cairo calls for a special emphasis on investments to reduce high rates of maternal mortality, to educate and empower women, and to increase access to safe and effective family planning and reproductive health information and services. 1.11 The Philippine Government has endorsed the Cairo Program of Action, and has committed to give greater priority to women's health, particularly women's reproductive health. This commitment stems from a recognition of: (a) the historical under-investment in interventions to improve the health status of women; and (b) the potential benefits of improved women's health for the survival, health and education of their children, for the productivity of women and their households, and for reducing the high fertility levels that currently absorb much of the benefits of economic growth. Under-investment in Women's Health 1.12 Much of the past investment in women's health was to have come through the MCH Program, but program resources have been concentrated almost entirely on the child. This focus on the child and relative neglect of maternal health needs have resulted from two key factors: (a) the existence of eloquent and effective institutional advocates for the child, such as UNICEF; and (b) the increased availability of simple and effective health technologies, such as immunizations for common childhood diseases and oral rehydration therapy for diarrhea. The minimal technology requirements of these child health interventions, along with the fact that they can be provided at the community level by basic health workers, supported by health volunteers, have made it possible to reach nearly every child with these programs. 1.13 In contrast, women's health risks cannot be fully met at the community level and require the involvement of doctors, nurses, hospitals and laboratories. Although basic health workers and volunteers do have important roles to play in delivering women's health services, such as family planning and pre- and post-natal care at the community level, large reductions in the major causes of mortality and morbidity in adult women can only occur through interventions which are clinical in nature and require medical skills, personnel and facilities (such as caesarian sections). At the same time, treating the major causes of disability and premature death for women ranks among the most cost-effective health interventions and yields some of the highest social and economic benefits, as demonstrated in the 1993 World Development Report, Investing in Health. Limited Availability of Women's Health Services 1.14 The availability of women's health services has been limited by past under-investment as well as the lack of a clear policy and program to address the major health risk factors among women. These risks relate to pregnancy and pregnancy-related complications, the lack of access to safe and reliable -4- contraception, reproductive tract infections (RTIs) and sexually-transmitted diseases (STDs), and cancer. 1.15 Maternal Care. The Philippines, a lower middle-income country, has much room for improvement in assuring the availability of safe motherhood services. According to the first Demographic and Health Survey (DHS) conducted in 1993, maternal mortality is 208 per 100,000 live births; even the lower, official figure of 74 is twice that of Thailand. The leading causes of maternal mortality are post-partum hemorrhage, hypertension and infections. Poor, rural women face a much higher risk when such obstetric complications ensue because of their pattern of birth attendance and location: about 60% of lower-income women are not attended by a trained physician or midwife at birth, and they are much more likely to live further away from hospital facilities that can deal with disabling or life-threatening situations. 1.16 The causes of maternal mortality and morbidity are related to poor pre-natal, obstetric and post-natal care, weak referral systems and inadequate management of obstetric emergencies. Traditional birth attendants, midwives and other primary health care workers have not been adequately trained or equipped to manage normal births, nor to identify signs of complications and refer patients to physicians or hospitals. Referral systems themselves, where they do exist, are weak, and most provincial and district hospitals do not have the capability to deal with obstetric emergencies. 1.17 In addition to adequate maternal care services and facilities, pregnancy outcomes are most affected by the mother's nutritional status. Nutritional deficiencies during pregnancy expose the mother to higher risks of pregnancy-induced morbidities and complication during delivery, and the child to prematurity, low birth weight and malnutrition. About 18% of newborn babies in the Philippines weigh less than the norm of 2.5 kg, and from one-half to two-thirds suffer from iron-deficiency anemia. Data from the 1993 DHS Safe Motherhood Survey show that 12% of Filipino women of reproductive age (15% of rural women) have a Body Mass Index (BMI, a combined measure of weight and height) less than 18.5, a level with likely adverse effects on fetal growth for those who become pregnant. A 1992 study of lactating women in the Philippines showed that, for a high proportion of women, maternal weight deficits left after pregnancy cumulate through subsequent births in a cycle of maternal depletion. For poor rural women, energy intakes during lactation were about half of recommended allowances, and 28% of these women started the next pregnancy with a BMI lower than 18.5. 1.18 A 1987 National Nutrition Survey found 40% of pregnant women and 50% of lactating women to be anemic; their dietary iron intakes were reported to be only 62% and 55%, respectively, of recommended levels. In addition, Vitamin A intake was found inadequate among 48% of pregnant and 52% of lactating women; iodine deficiency, as measured in visible goiter rates among pregnant and lactating women, was reported at 30%. More recent surveys have confirmed these levels of micronutrient deficiencies. The Government has been discussing long- term solutions, including food fortification and community gardens supported by nutrition information and education. However, micronutrient supplementation remains a cost-effective option in the short- to medium-term for vastly improving the nutritional status of women and their children. - 5 - 1.19 Family Planning. Although the Philippines has had a national program in family planning since 1970, the program has suffered from vacillating political support, uncertain financing from both domestic and external sources, lack of consensus on program goals, and diffused responsibility for program functions. Consequently, the program has not achieved its own stated objectives nor the results observed in many neighboring countries. Although the total fertility rate is down from the late 1960s level of 5.7, it remains high at 4.3, compared to 3.4 in Indonesia and 3.0 in Thailand. One-third of married women of reproductive age (15-45 years) report an unmet need for contraceptive services, and the 1993 DHS reported a contraceptive prevalence rate for modern methods of only 25%, representing virtually no increase in the past decade. 1.20 Political support for a more effective population program has strengthened in the past few years. In 1990, the Government requested technical assistance from the World Bank to review the family planning program, which resulted in a major sector report, New Directions in the Philippines Family Planning Program (Report No. 9579-PH, October 1991). The report noted that access to contraceptive services, even if limited to women at the highest health risk (i.e., those under 20, over 35, with four or more children, and those within 15 months of the last birth), could lead to a 25% decline in infant mortality. It also concluded that family planning efforts focussed primarily on such clients could have a significant impact on fertility. 1.21 The present Government is committed to the goal of eliminating the unmet need for family planning and thereby enabling women to space or limit their pregnancies according to personal choice. The Government has secured major funding for the national family planning program from UNFPA and USAID over the next five years. A wide range of family planning methods would be made available to meet projected contraceptive requirements, including the pill, intrauterine devices, condoms, injectables and implants. Only limited support, however, would be provided for voluntary surgical contraception, which is the preferred method claimed by about 28% of married women in the Philippines. Another issue raised by health care workers is the lack of private examination and counselling space and of sanitary facilities in the centers where family planning and other women's health services are to be provided. 1.22 RTIs/STDs. Reproductive tract infections include sexually-transmitted diseases and infections caused either by an overgrowth of organisms present in the genital tracts of otherwise healthy women or by unsafe medical procedures. When left untreated, RTIs can cause infertility, ectopic pregnancy and blindness in infants born to afflicted mothers, can preclude the use of certain contraceptive methods, and can predispose women to cervical cancer. The prevalence of RTIs in the general Philippine population is not known, since there has been no effort to gather relevant data and little capacity to manage RTIs in the basic health care system. It is believed that the prevalence of RTIs in the Philippines is similar to that in other developing countries. 1.23 In the public sector, RTI treatment has been mainly focussed in "social hygiene clinics," which perform mandatory STD examinations on commercial sex workers. These clinics are not utilized by the general public and no other public health facilities routinely provide RTI treatment. Health services for the general population have not been organized so that - 6 - opportunities can be taken to diagnose and treat early symptoms of RTIs among clients seeking maternal care and family planning services. 1.24 Cancer. The incidence of cancer in the Philippines ranks third following communicable and cardiovascular diseases, and fifth among the leading causes of death. In 1988, the Government established the Philippines Cancer Control Program aimed at the early diagnosis and treatment of common cancers. Breast and cervical cancer are the two most common forms of cancer affecting women. Although the prevalence of breast cancer is reported to be high, compared to other developing countries, breast cancer diagnosis and treatment is expensive, and thus is not likely to be cost-effective in the present Philippine situation. 1.25 Screening of cervical cancer, on the other hand, is particularly cost-effective because the disease can be treated relatively easily in its early stages. Treatment of early invasive cancer can also be treated cost- effectively through cryotherapy. There are as yet few cervical cancer screening, diagnosis and treatment services available in public sector facilities. Pap smears are offered primarily to family planning clients, whose younger ages make them unlikely to have developed the disease, rather than to women in the higher-risk age groups of 35 and above. Not surprisingly, few cases are identified through this route, and when cases are discovered, treatment is often not available. 1.26 Violence Against Women. Women's groups and other NGOs are increasingly raising awareness of the problem of violence against women. The health sector has been called to go beyond treating the physical consequences alone and to address the roots of the social legitimization of such violence. Health workers can be an important source of support and referral for victims of violence, but they can also make the situation worse through insensitive and judgmental behavior. Even where no special services are available, health workers can be trained to emphasize that no one deserves to be subjected to violence, and they can put women in touch with agencies and organizations that may provide assistance. Much can also be accomplished through public education initiatives that call attention to the damage to women's health (physical and mental) and productivity caused by violence. Institutional Issues 1.27 The development and implementation of an effective women's health program will also require efforts to address key institutional issues, with respect to the organization of women's health services, the network of service providers, and the efficient functioning of logistics systems for contraceptives, drugs and other medical supplies. 1.28 Organization of Women's Health Services. An effective women's health program requires an integrated package of women's health education and services on an outreach basis, since low client awareness means that clinic-based services will not be sought. This needs to be combined with a referral system which ensures that complications of pregnancy and delivery are directed to the appropriate levels of care. Until recently, the technical and administrative links within the DOH units responsible for family planning, maternal care and obstetrical management have been limited, and little field coordination of these services has taken place. Organizational changes in the DOH have now - 7 - placed the services for family planning, MCH and nutrition together in the Office of Special Concerns (OSC). The DOH is also establishing formal links between the OSC and the Hospital Administration, which manages the facilities and.facility-based staff necessary to treat obstetrical complications, as well as with the units responsible for the RTI/STD and cancer programs. In addition to the organizational concerns, technical shortcomings in existing service protocols and training packages need to be addressed. 1.29 Service Network. Health services are managed out of Provincial, City and Municipal Health Offices. Under these offices, a network of municipal-level rural health units and village-level barangay health stations deliver primary and secondary services, including maternal and child health, family planning, clinical consultation, health education and counselling, immunization, disease surveillance and nutrition services. A typical health unit/station is staffed by physicians, nurses and/or midwives, and assisted by barangay health workers. The ratios of health staff to client population vary widely from one jurisdiction to the next. Expanded and improved delivery of women's health services will require extensive training for most of the medical staff and health workers in the field. 1.30 Logistics. Poor and irregular supplies of contraceptives, drugs and other medical supplies have contributed to discontinuance of contraceptive use, poorly treated health conditions, and poor community acceptance of public health services. Pilferage, especially of goods with commercial value, and the lack of quality control in transportation and delivery, leading to deterioration of goods, are serious problems. These contribute to inefficiency and wastage within the health system, and increased health costs. In the past three years, the DOH has commissioned numerous studies and pilots to examine various options for logistics support. These studies have taken into account the role of the DOH under devolution, the efficiency of local drug purchases, and the comparative costs and benefits of utilizing the private sector. While committed to improving the efficiency and transparency of the public health logistics system, the DOH has as yet been unable to mobilize the technical and financial support to introduce the required reforms. 1.31 Need for Greater Community Involvement. The Government is committed to learning from and scaling up past efforts to organize and empower communities for greater self-reliance in addressing their health problems. The devolution of health services to LGUs should provide more opportunities for effective partnerships among communities, government agencies, NGOs and other local private resources to achieve this important objective. C. Strategy for Sector Development Country Development Goals and Strategy 1.32 The Government's Medium-Term Development Plan (1993-98), prepared by the National Economic Development Authority, emphasizes two main themes: (a) the need of the Philippine economy to strive for world competitiveness; and (b) the need to provide people with the economic means to gain control of their lives. The Plan's overall human development goals are to: (i) enable the majority of the population to meet their basic minimum needs; (ii) provide focused basic services at a level which would allow people to manage and control their resources as well as benefit from developmental interventions; - 8 - and (iii) harness the productive capacity of the country's human resource base toward international competitiveness. 1.33 The strategies proposed for poverty alleviation and human resource development include: focusing social services on the poor; developing social safety nets; directing public resources and efforts at basic social services, disadvantaged regions and specific groups; improving and strengthening the mechanisms for planning, policy formulation and implementation of social development programs; and providing the necessary infrastructure facilities to facilitate and improve delivery of basic social services. Health Sector Strategy and the Implications of Devolution 1.34 The Government's overall goals and strategies for the health sector are articulated in the ten-year Public Investment Plan of the DOH (para. 1.9; Annex 1). Its key objectives are to assure the sustainability of national health programs, support the process of devolution, rationalize sector spending, and enhance institutional capabilities in management and planning, procurement and logistics, and infrastructure development. 1.35 Among the six priority health programs, the women's health and safe motherhood program aims to ensure universal access to family planning information and services in accordance with health needs and the fertility preferences of couples, reduce maternal mortality through improved pre-natal care and safe delivery services, and reduce maternal morbidity though quality maternal care, better nutrition and adequate spacing of pregnancies. The program also aims to provide services for RTIs/STDs and cervical cancer on a more limited scale, while service protocols are being developed and evaluated for their cost-effectiveness and sustainability, with the eventual aim of including such services into a truly integrated women's health package. 1.36 Because the health sector is arguably the sector most affected by devolution, much of the DOH strategy is focussed on the development of institutional arrangements to make devolution work. The key features of the 1991 Local Government Code which mandated devolution are as follows: (a) Devolution of Basic Services. Local Government Units (LGUs) were given new responsibilities for important public services previously held by the National Government, including agriculture extension, forest management, health services, tertiary roads and social welfare programs. The National Government staff, equipment and facilities associated with the devolved functions were transferred to the LGUs. (b) Increased Revenue Sharing. All previous National Government grants to LGUs were consolidated into the Internal Revenue Allotment. From 1994, 40% of national revenues will be allocated to the different levels of local government according to the following formula: provinces 23%; cities 23%; municipalities 34%; and barangays 20%. Within each level of local government, the grants will be distributed based on the following formula: population 50%; land 25%; and equal share 25%. (c) Administrative Autonomy. LGUs were given more flexibility to raise local revenues, to borrow, and to determine types of local - 9 - expenditures. The amount of flexibility varies, however, according to level of local government, with cities and municipalities on the one hand gaining additional options to introduce new taxes and fees, while provinces, on the other, limited to collecting only those taxes specified in the Local Government Code. 1.37 Under devolution, the DOH has undergone a far-reaching structural and functional transformation. All DOH facilities at the local level, including hospitals, rural health units and barangay health stations, and 70% of the sector's staff, have been devolved to LGUs. Public health services and hospital operations at these levels are no longer subject to central financial or managerial control, and local governments must now manage large-scale public health responsibilities. Devolution carries with it the risk of reduced allocations for health and greater inequities. Some LGUs may not have the resources to provide adequate services, while others may lack the commitment. Even if health allocations are maintained, there is the danger that health resources may be diverted away from preventive toward curative care. Still another risk is that public health service quality may fall because of weak local government health management capability. 1.38 To avert these risks, the DOH is engaged in a three-pronged strategy to manage health services under devolution: (a) it has secured approval within the National Government of its ten-year Public Investment Plan for the health sector, which outlines national priority health goals and programs (paras. 1.9, 1.34); (b) it is negotiating and entering into annual Comprehensive Health Care Agreements (CHCAs) with individual LGUs, which commit the local governments to financing and implementing national health programs in exchange for financial and technical support from the DOH (para. 4.11); and (c)-it is mobilizing and coordinating additional financial resources for priority programs from a variety of sources, including local budgets, cost-sharing with LGUs, grants and loans from aid agencies, the private sector, and cost recovery schemes. Bank Experience and Strategy 1.39 Lessons from Previous Bank Experience. The Bank Group has supported four projects in the population, health and nutrition sector through two IDA credits and two IBRD loans. The first two projects, Population I (Ln. 1035-PH, approved 1974, closed 1982) and Population II (Cr. 0923-PH, approved 1979, closed 1988), had health as well as population objectives, and supported both the Population Commission (POPCOM) and the DOH. Project Performance Audit Reports (PPARs) for the two projects- concluded that their most significant achievement was the establishment of a nationwide PHC structure, including the para-professional, community-based midwife cadre. The proposed Women's Health and Safe Motherhood Project would continue to strengthen the PHC system and further enhance the efficiency and effectiveness of midwives through better service integration and training. 1.40 The Population I and II Projects were criticized, however, for failing to achieve their population objectives. The PPAR for the second project argued that the Family Planning Program would have been less vulnerable to failure if 1" Project Performance Audit Report Nos. 5544 and 9380, dated 03/19/85 and 02/15/91 for Population I and II, respectively. - 10 - program responsibility had not been split between the DOH and POPCOM; this was addressed in 1988 when the Government gave full responsibility for the National Philippines Family Planning Program to the DOH. In addition, the proposed Women's Health and Safe Motherhood Project would integrate family planning services into the PHC and MCH programs of the DOH, which the PPAR recommended as a means of improving the family planning program's likelihood of success. 1.41 Two other Bank-supported health projects are currently under supervision: the Philippine Health Development Project (Ln. 3099-PH, approved 1989) and the Urban Health and Nutrition Project (Cr. 2506-PH, approved 1993). The Health Development Project was designed to expand and improve the malaria, schistosomiasis and tuberculosis disease control programs and the MCH program, strengthen information systems, planning and budgeting, communications, training and evaluation in the DOH, and establish a program of grants for organizing and implementing partnerships for community health projects between the DOH, local governments and NGOs. The main objectives of the Urban Health Project are to improve the health and nutrition status of slum-dwellers in three major urban areas of the country, and to build the capacity of city and municipal governments in these areas to plan, finance and implement slum health and nutrition programs. 1.42 Under the Health Development Project, the innovative community partnerships component has met with exceptional success and the Government is keen to expand the program. Relatively good progress has also been achieved by the project's other components, despite cash flow problems due to the Government's inefficient practices relating to budget releases and utilization of project Special Accounts. The proposed project has been included in the Government's Core Public Investment Program, which ensures full funding for high-priority public investment projects; and improved arrangements for the operation of Special Accounts in the Philippines have been agreed upon with the Bank (para. 3.13). The Urban Health Project is the first post-devolution project in the sector and is being implemented in 21 cities and municipalities. The experience in preparing and launching this project has been utilized to work out devolution-related issues for the proposed project, including resource allocation and cost-sharing arrangements (paras. 4.10 to 4.18). 1.43 Country Assistance Strategy. The Bank's country assistance strategy (CAS) for the Philippines presented to the Board in February 1994 aims to assist the Government to attain the following key development objectives: (a) maintain a sound macroeconomic framework; (b) improve the business climate for private enterprise; (c) remove infrastructure bottlenecks; (d) protect the environment; and (e) alleviate poverty through economic growth and the provision of basic social services. The proposed project is consistent with and would be an important component of the CAS. It would provide a basic package of health services for women, which would both contribute to poverty alleviation and improve the human resource base required for sustained economic growth. 1.44 Rationale for Bank Involvement. The Bank has an established relationship with the Government in the health sector, developed through its policy dialogue, project portfolio and sector work. This relationship places the Bank in a strong position to assist in the sector's further development. The Bank has supported the case for investing in health for economic growth as well as for poverty alleviation, and assisted the DOH in preparing its Public. - 11 - Investment Plan. The Bank has also played a critical role in assisting the DOH to address the consequences of devolution--through a Government-requested study analyzing the impact of devolution on the delivery of public health services (Report No. 12343-PH, May 1994), and from the operational perspective of preparing and implementing projects under a devolved system. In addition, the Bank has pioneered with the DOH the development of health risk assessment and targeting mechanisms for directing resources to the poor and vulnerable, including area-based and life cycle approaches to service delivery and decision support models for resource allocation. 1.45 The Bank's interest in women's health in the Philippines originated in a 1989 women in development assessment which noted the relatively high fertility and maternal mortality rates, despite reasonably good female access to education. This was followed by the sector report reviewing the country's population program (para. 1.20), which was instrumental in the Government's adoption of a health--as opposed to a purely demographic--rationale for family planning, and in the DOH's decision to give priority to developing a Women's Health and Safe Motherhood Project. To support this project, the Bank has assisted the Government in mobilizing a substantial amount of concessional and grant cofinancing; the Bank would cover the remaining financing gap. The project's gender and poverty focus are also particularly important for supporting the development objectives of the Bank's assistance strategy. II. THE PROJECT A. Objectives and Scope 2.1 Project Objectives. The project's overall objectives are to improve the health status of women, with particular focus on women of reproductive age, and thereby support the Government's long-term goals of reducing fertility, female morbidity and maternal mortality. Its specific objectives would be to: (a) improve the quality and range of women's health and safe motherhood services; (b) strengthen the capacity of LGUs to manage the provision of these services, and of the DOH to provide policy, technical, financial and logistical support; (c) enhance the effectiveness and sustainability of health interventions through the participation of local communities and NGOs in the project; and (d) expand the knowledge base upon which to draw policy and technical guidance for women's health programs. 2.2 Project Scope. To accomplish these objectives, the project would consist of the following components and sub-components: (a) Service Delivery in the areas of (i) maternal care, and (ii) other women's health services, including 1) family planning, 2) diagnosis and treatment of RTIs and STDs, and 3) detection and treatment of cervical cancer; - 12 - (b) Institutional Development including (i) information, education and communication (IEC) programs to promote attitudes and practices that would improve women's health, (ii) training for public sector health care workers involved in delivering women's health services, (iii) development and installation of a national public health logistics system for the DOH that would ensure the efficient procurement and delivery of commodities to end users, and (iv) support to the DOH in project management; (c) Community Partnerships which would support local communities and NGOs working with LGUs and the DOH in planning and implementing community- based women's health services; and (d) Policy and Operations Research to conduct studies on women's health and related service delivery questions. B. Project Description Component I: Service Delivery (US$57.9 million equivalent estimated base cost) Maternal Care 2.3 The maternal care sub-component would: (a) strengthen existing maternal care services of the DOH, provinces and municipalities, including pre-natal care and screening, management of normal births and obstetrical complications, and post-natal care; and (b) improve the quality and accessibility of the services in first-referral level facilities, i.e., hospitals able to provide and support caesarean sections on a 24-hour basis. Further details on the maternal care sub-component are provided in Annex 3. 2.4 The following inputs would be provided on a nationwide basis: (a) micronutrients for pregnant and lactating women, including iron/folate, iodine and Vitamin A; (b) tetanus toxoid for pregnant women; (c) midwifery kits; (d) traditional birth attendant (hilot) kits; (e) safe delivery kits for home-based deliveries; and (f) emergency obstetrical drugs and supplies. The kits, drugs and supplies would support midwives, traditional birth attendants and rural health unit staff in providing improved pre- and post-natal care, managing normal births, and stabilizing the condition of women experiencing obstetric complications prior to their transfer to a first-referral facility. 2.5 Facilities and referral systems would be targeted for intensive upgrading in 40 provinces, selected on the basis of poverty levels and maternal mortality data. In these provinces, the project would: (a) upgrade selected hospitals to enable them to provide 24-hour obstetrical emergency care through improved ward, delivery and operating room, triage and laboratory facilities and essential equipment and furnishings; (b) renovate selected rural health units (four per province) to enable them to support the provision of prenatal and post-natal care, as well as safe deliveries and stabilization of emergency obstetrical clients prior to transportation and referral, through minor repairs, furnishings, equipment and supplies; and (c) upgrade selected barangay health stations (seven per province) to support the provision of pre-natal and post-natal services. - 13 - 2.6 To support the improvements in maternal care services, technical assistance would be provided in infection control, quality assurance, and development of standards and protocols. Technical assistance and support would also be provided to pilot the following: (a) maternity waiting homes and lying-in clinics in remote areas; (b) social marketing of disposable home-based delivery kits; (c) social marketing of iron, iodine and Vitamin A supplements; (d) food fortification for iron, Vitamin A and iodine; and (e) community-based transportation and mobilization of local transport to referral facilities. Family Planning 2.7 The project would assist the Government to fulfill the unmet need for family planning services, and thereby enable women to space or limit their pregnancies according to personal choice. This would be done by supporting voluntary surgical contraception for males and females, which would complement the contraceptive options being provided by USAID and UNFPA over a similar time period as the project. The project would finance minilaparotomy kits and medical supplies required to perform voluntary surgical contraception, as well as drugs to treat complications that may arise from the procedure. The minilaparotomy kits would be supplied nationwide to provincial and district hospitals which have not been provided such kits by UNFPA but would otherwise have the capacity to perform the procedures. Estimates for the medical supplies and drug requirements are based on the ten-year UNFPA projection of national public sector contraceptive needs prepared by the UNFPA in 1993 and adopted by the DOH. 2.8 The project would also upgrade rural health units and barangay health stations to increase private examination and counselling space, and to upgrade water, electricity and toilet facilities. Such improvements (including works, furniture and equipment) would be provided to selected rural health units and barangay health stations in the 40 provinces covered under the maternal care sub-component, as well as in the remaining 36 provinces. Diagnosis and Treatment of RTIs/STDs 2.9 The project would aim to reduce morbidity and mortality due to sexually and non-sexually transmitted RTIs among women of reproductive age in ten selected provinces (the list of provinces is given in Annex 2). Provincial selection was based on the number of women of reproductive age, urban concentration of the population (to cover high-risk groups), and the availability of facilities which are able to provide RTI services but currently do not offer them. 2.10 Women's access to early diagnosis and treatment of RTIs/STDs would be maximized by introducing the syndromic approach to RTI management, by integrating these services into family planning and maternal care services, and by targeting high-risk populations. With the syndromic approach, health workers match patient symptoms with those of locally-prevalent RTIs and provide the appropriate first-line treatment. Referral services would be provided for managing patients with complications and advanced infections. Women presenting for family planning or prenatal care would also be counselled about RTIs and, 1/ Metro Manila is covered under the Urban Health and Nutrition Project. - 14- where called for, diagnosed and treated. Management of STDs would involve treating both women and their male partners who present with symptoms at health facilities. 2.11 The project would provide foreign technical assistance to develop the approach for targeting high-risk as well as general populations for RTI management. It would also finance drugs, laboratory reagents and other medical supplies for RTI diagnosis and treatment. Detection and Treatment of Cervical Cancer 2.12 To assist in reducing the prevalence of cervical cancer, the project would support service delivery in 15 provinces identified by the Philippines Cancer Control Program (the list of provinces is given in Annex 2). The provinces were selected based on their capacity to provide referral facilities for early and complete treatment of cases detected during screening. The project strategy would be to shift diagnostic services away from family planning clients to older women, among whom cervical cancer usually appears; the aim would be to screen 75% of all women in the selected provinces between 45 to 55 years of age. All detected cases would receive treatment at a referral facility. 2.13 The project would concentrate on supporting early detection and treatment of cervical cancer through the use of Pap smears as the screening method, cervical biopsies for suspicious lesions (i.e., positive Pap smears), and cryotherapy for early invasive cancer. However, support would also be provided for surgical treatment of more advanced cases. To undertake these activities, the project would finance local technical assistance, supplies for Pap smears and cervical biopsies, transportation of slides to referral facilities, cryotherapy machines to 17 regional hospitals under a supply, train and 12-month maintenance contract, and supplies for simple and radical hysterectomies. Under the training sub-component, training would also be provided to health workers in smear taking and slide preparation, to cytologists in proper slide examination, and to gynecologists in cryotherapy (para. 2.24). Life Cycle Approach 2.14 As part of the service delivery component and in addition to strengthening facility-based services provided on demand, the project would pilot the life cycle approach as an active outreach service targeting strategy. In this approach, women of reproductive age are targeted for client-oriented services during critical high-risk periods in their lives. Focusing on managing risk is more efficient and cost-effective because it reduces the scope and work load of the public health system compared to more traditional population-based program approaches. This approach also helps to build a continuing relationship between client and service provider, which does more to build clients' capacity for self and family care than is possible through the current approach of unsystematic service encounters. Women 35 to 44 years of age would be screened and treated under an ongoing activity of the Philippines Cancer Control Program. - 15 - 2.15 The life cycle approach responds to the needs of women of reproductive age and children as they go through the critical stages covering the period from before pregnancy, pregnancy, childbirth, the immediate post-natal stage, and the child's first five years.i/ Under the project, the approach would be utilized mainly to deliver family planning and maternal care services. It would begin with household-level targeting. Through the outreach educational and promotional activities of midwives and barangay health workers, attempts would be made to identify all poor women of reproductive age who are at abnormal risk to pregnancy or who desire family planning services. The identified women are registered and given a choice to enroll in the family planning program. If a woman chooses a method provided only at a health facility (e.g., surgical contraception), the outreach workers facilitate the referral; once the service is provided, they follow up the woman in the home and provide advice to assure a successful patient outcome. Services not requiring a health facility would be provided directly by the midwife. 2.16 Through the same outreach approach, there would be an attempt to identify and register 100% of all women who become pregnant and to enroll them in a preventive pre-natal care service. The objective is to enroll the mother as early as possible in the pregnancy and provide her a minimum of three pre- natal visits, i.e., at least once during each trimester of a normal pregnancy. Women identified from the outreach activities and pre-natal visits to be at high risk to delivery (approximately 5%) would be monitored separately on a more frequent basis to minimize risk and assure optimum attention or referral at delivery. Another 10% of women who incur unforeseen complications at delivery would be referred and transported to a facility that can handle obstetric complications. 2.17 Although not directly supported by this project, all newborns will be registered and tracked monthly for the first two years of the child's life and quarterly until five years of age. The monthly visits to the health facilities will provide the opportunity to integrate a range of services for both mother and child. Through the combination of household outreach and health facilities, services for children would include promotion of breast feeding, growth monitoring, immunization, micronutrient supplementation and disease surveillance/consultation. For the mother, the immediate post-delivery period would focus on monitoring potential complications of delivery and provision of family planning counseling and services. 2.18 The life cycle approach to planning and integrating health services implies a radical change from traditional modes of service delivery, particularly in how health care workers organize their work. Its adoption will require a major re-training effort for health care workers and their managers. The Government has therefore decided to adopt the approach on a pilot basis prior to nationwide implementation. Piloting of the approach has begun in the 21 municipalities and cities involved in the Urban Health and Nutrition Project. Further testing and development would be undertaken during implementation of the proposed project, which will include time-and-motion The proposed project would primarily support services targeted to women. A proposed Early Childhood Development Project currently under preparation would focus on infants and children age 0-5. - 16 - studies on health care workers in the field to determine what staffing ratios are required and how work can be better prioritized. Component II: Institutional Development (US$32.7 million equivalent estimated base cost) Information, Education and Communication 2.19 The project would develop and utilize an integrated information, education and communication (IEC) strategy to reach women, service providers and the general public with messages to: (a) improve health practices among women, and direct changes in knowledge and attitudes towards that end; and (b) provide information about the availability of health services to various segments of the female audience to ensure that women take timely action to safeguard their health. The IEC strategy would utilize women's groups and communities as channels of communication, with mass media providing supportive messages about women's health. Thematic messages would be broadcast nationwide, while messages aimed at encouraging women to seek health services would be targeted to those areas where such services are available. Additional details and sample message areas are provided in Annex 5. 2.20 The IEC plan of action involves five steps, namely: (a) assessment of knowledge, attitudes and practices of women regarding their own health; (b) planning of a communication strategy with messages that would trigger appropriate health behavior among four main audiences--women in union, older women, adolescents, and special audiences (e.g., victims of domestic violence); (c) materials development and pretesting; (d) implementation of behavior change interventions; and (e) monitoring and evaluation of the impact of the interventions, using such information for planning subsequent phases. 2.21 The following materials would be produced and disseminated: (a) communication materials for interpersonal communication and mass media; (b) training videos using an interactive format to encourage learner participation; and (c) research information to guide the development of a behavior change strategy and to monitor and evaluate elements that contribute to the success of the intervention. 2.22 The project would provide technical assistance for the design and management of formative research, formulation of a behavior change strategy, and monitoring and evaluation. The project would also finance planning workshops at national and local government levels, equipment, broadcast time for radio and television IEC spots, and publication of IEC materials. Training 2.23 The project would provide quality in-service training for public sector health care workers involved in delivering maternal care, family planning, RTI/STD and cervical cancer services. This would involve the development of competency-based training approaches, development of integrated curricula for women's health, improved training of trainers, and the conduct of basic training in the developed curricula. In addition, the project would support the development, piloting and expansion of distance learning approaches for refresher training of health care workers. - 17 - 2.24 Training would be provided to trainers and supervisors on regional and provincial training and supervisory teams, who would, in turn, conduct the basic training for primary and secondary health care workers under the guidance of professional associations and consultants. At the primary health care level, training would be provided for rural health midwives, public health nurses, rural health doctors, traditional birth attendants, and barangay health workers. Secondary health care workers to be trained would include doctors, nurses and laboratory staff at first-referral level hospitals, and gynecologists, cytotechnicians, pathologists at regional medical centers. Details on the training to be provided are given in Annex 6. 2.25 The full complement of training courses would be provided to health care workers in the 40 provinces covered by the maternal care sub-component. For the provinces included in the RTIs/STDs and cervical cancer sub-components, training would be provided to secondary health care workers involved in the delivery of these services, as well as to all primary health care workers. For the remaining provinces, training would be limited to primary health care workers. To carry out the activities under this sub-component, the project would finance technical assistance, in-country and overseas training, training equipment, materials production and distribution, travel, salaries and honoraria for trainers, and other incremental operating costs. Logistics 2.26 The project would strengthen the national public health logistics system to improve the supply of drugs and medicines, vaccines, reagents and other medical supplies to health units at all levels. Existing commodity- specific systems and procedures would be consolidated into an overall DOH logistics system able to accommodate the commodity requirements of the Women's Health and Safe Motherhood Program at the outset, with a view to eventually serving all DOH essential programs. This would require the design and implementation of the following logistic system components: (a) procurement system, including commodity forecasting, a program-logistics logical commodity procurement schedule, requisition, bidding and ordering procedures, and a random sampling system for drugs; (b) a distribution system from the center to provinces/cities to municipalities/barangays; (c) a storage and materials handling system, including warehousing and inventory; and (d) a logistics information system, including data on stock prices, ordering status, inventory control, demand analysis, supplier performance and distribution verification. 2.27 This sub-component would center around improvements in the DOH in organizational structure, technical competence of logistics staff, collection and use of logistics information, storage ownership, capacity and methods, distribution from the DOH to provincial stores, delivery to end users within provinces, and methods and timing of procurement. Similar improvements would be undertaken for procurement, distribution, materials handling, storage and information systems at the provincial level to complete the requirements for a national health logistics system that can ensure the efficient delivery of commodities to their beneficiaries. 2.28 The project would specifically support: (a) provision of integrated logistics support information and procurement computerized systems (hardware and software); (b) provision of technical assistance and training in logistics management and information systems; (c) contracting of private drug - 18 - distributors or other commercial materials handlers, where they prove cost- effective, to deliver drugs and medicines, vaccines, reagents and other medical supplies; and (d) rehabilitation or expansion of public logistics facilities, where private logistics contractors are unable to cost-effectively meet the requirements, including the provision of equipment and vehicles, financing of related operational costs and expenses, constructing or rehabilitating and equipping of about four (4) DOH central and about seventy-six (76) provincial warehouses, as well as upgrading of storage and materials handling systems and inventory facilities. Project Management 2.29 The project would support project management and coordination activities of the DOH and, in doing so, strengthen its capacity to provide policy guidance, technical assistance, training, information, logistical and financial support for the consistent implementation of public health programs nationwide under devolution. The management responsibilities of the DOH would include the overall monitoring and evaluation of project performance, processes and impact. DOH skills in these areas would be upgraded through technical assistance and training. The project would also finance the salaries of contractual staff for a Project Management Office in the DOH (para. 4.2), computers and other office equipment, vehicles, supplies, materials and other incremental operating costs. Component III: Community Partnerships (US$11.8 million equivalent estimated base cost) 2.30 The project would assist in establishing partnerships among NGOs, local communities, local governments and the DOH, with the objective of empowering women and their communities to improve their health situations. Building on the experience with community partnerships under the Philippine Health Development Project, the project would specifically seek out the involvement of women's health and advocacy groups. This component would be implemented in 15 provinces, with poorer provinces and communities to be targeted for coverage. It would support activities related to establishing the partnerships, organizing communities, and developing institutional capacities of local groups involved in the partnerships. 2.31 At the provincial level, the partnerships would involve the regional field offices of the DOH and other related line agencies, provincial health officers and health board members and local NGOs. Their purpose would be to establish and maintain consultative and information networks as vehicles for local policy formulation, planning, training, monitoring and evaluation, and advocacy. They would sponsor orientation and planning seminars, gender and other training, fora for linking groups supporting community health initiatives, advocacy activities for women's health and family planning, and the formation of provincial teams to assist in community organization. 2.32 At the community level, activities to be supported through the partnerships would include community-based initiatives in women's health care, family planning and IEC, the development of women's organizations, and self- help projects. Community organizing efforts would be undertaken mainly by partner NGOs. In barangays where partnerships have already been established under the Philippine Health Development Project, the project would support the - 19 - incorporation of women's health concerns into community activities. In barangays where no organizing effort has yet taken place, the project would support the integration of women's health in all phases of community organizing and capacity-building. 2.33 To develop capacities in planning, managing, implementing and monitoring community health activities, staff development needs would be analyzed, trainers trained, and training provided to LGU, NGO and community participants. Areas of training would include situation analysis, project planning and management, community organizing, monitoring and evaluation, and IEC on women's health and family planning. Component IV: Policy and Operations Research (US$1.0 million equivalent estimated base cost) 2.34 The project would support research to provide policy and operational guidance to women's health and safe motherhood programs. This research agenda would include: (a) studies to assess the cost-effectiveness of service delivery options, including (i) alternative approaches to the screening and early detection of cervical cancer, (ii) active contact tracing for STDs, and (iii) alternative iron supplementation regimes for pregnant and- lactating women; (b) research on priority issues affecting women's health, including (i) the incidence of breast cancer, and (ii) the incidence of violence against women, community attitudes towards the problem, and the availability of services and counselling; and (c) the monitoring and evaluation studies described in paras. 4.24-4.27. 2.35 The Project Management Office would be responsible for the overall direction of the studies and developing their terms of reference in consultation with concerned DOH program offices. The studies would be undertaken through technical assistance contracts with local university-based or other qualified research groups. Terms of reference would be reviewed and agreed upon with the Bank. Technical Assistance Summary 2.36 The total estimated base cost of the technical assistance to be provided under the project (including consultant services, training and studies) is US$24.6 million. This assistance can be classified as follows: (a) policy support--studies under the policy and operations research component (about US$1.0 million); (b) project implementation support--consultant services and training under the service delivery, IEC and community partnerships components (about US$9.6 million); and (c) institutional development-- consultant services and training under the training, logistics and project management components (about US$14.1 million). The technical assistance for policy and project implementation support is also expected to contribute to capacity-building and institutional development. Draft terms of reference have been prepared for the technical assistance requirements, including detailed terms of reference for the larger and more critical assignments. - 20 - III. PROJECT COSTS, FINANCING, PROCUREMENT AND DISBURSEMENT A. Cost Estimates 3.1 Summary of Project Costs. The total cost of the project is estimated at Philippine Pesos 3.82 billion or US$136.4 million equivalent, including contingencies and taxes. A summary of costs by project component is given in Table 3.1 and by category of expenditure in Table 3.2. Costs by component, category of expenditure and year are given in Annex 12. Table 3,1: SUMMARY OF PROJECT COSTS BY COMPONENT Local Foreign Total Local Foreign Total For. Base Project Component ---------Peso million-------- ------US$ million------- Exch. Cost Service Delivery Maternal Care 508.13 1,113.31 1,621.44 18.15 39.76 57.91 69 48 Other Services Family Planning 78.67 87.63 166.30 2.81 3.13 5.94 53 5 RTIs/STDs 18.54 228.52 247.06 0.66 8.16 8.82 92 7 Cervical Cancer 17.09 46.96 64.04 0.61 1.68 2.29 73 2 Total, Other Services 114.30 363.10 477.40 4.08 12.97 17.05 76 14 Total, Service Delivery 622.43 1,476.41 2,098.84 22.23 52.73 74.96 70 62 Institutional Development Training 341.68 88.39 430.06 12.20 3.16 15.36 21 13 IEC 147.84 30.03 177.86 5.28 1.07 6.35 17 5 Logistics 170.89 101.37 272.26 6.10 3.62 9.72 37 8 Project Management 31.95 2.96 34.91 1.14 0.11 1.25 8 1 Total, Institutional Dev. 692.35 222.75 915.10 24.73 7.96 32.68 24 27 Community Partnerships 225.1 105.28 4 8.04 3 11.80 ia 12 Policy/Operations Research 21.44 5.36 26.80 0.77 0.19 0.96 20 i Total Baseline Cost 1,561.34 1.809.80 3,371.14 55.76 64.64 120.40 54 100 Physical Contingencies 64.59 74.87 139.46 2.31 2.67 4.98 54 4 Price Contingencies 162.41 147.41 309.62 5.80 5.26 11.07 48 9 Total Project Cost 1,788.34 2,032.09 3,820.43 63.87 72.57 136.44 53 113 Note: The totals in this and subsequent tables may not add up exactly due to rounding. 3.2 Contingency Allowances. Project costs include a contingency allowance for unforeseen physical additions (US$4.98 million equivalent) and for inflation (US$11.07 million equivalent). Price contingencies are equivalent to 9% of base costs plus physical contingencies. For IBRD-financed components, physical contingencies are estimated at 5% of base costs; and, in accordance with Bank-wide and regional guidelines, price contingencies are based on the following annual inflation factors: 2.5% for foreign costs and 7% for local costs throughout the project period. - 21 - Table 3,2: SUMMARY OF PROJECT COSTS BY CATEGORY OF EXPENDITURE Local Foreign Total Local Foreign Total Base Expenditure Category --------Peso million-------- -----US$ million----- Cost Investment Costs Civil Works 216.26 216.84 433.10 7.72 7.74 15.47 13 Furniture 2.79 0.70 3.48 0.10 0.02 0.12 .1 Equipment 38.00 243.47 281.47 1.36 8.70 10.05 8 Vehicles 7.12 48.99 56.11 0.25 1.75 2.00 2 Initial Medical Supplies 1" 185.76 704.41 890.17 6.63 25.16 31.79 26 Media 1/ 92.80 23.20 116.00 3.31 0.83 4.14 3 Foreign Consultants 13.65 121.41 135.05 0.49 4.34 4.82 4 Local Consultants 183.33 20.37 203.70 6.55 0.73 7.27 6 Overseas Training 0.95 8.57 9.53 0.03 0.31 0.34 .2 Local Training 288.78 25.34 314.12 10.31 0.91 11.22 9 Grants 219.52 54.88 274.40 7.84 1.96 9.80 8 Studies 21.44 5.36 26.80 0.77 0.19 0.96 1 Total. Investment Costs 1,270.39 1,473.54 2,743.93 45.37 52.63 96.00 81 Incremental Recurrent Costs Drugs/Reagents 18.04 336.26 354.30 0.64 12.01 12.65 11 Medical Supplies/Materials 55.31 - 55.31 1.98 - 1.98 2 Salaries 62.41 - 62.41 2.23 - 2.23 2 Maintenance 70.63 - 70.63 2.52 - 2.52 2 Other Operating Costs 84.57 - 84.57 3.02 - 3.02 3 Total, Recurrent Costs 290.95 336.26 627.21 10.39 12.01 22.40 19 Total Baseline Cost 1,561.34 1,809.80 3,371.14 55.76 64.64 120.40 100 Physical Contingencies 64.59 74.87 139.46 2.31 2.67 4.98 4 Price Contingencies 162.41 147.41 309.82 5.80 5.26 11.07 9 Total Project Cost 1,788.34 2,032.09 3,820.43 63.87 72.57 136.44 113 a/ ADB expenditure category including obstetric kits (drugs and supplies) and micronutrients. b/ Includes broadcast time for television and radio IEC spots, and publication of IEC materials. 3.3 Taxes and Duties. Project costs include an estimated US$1.24 million equivalent in construction-related duties and taxes. All goods imported under the project would be exempt from duties and taxes. 3.4 Foreign Exchange Costs. Direct and indirect foreign exchange costs are estimated at US$72.57 million equivalent, or about 53% of total project cost, including contingencies. The estimated foreign exchange component for the various expenditure categories are as follows: (a) 95% for drugs and reagents; (b) 90% for equipment, vehicles, foreign technical assistance and overseas training; (c) 80% for initial medical supplies; (d) 50% for civil works; (e) 20% for furniture, media, grants and studies; and (f) 10% for local technical assistance and local training. 3.5 Incremental Recurrent Costs. Project cost estimates include the following incremental recurrent costs: (a) drugs, reagents and medical - 22 - supplies for service delivery expansion; (b) salaries for contract staff; (c) maintenance of buildings, vehicles and equipment, staff travel and other operating costs. B. Financing 3.6 The estimated total project cost of US$136.4 million equivalent would be financed by: (a) a local contribution of US$26.7 million, mainly from LGUs through cost-sharing arrangements to be implemented under the project; (b) an IBRD Loan of US$18.0 million; and (c) cofinancing contributions totalling US$91.8 million from the Asian Development Bank (ADB), the Australian International Development Assistance Bureau (AIDAB), the European Commission (EC) and Kreditanstalt fQr Wiederaufbau (KfW) of Germany. 3.7 Project financing is summarized in Table 3.3 below and would be as follows: (a) ADB would provide a US$54.0 million concessional loan to finance (i) the maternal care sub-component (except for equipment and kits to be financed by KfW), (ii) the IEC sub-component, and (iii) the project management sub-component; (b) AIDAB would provide a grant of AUD15.1 million (US$10.6 million equivalent) for the training sub-component of the project, specifically to finance (i) all national-level institutional strengthening activities (training of trainers, curriculum development), (ii) training of first-referral level doctors in obstetrical care in all 15 regional training hospitals, (iii) development and piloting of distance learning, and (iv) the conduct of basic integrated training and distance learning for primary and secondary health care providers in the 40 provinces covered under the maternal care sub-component; (c) EC would provide a grant of ECUl5.6 million (US$13.0 million equivalent) to finance the community partnerships component; (d) KfW would provide a grant of DM24.2 million (US$14.2 million equivalent) to finance (i) medical equipment, midwifery kits and hilot kits for maternal care, (ii) minilaparotomy kits, drugs and reagents for family planning, (iii) drugs for RTIs/STDs, (iv) freight and handling for procured commodities, and (v) a procurement consultant; (e) the total Government contribution to the project would cover about 20% of total project costs, and would include the National Government counterpart as well as local government cost-shares; and (f) the IBRD Loan of US$18.0 million equivalent would cover the remaining financing gap, including (i) drugs and reagents for other women's health services (except for those financed by KfW), (ii) under the training sub-component, the conduct of basic integrated training for primary and secondary health care providers in the 36 provinces not covered by the maternal care component, (iii) the logistics sub- component, and (iv) the research sub-component. - 23 - Table 3.3: FINANCING PLAN a/ (Amounts in US$ million equivalent, including contingencies) Est. Share Expenditure ------------------------ us$ million ------------------------ of IBRD Category Local ADB AIDAB EC KfW IBRD Total Financing Civil Works 4.74 10.60 - - - 2.54 17.88 14% Furniture 0.04 - - - - 0.10 0.15 70% Equipment/Vehicles 0.60 2.18 0.50 - 6.75 3.18 13.20 24% Initial Medical Supplies 5.51 31.15 - - - - 36.66 - Media 1.27 3.69 - - - - 4.96 - Training/TA/Studies 4.05 5.19 10.06 2.20 0.13 5.51 27.13 20% Grants - - - 10.80 - - 10.80 - Drugs/Reagents - - - - 7.36 6.68 14.04 48% Medical Supplies/Materials 2.55 - - - - - 2.55 - Operating Costs 7.89 1.19 - - - - 9.08 - Total Project Cost 26.66 54.00 10.55 13.00 14.24 18.00 136.44 13% A/ Costs by component and financier are given in Annex 12. 3.8 All cofinancing would be on a parallel basis and administered by the respective donors. C. Procurement 3.9 Estimated project costs by expenditure category and procurement method are summarized in Table 3.4 below. Procurement of works, goods and services financed by the IBRD Loan would be undertaken in accordance with Guidelines for Procurement Under IBRD Loans and IDA Credits (May 1992) and Guidelines for the Use of Consultants by World Bank Borrowers and by the World Bank as Executing Agency (August 1981). The project's four cofinanciers--ADB, AIDAB, KfW and EC--would administer procurement for the parts of the project that they are financing according to their respective rules and procedures. 3.10 Procurement arrangements for works, goods and services to be financed by the IBRD Loan would be as follows: (a) Civil Works, totalling about US$4.3 million equivalent, with an average contract value of under $70,000, would be grouped into about 60 contracts and procured through Local Competitive Bidding (LCB) procedures acceptable to the Bank. The small average size of the contracts, the nature of the works (mainly minor renovation of rural health facilities, and construction/rehabilitation of provincial warehouses) and their geographical dispersion are unlikely to attract the interest of foreign bidders. Overall responsibility for works procurement would rest with the DOH Health Infrastructure Service; bid evaluation and award would be carried out by Department of Public Works and Highways staff of the concerned city or municipality, subject to the approval of the DOH Infrastructure Service. - 24 - Table 3.4: PROJECT COSTS BY PROCUREMENT ARRANGEMENTS (in US$ million equivalent) Procurement Method Total Cost Expenditure Category ----------------------------- (including ICB LCE Other N.B.F. contingencies) 1. Works 4.3 13.5 d/ 17.9 (2.5) (2.5) 2. Goods 2.1 Furniture - - .15 a/ - .15 (.10) (.10) 2.2 Equipment and vehicles 2.1 0.9 0.5 b/ 9.8 e/ 13.2 (2.1) (0.8) (0.3) (3.2) 2.3 Drugs, reagents, medical 2.7 3.3 3.3 b/ 44.0 f/ 53.2 supplies and materials (2.7) (2.0) (2.0) (6.7) 2.4 Media 5.0 d/ 5.0 3. Services 3.1 Consultant services 2.0 c/ 11.5 q/ 13.5 (1.9) (1.9) 3.2 Training 2.7 C/ 9.7 h/ 12.4 (2.6) (2.6) 3.3 Studies 1.2 c/ _ 1.2 (1.0) (1.0) 4. Miscellaneous 4.1 Grants _ 10.8 i/ 10.8 4.2 Salaries 2.6 d/ 2.6 4.3 Other operating costs 6.5 d/ 6.5 Total 4.8 8.5 9.9 113.3 136.4 (4.8) (5.3) (7.9) (18.0) Note: N.B.F. = Not Bank-Financed. Figures in parentheses are the amounts to be financed by the IBRD Loan. a/ Local shopping. 1/ Shopping, Limited International Bidding or direct procurement. c/ In accordance with Bank policies and procedures for specialist services, overseas training and studies, and with regular Government procedures for local training. d/ To be financed by the ADB and the Government. I/ To be financed by the ADB, AIDAB, KfW and the Government. f/ To be financed by the ADB, KfW and the Government. _/ To be financed by the ADB, AIDAB, the EC, KfW and the Government. h/ To be financed by the ADB, AIDAB and the Government. i/ To be financed by the EC. - 25 - (b) Goods (Equipment, Vehicles, Drugs, Reagents. Medical Supplies and Materials), totalling about US$12.95 million equivalent, would to the extent practicable be grouped into bid packages estimated to cost at least US$200,000 each, which would be procured under International Competitive Bidding (ICB) procedures. It is estimated that up to an aggregate amount of US$4.8 million would be procured under ICB. In accordance with Bank guidelines, eligible domestic manufacturers would be allowed a preferential margin of 15% or the existing customs duty, whichever is lower, over the c.i.f. prices of competing imports in the comparison of bids for goods to be procured through ICB. Contract packages valued at less than US$200,000, up to an aggregate total of US$4.2 million, would be awarded through LCB procedures acceptable to the Bank. Contracts estimated to cost less than US$100,000, not to exceed US$2.2 million in the aggregate, would be procured through shopping procedures based on written quotations from at least three local or foreign suppliers. Limited International Bidding (LIB) or direct procurement would also be authorized for specialized equipment, drugs and reagents with single or limited suppliers, and would total no more than US$1.75 million. (c) Consultant Services. Training and Studies, totalling about US$5.9 million equivalent, would be procured in accordance with Bank policies and procedures on the selection and employment of consultants for specialist services, overseas training and studies, and in accordance with regular Government procedures for local training. An estimated total of 470 staff-months of local and foreign specialist services would be provided through approximately 12 consulting contracts with values ranging from US$20,000 to US$1 million. About 4,000 staff- months of training would also be provided, mainly through local training programs. 3.11 The following would be subject to prior review by the Bank: (a) contracts awarded on the basis of ICB procedures; (b) contracts for works and goods with an estimated value of at least US$200,000 equivalent; (c) standard bidding documents for LCB procurement and the first LCB contracts for works and goods, regardless of amount; (d) consultants' contracts with an estimated value of at least US$100,000 equivalent for firms and US$50,000 equivalent for individuals; (e) all single-source consultant contracts, consultant contracts for assignments of a critical nature as determined by the Bank, amendments to contracts of consulting firms raising the contract value to the equivalent of US$100,000 or more, and amendments to contracts of consulting individuals raising the contract value to the equivalent of US$50,000 or more; and (f) terms of reference for all technical assistance (including studies) and training. Contracts not covered by these prior review requirements, as well as expenditures not covered by contract, would be subject to selective post-review by the Bank. For goods and works, respectively, the prior review process would cover about 85% and 80% of the total value of Bank-financed contracts. The Bank's standard bidding documents will be used for all ICB procurement. - 26 - D. Disbursements 3.12 The proposed IBRD Loan of US$18.0 million equivalent would be disbursed over six years, with disbursements to be completed by a Closing Date of December 31, 2000. The proposed disbursement schedule is two years shorter than the disbursement profile for population, health and nutrition projects in the East Asia and Pacific Region (Annex 14), but is considered feasible given project management capacities in the DOH, the attention given to implementation planning during project preparation, and recent measures taken by the Bank and the Government to address disbursement issues in the Philippines. 3.13 The disbursement performance of projects in the Philippines has not been uniformly good, with profiles ranging from 5 years for the financial sector to 9 years for the transport sector. Poor disbursements have been related to inadequate budgetary provisions for foreign-assisted projects, cash flow shortages caused by inefficient budget release practices, and restrictions on the operation of Special Accounts. Addressing these generic causes of disbursement delays has been a central focus of Government and Bank efforts to improve the performance of the country portfolio. Measures have been taken to ensure that budgetary requirements for priority projects (including the proposed project) would be provided, and improved Special Account arrangements have been agreed upon which, among others, would allow implementing agencies direct access to the Accounts. 3.14 For the proposed project, project costs will be linked to project implementation plans (through the use of Computerized Project Management) in order to develop realistic forecasts of cash flow requirements. Project management capacities in the DOH are also well-developed, relative to other implementing units, and while initial implementation difficulties are being experienced with the Urban Health and Nutrition Project, disbursements for the Philippine Health Development Project approved in 1989 have been consistently ahead of schedule. 3.15 Disbursements to be made against the proposed IBRD Loan are summarized in Table 3.5. Disbursements would be made against: (a) 90% of total expenditures for civil works; (b) for drugs, reagents, medical supplies, equipment, vehicles and furniture, 100% of foreign expenditures for directly imported goods, 100% of local expenditures (ex-factory cost) for locally- manufactured goods, and 85% of local expenditures for other goods procured locally; and (c) 100% of total expenditures for consultant services, training and studies. 3.16 Disbursements would be made on the basis of Statements of Expenditures (SOEs) for actual expenditures against: (a) contracts of less than US$200,000 equivalent for works and goods; (b) consultants' contracts of less than US$100,000 equivalent for firms and US$50,000 equivalent for individuals; and (c) local training. Disbursements for all other expenditures would be supported by full documentation. Supporting documentation for all disbursements against SOEs would be held by the DOH and made available upon request for examination by Bank review missions. 3.17 To facilitate timely project implementation and disbursements, the Government would establish and operate, under terms and conditions satisfactory to the Bank, a Special Account. During negotiations, agreement was reached - 27 - with the Government that the Special Account would be established and held in the Central Bank of the Philippines. The Account would cover the Bank's share of eligible project expenditures in all disbursement categories. The Account would be denominated in US Dollars, with an authorized allocation of US$1.0 million; however, the Authorized Allocation shall be limited to an amount equivalent to US$300,000 until disbursements and outstanding commitments against the Loan equal or exceed US$5.0 million. Applications for replenishment of the Account, supported by appropriate documentation, would be submitted regularly (preferably monthly, but not less than quarterly) or when the amounts withdrawn equal 50% of the initial deposit. 3.18 Cofinancing from the ADB, AIDAB, KfW and the EC would be on a parallel basis and each donor would administer its respective contribution. During negotiations,.agreement was reached with the Government that the following would be conditions of Loan disbursement: (a) effectiveness of the cofinancing agreement with KfW, in respect of expenditures for drugs and reagents for the RTIs/STDs sub-component of the project; and (b) effectiveness of the cofinancing agreement with AIDAB, in respect of expenditures for consultant services, studies and training for the training sub-component of the project.- Table 3.5: DISBURSEMENT CATEGORIES Financing Expenditure Category Amount in US$ million Percentage (1) Civil works 2.4 90% of total expenditures (2) Goods, including drugs and 6.2 reagents (except for the RTIs/ STDs sub-component), medical 100% of foreign expenditures; supplies, equipment, vehicles 100% of local expenditures and furniture (ex-factory cost); 85% of local expenditures (3) Drugs and reagents for the 3.3 for other items procured RTIs/STDs sub-component _ locally (4) Consultant services, studies 2.7 and training (except for the training sub-component) 100% of total expenditures (5) Consultant services, studies 2.5 and training for the training sub-component (6) Unallocated 0.9 Total 18.0 The Bank's main concern with the ADB cofinancing agreement is covered by specific conditionalities pertaining to the Project Management Office (para. 4.3), and no condition is required for the EC grant since there is less cross-dependency between the Community Partnerships Component, which will be fully financed by the EC, and other project components. - 28 - IV. PROJECT MANAGEMENT AND IMPLEMENTATION A. Organization 4.1 The proposed project would be implemented over a five-year period (1995-99) by the DOH and local health offices at the provincial/city, municipal and barangay levels. Under the devolved system, the DOH would provide overall technical and managerial direction, as well as undertake direct implementation of nationally-retained functions, including training, IEC, logistics and research. LGUs would be responsible for the actual delivery of project services in their respective jurisdictions, and for integrating these services into their regular public health programs. The DOH would support LGUs in project implementation by, among others, distributing goods and services that, for reasons of cost and efficiency, will continue to be procured centrally. A more detailed description of the project management and implementation arrangements is given in Annex 9. 4.2 overall responsibility for the project would be placed in the DOH Office of Special Concerns, which is headed by an Assistant Secretary reporting to the Undersecretary-level Chief of Staff. The Chief of Staff and OSC Assistant Secretary would serve as the Project Director and Project Coordinator, respectively. Day-to-day coordination of project activities would be delegated to a Project Management Office (PMO) for the Women's Health and Safe Motherhood Project, which would be established in the OSC and headed by a full-time Project Manager. A Project Steering Committee, chaired by the Project Director and comprising Undersecretaries of the DOH and other concerned Government agencies, would provide policy guidance on the implementation of the project and approve annual implementation plans and budgets. 4.3 The PMO would be responsible for consolidating project plans and budgets, monitoring project activities, preparing project reports and documentation, and liaising with external donors. For procurement and disbursement, the PMO would rely on an existing Project Coordination Unit which handles these functions for externally-financed DOH projects, including the two ongoing Bank-assisted projects. During negotiations, agreement was reached that the Government would establish and maintain until project completion the PMO, headed by a qualified Project Manager and staffed by qualified personnel in adequate numbers; understandings vere reached on the PMO's staffing complement. The establishment of the PHO and appointment of the Project Manager would be conditions of Loan effectiveness. 4.4 Agreement was further reached during negotiations that the Government would, not later than July 1, 1995: (a) establish the Project Steering Committee; (b) designate the DOH Undersecretary/Chief of Staff and Assistant Secretary for Special Concerns as the Project Director and Project Coordinator, respectively; (c) employ and assign to the PMO a Desk Officer, acceptable to the Bank, who shall be responsible for overseeing the implementation of activities financed out of the proceeds of the Loan; and (d) assign to the DOH regional field offices responsibility in their respective regions for coordination of project implementation, monitoring of progress in project performance, assisting in the collection of documentation to support statements of expenditures, and preparation of financial statements and accounts. - 29 - 4.5 As the managers of all devolved primary health care workers and facilities, LGUs would be responsible for the actual delivery of project services in provinces, cities, municipalities and barangays. Project implementation responsibility at the local level would be centered on the Provincial, City or Municipal Health Officer, who works under the authority of the Provincial Governor, City or Municipal Mayor, respectively, and local councils. The Health Officer would be responsible for coordinating the inputs of central and local government departments and NGOs involved in implementation. 4.6 The project would provide goods and services to LGUs (and from there, to project communities) through two administrative channels: (a) the DOH and its regional field offices for items to be procured centrally and distributed to individual health units (e.g., drugs) and for items to be provided through the regions (e.g., training); and (b) the LGUs procuring or providing goods or services (e.g., medical supplies, midwives). The appropriate channel for each project activity would be reflected in the LGUs' annual plans and budgets. 4.7 The DOH units responsible for various technical and functional disciplines related to the project would provide guidelines and technical assistance to LGUs to assist in implementing project activities in their respective disciplines. The DOH central units would be assisted in this technical support role by its regional field offices. In addition, staff from the relevant technical units would form a task force to initiate, oversee and sustain the changes required by the life cycle approach to be piloted under the project (paras. 2.14-2.18). 4.8 For the implementation of civil works activities, the DOH Infrastructure Service would contract private consultants in accordance with Bank guidelines. The consultants would be responsible for the preparation of contract documents, detailed architectural and engineering plans, technical specifications, estimates and bidding documents based on model plans, schematic plans and outline specifications prepared by the DOH. They would appraise the sites or existing facilities and assist the local authority in the bidding process. They would also provide construction supervision, including time and cost control. 4.9 The project would be carried out on the basis of an overall implementation plan satisfactory to the Bank. During negotiations, understandings were reached on the Government's initial implementation plan, and agreement was reached that the Government would update its project implementation plan in consultation with the Bank not later than December 31 of each year, beginning in 1995. B. Project Implementation under Devolution 4.10 The devolution strategy of the DOH aims to provide fair and equitable opportunities to LGUs to participate in and benefit from the project, to build sustainable DOH-LGU partnerships, and to assure coherent and effective nationwide implementation of the project. Towards these ends: (a) project- specific agreements would be entered into between the DOH and LGUs within the context of the CHCAs (para. 1.38); and (b) project resources would be allocated and provided as grants to participating LGUs on the basis of need and under variable cost-sharing arrangements. - 30 - CHCAs and PIAs 4.11 The CHCAs are the overall agreements between the DOH and LGUs under which the local governments commit to financing and implementing health programs in their localities in exchange for services and additional resources to be provided by or through the DOH. The CHCAs provide for LGUs to finance the operation of their devolved health systems at a baseline set roughly at the pre-devolution level of DOH spending in the locality; in addition, the LGUs commit to spending incremental amounts in the implementation of priority health programs, including the Women's Health and Safe Motherhood Program. To cover specific program or project requirements, supplementary agreements are to be negotiated and appended to the CHCAs as these requirements are defined and as funds (local or external) become available. 4.12 Supplementary agreements to the CHCAs, in the form of Project Implementation Agreements (PIAs) between the DOH and individual LGUs, would cover the implementation of the proposed project. During negotiations, understandings were reached with the Government that the PIAs would be modelled after the Memoranda of Agreement entered into between the DOH and LGUs under the Urban Health and Nutrition Project. Agreement was also reached that the PIAs would include: (a) the project activities that the LGU is committing to undertake and/or support; (b) the financing share of the National Government to be allocated and made available to the LGU on a grant basis; (c) the financing share of the LGU; (d) the delineation of tasks and responsibilities of the DOH and the LGU in the implementation of the project; (d) undertaking by a provincial LGU to negotiate, within three months of the execution of its PIA, agreements with the municipalities located within the province regarding their respective responsibilities and contributions under the project; (e) undertaking by the LGU to release its health staff to participate in training activities under the project; and (f) provision for suspension or cancellation of the assistance to the concerned LGU in the event of its failure to comply with its obligations under its PIA. Resource Allocation and Cost-Sharing 4.13 Consistent with devolution, the project would be implemented based on the principle that health services delivery is the responsibility of local governments. However, financing assistance from the National Government can be justified and would be provided to: (a) correct inherent inequities arising from the patterns of local subsidies for retained national health facilities and the distribution of devolved assets, as well as from differences in revenue-earning ability; (b) assist LGUs in making the transition to a devolved system; and (c) encourage local spending on priority health programs with significant national public good characteristics and spillover benefits. A further discussion of the public financing of health under devolution is provided in Annex 7. 4.14 The National Government will seek to ensure that health services are provided efficiently and equitably through grant transfers which combine incentives and conditionality. By participating in the project, LGUs would obtain additional resources for meeting local needs for women's health and safe motherhood services. At the same time, the LGUs would agree to providing a specific set of services and to sharing in the cost of their provision. A decision support model would be used as the basis for allocating project - 31 - resources and determining the appropriate cost-share levels to be borne by LGUs. 4.15 Resources would be allocated to LGUs on the basis of need, using specifically-defined criteria, and most of the resources under the project would be allocated by design. Where resources cannot be tied to a specific indicator of need, a resource allocation index incorporating measures of maternal mortality, infant mortality, contraceptive prevalence, poverty and population indicators would be utilized. 4.16 LGUs would share financial responsibility for the services to be provided under the project. The basis for estimating cost-share levels to be assumed by LGUs would be an index incorporating the following principles: (a) localities that are richer should bear a larger share of the costs than those which are poorer; (b) LGUs that spend less for health relative to their total revenues should bear a larger share of the costs than those that are already spending more; (c) localities with a lower absolute poverty burden should bear a larger share of the costs than those with a higher poverty burden; and (d) LGUs with a lower fiscal burden for health should bear a larger share of the costs than those with a higher fiscal burden. Cost-sharing arrangements would be designed to result in an LGU contribution of at least 15% of the total project cost. 4.17 The DOH would estimate the amounts of project resources to be allocated to each province and the cost-share levels to be borne by each LGU. These estimates would serve as a starting point for negotiations with LGUs to determine the actual amounts the DOH and LGUs would commit to the project. In addition to resource and cost-share levels, the phasing of the cost-share contributions of LGUs would also be negotiated. In general, LGUs would be required to pick up in their budgets an increasing annual share of these incremental costs to help ensure sustainability. 4.18 The conceptual framework and application of the resource allocation and cost-sharing models are further described in Annex 8. During negotiations, understandings were reached with the Government on the principles and criteria for determining resource allocations, cost-share levels and phasing thereof for each LGU. Given that the process of devolution is still at a stage of transition, the experience of negotiating with LGUs and their compliance with the provisions of the PIAs would be closely monitored for the first two years and reviewed in depth as part of the project mid-term review (para. 4.23). 4.19 Services under the project would be offered free of charge and no formal cost recovery arrangements would be instituted since the Government does not want to limit access to services which have substantial public good characteristics and spillover benefits. Recent surveys have also confirmed that the large majority of users of public health facilities and services belong to the lowest-income groups. In addition, there was concern over the complications of setting up cost recovery systems during a period of transition to a devolved system of public health service delivery. The project would, however, pilot the social marketing of iron, iodine and Vitamin A supplements and disposable home-based delivery kits (para. 2.6) to determine the ability and willingness to pay among clients for such interventions. The DOH is also studying, with the support of USAID, the full range of health financing options - 32 - (including user fees and health insurance schemes) with a view to promoting the sustainability of and access to public health services. C. Accounts and Auditing 4.20 The DOH and participating LGUs would maintain separate accounts of project expenditures in accordance with sound accounting practices, and project accounts would be audited in accordance with Guidelines for Financial Reporting and Auditing of Projects Financed by the World Bank (The World Bank, March 1982). Proposals from NGOs under the community partnerships component would include related record-keeping and audit requirements. During negotiations, agreement was reached that the Government would provide to the Bank an audit report, including separate opinions by the auditor on the operation of the Special Account and on disbursements against certified SOEs, within nine months of the end of each Government fiscal year. D. Progress Reviews and Reporting 4.21 The PMO would be responsible for monitoring project implementation progress and performance. During negotiations, understandings were reached with the Government on selected key indicators to monitor and evaluate overall project implementation progress and results. These key indicators, as well as the more detailed list of input, process, outcome and impact variables against which each of the project components would be assessed, are given in Annex 11. 4.22 The PMO would produce progress reports based on service statistics and other field data. Agreement was reached during negotiations that the Government would furnish semi-annual reports to the Bank by June 30 and December 31 of each year, beginning in 1995. These reports would constitute the basis for semi-annual project performance reviews to be undertaken with the Bank. To help ensure proper coordination, at least one of the two reviews each year would be held jointly with all of the project's cofinanciers. The PMO would also be responsible for organizing annual workshops to review implementation progress with LGUs, which would be timed to support the annual preparation of operational plans and budgets. 4.23 At mid-term, the DOH would conduct a comprehensive review to determine if there is a need for major changes to project design and implementation targets. Particular attention would be given to the experience with the implementation of devolution-related strategies (paras. 4.10-4.18). Agreement was reached during negotiations that the Government would, by June 30, 1998, carry out a comprehensive mid-term review of project implementation on the basis of terms of reference developed in consultation with the Bank. Agreement was also reached that, within six months of the Closing Date, the Government would submit to the Bank a final evaluation report on the project and a plan of such scope and detail as the Bank may request for the future operation of the completed project. E. Project Evaluation 4.24 The project would be evaluated from three perspectives: performance, process and impact. Project performance evaluation would focus on the annual measurement of outputs with respect to physical accomplishments, financial performance and client satisfaction. Its objective would be to identify - 33 - problems and issues that arise in the course of project implementation, and recommend measures to accelerate activities or redirect project efforts. It would include the review of program indicators as well as of client feedback on the performance of the DOH and local health offices. Data would be generated from program monitoring systems and ongoing beneficiary analysis. 4.25 Process evaluation would examine the approaches used in service delivery and for community participation, attempt to explain variations in levels of performance for comparable project inputs, and derive suggestions for improved approaches. This type of evaluation would be undertaken at mid-term and the end of the project, and would utilize mainly structured interviewing, participant observation and focus group methodologies. 4.26 Impact evaluation would focus on project outcomes in terms of improved efficiency of DOH systems, improvements in equity of access to DOH services, and morbidity and mortality reductions which can be measured by the end of the project. This evaluation would primarily be a quantitative analysis of the contribution of project inputs to sector outcomes, the cost-effectiveness of interventions supported by the project, and the financial sustainability of project benefits. During negotiations, understandings were reached with the Government that implementation of the different service packages under the project would be evaluated separately, i.e., provinces receiving maternal care, RTIs/STDs and cervical cancer services as an integrated package would be compared to those receiving only one or two components. 4.27 The three types of evaluations would be undertaken through technical assistance contracts with local university-based or other qualified research groups, and supported under the policy and operations research component of the project. The PMO would be responsible for their overall direction and ensuring that they are carried out. Terms of reference for each of the studies would be reviewed and agreed upon with the Bank. V. PROJECT BENEFITS, RISKS AND IMPACT A. Benefits 5.1 The main project benefit would be better health for women as a result of improved access to women's health services. Project beneficiaries are estimated to include: about 4 million women who will become pregnant during the life of the project; about 500,000 of these pregnant women who will suffer from obstetric complications; about 1.7 million women of reproductive age who have declared an unmet need for family planning services and a preference for voluntary surgical contraception; an estimated 300,000 women who would not otherwise be treated for RTIs/STDs; and an estimated 1.1 million women who would be screened for cervical cancer. Better health for women would eventually be reflected in reduced levels of fertility, female morbidity and maternal mortality. These improvements would have substantial spillover benefits on the productivity of women and that of their households and communities, and on the survival, health and education outcomes of their children. Progress in realizing these benefits would be assessed on the basis of monitoring indicators agreed upon with the Government. - 34 - 5.2 The project's institutional benefits would include: building the capacity of LGUs in managing health programs, and of the DOH to provide support to local governments; and involving NGOs and project beneficiaries in formulating and implementing solutions to women's health problems in their communities. In addition, research on priority women's health issues for which there is currently limited information will help design future interventions that can further enhance the quality of women's lives. B. Risks 5.3 There are two main risks related to implementing a project of national scope in a devolved system. In the first instance, LGUs will themselves decide whether to participate in the project. Populations in LGU jurisdictions that opt out could not therefore benefit from the project, the scope of the project would be reduced, and national program objectives would be threatened. The following measures have been undertaken to address this risk: (a) cost-sharing arrangements would provide adequate financial incentives for LGU participation; (b) the project has been designed for phased implementation by province over the life of the project, giving the DOH time to negotiate acceptable arrangements with other LGUs; (c) the DOH has initiated the dialogue with LGUs through the CHCA negotiations process with a view to building commitment to national health priorities, including the proposed project; and (d) women's NGOs and community groups were actively involved in project preparation and are likely to press local officials to participate in the project. 5.4 The second devolution-related risk is that LGUs would not have the managerial and technical capacities to implement the project. Substantial institution-building activities are included in the project to address this risk. Phased implementation of the project will also help ensure that adequate training will have been provided before service activities are undertaken in a particular jurisdiction. 5.5 A third project risk is that implementation would be delayed by the lack of adequate cash flows which have plagued other projects in the sector. This risk has been reduced by actions taken on the country portfolio level to ensure that a limited number of priority projects, including the proposed project, would be fully funded; the new Special Account arrangements are also expected to improve the situation. Finally, there is the risk of poor or insufficient coordination of activities financed by the various donors. This risk would be minimized by assigning overall responsibility for the project to the PMO in the DOH, agreeing upon an integrated implementation plan, and conducting joint annual reviews during implementation. C. Impact 5.6 Women in Development. Women are the primary targets of the project, thus project benefits would accrue directly to them. In addition, the project would provide further training for the mainly female midwife cadre which would deliver most of the services under the project, thus increasing their skill level and status. Women's groups are likely to represent a substantial proportion of the beneficiaries of the community partnerships component, and the policy and operations research component would help to establish the scope of other women's health problems (such as breast cancer and violence against women) and to define appropriate public health responses. - 35 - 5.7 Environmental Aspects. No project-related risks to the environment are foreseen. In the long-term, an effective women's health program will lower fertility rates and reduce the environmental pressures associated with rapid population growth. 5.8 Poverty Alleviation. Providing basic health services is a key element of poverty alleviation, and women's health interventions yield some of the highest social and economic benefits. Poor women would benefit most from the project because they are disproportionately affected by the disease burden, tend to have larger family sizes, and are the main users of public health facilities and services. The project would also apply specific health risk assessment and targeting mechanisms for directing resources to the poor and vulnerable, including area-based and life cycle approaches to service delivery, and the use of resource allocation and cost-sharing indices which incorporate poverty indicators. D. Sustainability 5.9 To help ensure the financial sustainability of the project, the DOH developed its Ten-Year Public Investment Program as the framework for measuring project investments in light of total resources available to the sector, the impact project investments would have on health expenditures, and the priority the Government attaches to the project. Under the project itself, funds would be made available through cost-sharing arrangements in which participating LGUs would absorb an increasing share of recurrent costs during the life of the project. Increased community awareness of and involvement in project activities would help generate popular demand for sustained budgetary commitments to women's health care. As a longer-term measure, the DOH is being assisted by USAID to identify other alternatives for financing health services. 5.10 The project would support training, technical assistance and administrative systems to help strengthen the technical and managerial skills of DOH and LGU staff, and thereby develop the institutional capacities required to sustain the delivery of women's health services and their expected benefits beyond the project. VI. AGREEMENTS REACHED AND RECOMMENDATION 6.1 During negotiations, agreement was reached with the Government on the following, as covenants in the Loan Agreement: (a) that a Special Account would be established and held in the Central Bank of the Philippines [para. 3.17; Sec. 2.02 (b)1]; (b) that the Government would establish and maintain until project completion the PMO, headed by a qualified Project Manager and staffed by qualified personnel in adequate numbers [para. 4.3; Sec. 3.03]; Paragraph numbers indicate references within this Staff Appraisal Report; section and schedule/paragraph numbers indicate references in the Loan Agreement. - 36 - (c) that the Government would, not later than July 1, 1995: (i) establish the Project Steering Committee, (ii) designate the DOH Undersecretary/ Chief of Staff and Assistant Secretary for Special Concerns as the Project Director and Project Coordinator, respectively, (iii) employ and assign to the PMO a Desk Officer, acceptable to the Bank, who shall be responsible for overseeing the implementation of activities financed out of the proceeds of the Loan, and (iv) assign to the DOH regional field offices responsibility in their respective regions for coordination of project implementation, monitoring of progress in project performance, assisting in the collection of documentation to support statements of expenditures, and preparation of financial statements and accounts [para. 4.4; Schedule 5, paras. 1-5]; (d) that the Government would update its project implementation plan in consultation with the Bank not later than December 31 of each year, beginning in 1995 [para. 4.9; Schedule 5, para. 7]; (e) that the PIAs would include: (i) detailed description of the project activities that the LGU is committing to undertake and/or support, (ii) the financing share of the National Government to be allocated and made available to the LGU on a grant basis, (iii) the financing share of the LGU, (iv) the delineation of tasks and responsibilities of the DOH and the LGU in the implementation of the project, (v) undertaking by a provincial LGU to negotiate, within three months of the execution of its PIA, agreements with the municipalities located within the province regarding their respective responsibilities and contributions under the project, (vi) undertaking by the LGU to release its health staff to participate in training activities under the project, and (vii) provision for suspension or cancellation of the assistance to the concerned LGU in the event of its failure to comply with its obligations under its PIA [para. 4.12; Schedule 5, para. 6]; (f) that the Government would provide to the Bank an audit report, including separate opinions by the auditor on the operation of the Special Account and on disbursements against certified SOEs, within nine months of the end of each Government fiscal year [para. 4.20; Sec. 4.01 (b)]; (g) that the Government would furnish to the Bank semi-annual reports by June 30 and December 31 of each year, beginning in 1995 [para. 4.22; Schedule 5, para. 8]; (h) that the Government would, by June 30, 1998, carry out a comprehensive mid-term review of project implementation on the basis of terms of reference developed in consultation with the Bank [para. 4.23; Sec. 3.05]; and (i) that, within six months of the Closing Date, the Government would submit to the Bank a final evaluation report on the project and a plan of such scope and detail as the Bank may request for the future operation of the completed project [para. 4.23; Sec. 3.02]. - 37 - 6.2 During negotiations, understandings were reached with the Government and recorded in the Minutes of Negotiations on the following: (a) the staffing complement of the PMO [para. 4.3]; (b) the Government's initial implementation plan [para. 4.9]; (c) that the PIAs would be modelled after the Memoranda of Agreement entered into between the DOH and LGUs under the Urban Health and Nutrition Project [para. 4.12]; (d) the principles and criteria for determining resource allocations, cost-share levels and phasing thereof for each LGU [para. 4.18]; (e) selected key indicators to monitor and evaluate overall project implementation progress and results [para. 4.21]; and (f) that implementation of the different service packages under the project would be evaluated separately, i.e., provinces receiving maternal care, RTIs/STDs and cervical cancer services as an integrated package would be compared to those receiving only one or two components [para. 4.26]. 6.3 Agreement was reached during negotiations that the establishment of the PMO and the appointment of the Project Manager would be conditions of Loan effectiveness [para. 4.3; Sec. 6.01]. 6.4 Agreement was reached during negotiations that the following would be conditions of Loan disbursement: (a) effectiveness of the cofinancing agreement with KfW, in respect of expenditures for drugs and reagents for the RTIs/STDs sub-component of the project [para. 3.18; Schedule 1, para. 3 (b)]; and (b) effectiveness of the cofinancing agreement with AIDAB, in respect of expenditures for consultant services, studies and training for the training sub-component of the project [para. 3.18; Schedule 1, para. 3 (c)]. 6.5 Subject to the conditions in paras. 6.1 to 6.4 above, the proposed project would constitute a suitable basis for an IBRD Loan of US$18.0 million equivalent to the Republic of the Philippines for a term of 20 years, including 5 years of grace, at the Bank's standard variable interest rate. - 38 - LIST OF ANNEXES 1: Public Investment Strategy and Plan for the Health Sector 2: List of Provinces To Be Covered by the Maternal Care, RTIs/STDs and Cervical Cancer Sub-components* 3: Maternal Care Sub-component* 4: List of Drugs, Reagents and Medical Supplies for Other Women's Health Services* 5: Information, Education and Communication Sub-component* 6: Description of Training for Health Care Workers* 7: Public Financing of Health in the Post-Devolution Era 8: Decision Support Models for Central-Local Financing of Public Investments in Health: Conceptual Framework and Application 9: Project Management and Implementation Arrangements* 10: Implementation Schedule* 11: Monitoring Indicators* 12: Costs by Component, Category of Expenditure, Project Year and Cofinancier* 13: Procurement Plan* 14: Disbursement Schedule and Profile 15: Supervision Plan 16: Selected Documents Available in the Project File * Elements of the Borrower's Implementation Plan. - 39 - Annex 1 Page 1 of 6 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Public Investment Strategy and Plan for the Health Sector1' Public Investment Strategy The DOH [Department of Health] proposes an investment strategy for the central government which responds to the following considerations: a assure the sustainability of current national health programs such as EPI [Expanded Program of Immunization], CDD [Control of Diarrheal Diseases], ARI [Control of Acute Respiratory Infections], and control of prevalent diseases particularly of the workforce, including TB [tuberculosis] and CVD [cardiovascular disease]; " address the gaps in priority programs such as family planning, maternal care, nutrition and environmental health; " support the development of new institutional arrangements and capabilities under devolution; m rationalize capital expenditures for health facilities, equipment and infrastructure necessary for the personal health care needs of the poor. The bulk of the proposed investments would be in support of incremental recurrent costs for undertaking activities with a future stream of benefits. Typically, the investment packages would consist of expenditures for expanded and improved health service delivery, particularly of priority health programs; for enhanced institutional capabilities in such areas as information systems, procurement and logistics management and planning, particularly of local governments; for development of community partnerships between LGUs, NGOs and the communities themselves; and for research and development of policies, operations and appropriate technologies. The proposed public investment strategy consists of the following elements: 1. Program content. It will be focussed on priority health services and essential health service capabilities. It will be targeted to meeting the health needs of the population, namely: of mothers and children such as women's health and safe motherhood services as well as child survival and development services including nutrition; of people in the workforce at risk from the prevalent diseases of tuberculosis, cardiovascular diseases, trauma, injuries, poisoning from industrial pollution, malaria, schistosomiasis, sexually-transmitted diseases; of households and communities at risk from environmental degradation and sanitation deficiencies; and of the acutely ill Excerpted from Investing in Equity in Health: Ten Year Public Investment Plan for the Health Sector (1994-2004). Prepared by the Department of Health, January 1994. - 40 - Annex 1 Page 2 of 6 poor population requiring access to medical and hospital care. It will also be directed to improving the efficiency and equity of the public health network under devolution including the clinical referral system, expanding the participation and contribution of NGOs and the private sector, and creating basic technical capabilities in health service management and policy direction. While the costs of addressing these problems are large, the costs of not dealing with them adequately may even be larger. In addition, considerable past investments may be eroded and their potential returns foregone if further investments in these areas are not undertaken. 2. Package approach. The strategy will require the deployment of resources in large scale coherent nationwide packages. The fragmentation of the health system under devolution and the multiplication of factors affecting health services output and impact demand that investment interventions do not come in many small projects that are difficult to implement coherently and costly to coordinate. On the other hand, the need to focus on the beneficiaries and the population at risk, as well as the synergies inherent in the coordinated delivery of technically inter-related services present opportunities for more cost-effective investments. These reasons argue for investment packages. 3. Devolution responsive. The strategy will mobilize resources to address the backlog of pre-devolution problems in the health sector, prevent the transitional problems and risks of devolution from eroding recent gains, and exploit the opportunities for efficiencies presented by devolution. The investment projects will be planned and implemented in a manner consistent with the goal of creating sustainable partnership between DOH and LGUs [local government units] within the parameters of devolution. Consultative processes will involve local governments; cost-sharing between national and local governments will be a feature; division of labor and functions will be in accordance with the LGC [Local Government Code]; the early projects will seek to respond to the transitional problems of devolution; the later projects will support the central government roles and functions beyond the transition. The packages are designed to focus central government resources towards correcting the inherent disincentives in local government expenditures for programs with large spillover effects across localities and for providing services to the non-taxpaying poor. On their own, local governments may tend to underinvest as a whole and may tend to unevenly support programs whose benefits spillover to other localities such as communicable diseases control. They may also underinvest in providing adequate service coverage to the poorest as they would place greater emphasis in maintaining or attracting a desirable tax base. Health services are the local governments' responsibility. There is no intention of supplanting their role through these investments. The object of these projects and packages is to correct the disincentives which could limit the efficiency and equity of local government behavior in this area. 4. Sources of investment funding. The proposed investments would be financed by increased central government expenditures in health, shifting of current central expenditures from less cost-effective measures (curative care, overhead, lower priority programs) to more cost-effective national public good priorities, greater mobilization of foreign assistance, greater contribution from cost recovery measures, and appropriate cost sharing with local governments. While the strategy is concerned with assuring that government is spending the right amounts for the right things benefitting the right people, - 41 - Annex 1 Page 3 of 6 it also needs to insure that sourcing the spending is equitable, efficient, adequate and sustainable. Proposed Public Investment Package The investment strategy proposes to mobilize incremental resources in amounts and duration indicated in support of the following packages. As of the end of 1993, the DOH was implementing current and on-going investment projects estimated to cost about P7.8 billion. In addition to these, the DOH proposes to put in place projects in packages with an estimated aggregate of P17.5 billion over the next five years. The following packages are proposed: 1. Safe Motherhood and Women's Health. This package is addressed to the basic health needs of women, primarily poor women of reproductive age, with special emphasis on the needs of mothers. The services to be financed include family planning, maternal care, and the management of prevalent diseases of women. The goal of the package is to insure universal access to family planning information and services in accordance with the health needs and fertility preferences of couples; reduce maternal mortality through proper pre- natal care and delivery; reduce maternal morbidity through better mother's nutrition, adequate spacing of pregnancies and improved access to quality maternal care. The proposed investment will attempt to correct the imbalance in public expenditures between health interventions addressed to children and those addressed to the women who bear these children. The estimated cost of the investment is P6.5 billion for the first five years from 1995 to 1999. 2. Child Survival and Development. This package is addressed to the basic survival and essential early childhood intervention needs of the under-five population. This includes sustaining immunization for the six childhood diseases with particular emphasis on measles and polio eradication; control of acute respiratory illnesses and diarrheal diseases; reduction of protein-energy malnutrition and micronutrient deficiency in children. In addition to the service delivery provisions, the package would address the policy, operational and institutional issues of child survival and development. Particular emphasis would be given to achieving the effective assumption of child survival and development responsibility by the LGU with the participation of the community. The proposed investment is estimated at approximately P5 billion for the first 5 years (1995 to 1999). 3. Control of Prevalent Diseases Affecting the Workforce. This package includes case finding and treatment of TB, case management and vector control of malaria, continued case management of schistosomiasis, initiation of a national capacity build-up for dealing with the HIV/AIDS epidemic, control of sexually-transmitted diseases, start-up of national control programs for cardiovascular diseases and cancers. The emphasis of the proposed investments is primary prevention and early cure with priority on risk reduction factors. The package could also include the strengthening of disease control capabilities such as epidemic surveillance and disease monitoring system, the public health research and development infrastructure including public health laboratories, and the other technical support systems for nationwide disease control (IEC [information, education and communication], training, and logistics. One particular need is the development of a cadre of disease control specialists that can be deployed in local governments, and the general - 42 - Annex 1 Page 4 of 6 upgrading of health workers to deal with new diseases such as HIV/AIDS, cancers, and cardiovascular diseases. The estimated cost of the investment is approximately P4 billion for the period 1995 to 1999. 4. Health Service Capacity Improvement. This package includes future capital investments in additional health facilities and in further health human resource development. Policy reform in the public financing of hospitals will be initiated in the direction of greater cost recovery from the population with the means to pay, shifting of public subsidies in personal health care from financing service production to public institutions to financing the service consumption of the poor, and the establishment of clinically-based regulations and standards. Planning standards for evaluating the efficiency and equity of health facilities provisions for each locality would be developed. Based on the application of these standards, a package of capital grants for facilities, equipment and infrastructure would be provided to carry out local health systems reforms including the improved linkage of DOH-retained facilities, local government facilities and private facilities. In the health human resource development area, a set of initiatives directed at production and management of health human resources would be planned to achieve the improved linkage of the health services production sector with the health manpower development sector. Facilities needed by the first three packages including vaccine production laboratories, upgrading of district hospitals and similar inputs will be included in this package. An estimated P2 billion in addition to the projected P3.3 billion in capital outlays already included as on-going local projects is being proposed for the 1995 to 1999 period. 5. Safe Water and Healthy Environment. This package would seek to address the remainder of the population without access to safe water and sanitary toilets, start the development of better community sanitation through improved waste management and better sewerage systems, and initiate initiatives towards reduced pollution, lesser exposure to environmental hazards, and better linkage between health and environment. This package is being proposed for inclusion in the DPWH [Department of Public Works and Highways] and/or DENR [Department of Environment and Natural Resources] as these sectors' contribution to a better health. 6. National Health Insurance. This package consists of improvements and reforms in the existing Medicare Program, establishment of a national framework for universal insurance coverage, and the interim promotion of decentralized and community-based health insurance schemes. The investment is gong to be off-budget, using existing statutory funds as well as additional contributions from households, employers, and local governments. Financing the Proposed Public Investments Total health expenditures are estimated at about 2 percent of GNP from 1985 to 1991, a level well below that of many other Asian countries. (The Philippines ranks below Nepal, Bangladesh, Indonesia, Thailand, Sri Lanka, China, Malaysia and India in terms of health spending as a proportion of GNP.) In the light of the lack of basic health service coverage in many communities and segments of the population and the extent of unmet needs in such necessities as family planning, nutrition and control of prevalent diseases, the Philippines is probably underspending for health. - 43 - Annex 1 Page 5 of 6 The pattern of current spending presents additional problems. Much of current sector expenditures, about 55%, come from out-of-pocket payments of families, payments which are not likely to go for basic preventive, promotive and early cure services. In fact, much of these expenditures go for drugs, hospital charges and doctors' fees. The government accounts for 36% of total spending. This portion now becomes less easily manageable as it breaks up into the central and local governments' portions. The rest of total expenditures come from employers, private insurance and Medicare, sources which are also unlikely to finance current as well as future provision of basic public health programs. In the light of these conditions, the following approaches are being proposed in order to finance the requirements of the above investment program: 1. Increase the efficiency of the current DOH budget. This can be done through the possible reduction of overhead expenditures (about P1.7 billion of the P7.1 billion of the 1994 budget) via streamlining and cost containment and also the deployment of this overhead to achieve program efficiencies (leading to reductions in the cost of investments without reducing the benefits). Another possibility is the reduction in the cost of retained facilities (about P2.9 billion of the 1994 budget) via greater cost recovery possibly from user charges and service revenues as well as cost containment measures. Another possibility is the reallocation of program expenditures (about P2.5 billion of the 1994 budget) to better emphasize health priorities. Another measure of efficiency improvement is the better use of program expenditures in order to mobilize more counterpart funds from LGUs and NGOs, and also produce more output and impact from the given outlays. 2. Increase the level of public expenditure in health programs. There are many good reasons for increasing central government expenditures in health. The areas of investments (immunization, family planning, prevalent diseases, child care, safe motherhood) are not only politically attractive but also economically valuable. The effective operation of the devolved system is at stake in the transition period, and together with it the fate of the overall decentralization and local autonomy program. The sector has demonstrated previous capacity to succeed. Service delivery capacities are still largely intact and available for mobilization, hence absorptive capacity concerns may not be serious. 3. Finance part of the expansion via foreign grant sources blended vith regular revenue sources and foreign loan sources. Under the overall fiscal program of the government, there is room for the financing of public health sector expansion. Considering all the sources of expenditure financing versus all the possible claims for expenditures, investment projects in health consistent with the above strategy can rank among the best application of funds. Current practice restricting health programs to grant sources reduces the overall level of financing available, tends to fragment health programs into small grant-financed projects, and misses out on the opportunity to coherently design comprehensive nationwide coordinated programs. On the other hand, if the government has determined for macro-economic policy reasons that it shall borrow from various sources, then the project attributes of the health investments should allow it access to all forms of financing available, including loan financing when necessary. - 44 - Anex 1 Page 6 of 6 4. Establish cost sharing requirements for various health programs from local governments. In addition to financing the costs of the basic service infrastructure, the local governments could be asked to carry part of the additional burden of financing the above investments. Some investments, being national public goods, may have to be borne by the national government. But for many programs, cost shares from local governments could account for significant portions of the required investment financing. Ability and willingness to pay would have to be considered in determining these cost shares in addition to the character of the items to be financed and the nature of the benefits that they yield. - 45 - Annex 2 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT List of Provinces Tareted for Intensive Coverage by the Maternal Care, RTIs/ISTDs and Cervical Cancer Sub-cmponents Maternal Care R7s/STDs Cervical Cancer (40 provinces) (10 provinces) (15 provinces) REGION I Pangasinan La Union CAR Abra* Kalinga-Apayao* Mountain Province* Ifugaoo Benguet* Benguet* REGION H Batanes* Cagayan Cagayan Quirino Isabela REGION M Bulacan Nueva Ecija REGION IV Aurora* Quezon Quezon Romblon* Mindoro Occidental Mindoro Oriental Palawan Rizal REGION V Camarines Sur Camarines Sur Camarines Sur Cataiduanes Sorsogon Masbate* REGION VI Capiz* Antique* Guimaras* Negros Occidental Negros Occidental Iloilo REGION VII Negros Oriental* Negros Oriental* Negros Oriental* Cebu REGION VIII Northern Samar Western Samar Eastern Samar* Leyte del Norte* Leyte del Norte* Leyte del Norte* Leyte del Sur* Bilirin REGION IX Zamboanga del Norte Zamboanga del Sur* Zamboanga del Sur- Zamboanga del Sur' Basilan* REGION XSurigao del None Agusan del Sur* Misamis Oriental REGION XI Surigao del Sur* Davao del Norte Davao del Sur ARMM Lanao del Sur Lanao del Sur North Cotabasto* North Cotabatol Maguindansol Sulu* Tawi-Tawis *President's Priority Provinces - 46 - Annex 3 Page 1 of 8 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Maternal Care Sub-component 1. In support of the national safe motherhood program of the Department of Health (DOH), the maternal care sub-component of the Women's Health and Safe Motherhood Project aims to decrease maternal mortality and morbidity, and to strengthen the delivery of safe motherhood services in the provinces and municipalities. Strengthening will be done through the provision of quality pre-natal and screening services, management of normal births and obstetrical complications, and post-natal care. The component will entail improvements in the quality, accessibility and expansion of services at all levels, most especially at the first level referral facilitiesYi 2. The sub-component has the following specific objectives: (a) to strengthen the referral systems and services of the public sector; (b) to improve safe home births; (c) to provide logistical support to maternal health care; and (d) to provide technical assistance and management. 3. Intensive interventions will be focused on 40 priority provinces listed in Table 1. The provinces were chosen based on the following criteria: (a) high maternal mortality and morbidity; (b) poor provinces (based on the Presidents priority province list which includes poverty levels and potential for income generation); and (c) upgrading has not been undertaken in the facility in the recent past. Strengthening of the Referral System 4. The maternal care sub-component project will strengthen the referral system through improvements in infrastructure facilities and the provision of required logistics. Specifically, the project will provide for the following: (a) Upgrading of obstetric units in 40 provincial hospitals. This would involve minor civil works for rAnovation of existing structures, provision of essential obstetric equipment, instruments, and provision of required drugs and supplies. The list of hospitals to be upgraded will be validated by the DOH before project implementation. The upgrading/renovation of the facility will follow internationally- accepted guidelines of minimum standards required for the provision of first-referral level obstetric care. Before construction begins, a detailed needs assessment will be undertaken. This will involve detailed site visits to review the actual needs for upgrading (i.e., rating the existing facility versus the list of requirements for construction, equipment, staffing, etc.) as well as assessing the capacity of the provincial hospital to absorb The first-referral level obstetric facility is defined as a hospital able to support Cesarean sections on a 24-hour basis. - 47 - Annex 3 Page 2 of 8 such upgrading. The scope of construction work will focus on upgrading of existing delivery suites, including expansion if necessary, to suit the recommended prototype design. Prior to upgrading activities, project related activities such as agreement with the local government units, identification of counterpart funds and agreements on maintenance and renovation plans, as well as the site surveying and architectural modifications and bidding for works, have to be finalized. (b) Upgrading of 52 remote district hospitals in the 40 provinces to meet the minimum international standards of a first-level health facility. In remote areas, the provincial hospital may be too far from the community to be able to provide the services to a woman suffering from an obstetrical emergency on time. In this case, a facility closer to the community needs to be upgraded to supply the first-referral level of services. As previously indicated, the upgrading/renovation of the facility will follow the internationally-accepted guidelines of minimum standards required for the provision of first-referral level obstetric care. The 52 district hospitals to be upgraded by the project were chosen based on the following criteria: (i) a 25-bed or greater capacity, (ii) a facility to which the rural health midwives and rural health doctors can directly refer, and which is a maximum of 2 hours via common local transport distance from the majority of the rural population; and (iii) a need for upgrading. An initial list of the 52 district hospitals will be validated through a needs assessment to be undertaken based on actual site visits. (c) Establishment of 15 pilot lying-in clinics in remote rural health units (RHUs). A lying-in clinic is a facility that provides normal delivery care with overnight bed facilities for women and 24-hour care. The project will support the construction of lying-in facilities to offer a patient privacy and sanitation during examination, delivery, and rooming-in (mother and infant). (d) Establishment of 10 maternity waiting homes on a pilot basis. A maternity waiting home is a halfway house for at-risk obstetrical cases and women who live in very remote areas. The project will support construction of these facilities. (e) Upgrading of 160 RHUs in remote areas. This will involve civil works (mainly renovation of facilities), and the provision of equipment, instruments, drugs, and supplies and materials for remote RHUs. Approximately 4 RHUs per province will be upgraded. (f) Upgrading of 280 barangay health stations (BHSs) in remote areas. This will entail renovation of existing facilities, and the provision of medical instruments, drugs, an supplies and materials for these remote BHSs. Approximately 7 BHSs per province will be upgraded. - 48 - Annex 3 Page 3 of 8 Technical Assistance and Training 5. Technical assistance, training, and logistical support would be provided to promote safe home births, and improve the management of maternal care services of the DOH central and regional field offices, and service delivery in the provinces and municipalities. Specifically, the project will provide for the following: (a) Training on maternal care and the provision of trainee-replacement scheme for staff in project-assisted facilities. (b) Logistical support in the form of (i) 13,500 midwife delivery kits, (ii) 1,900,000 disposable kits for mothers, (iii) 9,000 traditional birth attendant kits, (iv) micronutrients (vitamin A, iodine, iron), and (v) 5 million home-based mother's records. (c) Consulting services to support key technical and implementation functions of the project. This will include the organization of the following technical assistance teams: (i) a Maternal Care Technical Support team to provide technical inputs for maternity care service deliveries, (ii) a Project Design and Implementation Team to oversee the design and construction of all civil works to be undertaken by the project; (iii) an Equipment and Medical Supply team to assist in the development of specifications for equipment, preparation of tender documentation and evaluation of tenders, and arrangements for equipment and supplies distribution; (iv) a Benefit Monitoring and Evaluation (BME) team to undertake BME activities for the project; and (v) a Project Management Specialist. (d) Nutritional support activities to all women, particularly pregnant women, to avert the high prevalence of nutritional disorders among women for iron, iodine, and vitamin A. This will entail the provision of micronutrient supplementation, and investments in food fortification promotional efforts and social marketing. 6. The nutritional support activities will specifically provide for the following: (a) Iron supplementation (ferrous sulfate/folate) to 7.09 million pregnant and 5 million lactating women. The project would also support studies that will strengthen this activity in terms of the following: (i) The Nutrition Service and other agencies have commenced activities regarding fortification of rice with iron. A blender has been developed that can successfully fortify rice at local milling levels with iron. However, the unit price of US$10,000 is more than what most millers can afford as an investment. Testing of widespread acceptability in terms of taste, color and price implications needs to be investigated. (ii) The provision of free iron supplementation to women who can afford to pay needs to be reviewed. The project will carefully investigate means of social marketing of iron supplementation to - 49 - Annex 3 Page 4 of 8 pregnant women, keeping a careful review on the profile of clients, ability and willingness to pay and price elasticity. (iii) Iodine supplementation (potassium iodate in oil). The project will target the pregnant women in provinces found endemic for iodine deficiency. This basically refers to areas that have more than 5% of the population with visible goiter, or more than 5% of the 6-12 year old population with goiter and thyroid enlargement. Further, in support of the Government's goal of making available nationwide iodized salt by 1995, the project will assist the Nutrition Service in reviewing the utilization of iodized salt, especially by the project's target groups, and will support piloting of a social marketing approach to supplementation with cost-recovery arrangements. (b) Vitamin A supplementation to 6.1 million lactating women. Supplementation is only a short term-measure for Vitamin A deficiency disorders. Longer-term approaches to improving diets in Vitamin A rich foods need to be strengthened. The women's health training and information, education and communication (IEC) sub-components and nutrition gardens will assist in finding a more sustainable approach to this problem. 7. To increase the chance for sustainability of the above nutritional interventions the project will support promotional activities for generating private sector initiatives on food fortification (e.g., iron fortification of rice, salt iodization, vitamin fortification of so-called junk foods), and proper nutritional awareness through IEC. List of Kits to be Provided 1. Safe Home Delivery Kits Contents: The kits would include the following items, packaged in a low- cost container: sterile pads (2 pieces); plastic cord clamp (1 piece); sterile razor blade (1 piece); sterile gauze pads (4 pieces); sterile cotton balls (4 pieces); sterile gloves (1 pair); sterile cord tie (4 10-cm. sterilized pieces); Terramycin ointment (1 unit); Soap (1 unit). Users: The kit will be used by traditional birth attendants (TBAs) and midwives for home deliveries and for the woman to take for normal deliveries in a facility. The aim of the kit is to reduce the risk of infection to mother and infant due to unsterile delivery and tools. 2. Obstetrical Kits for Traditional Birth Attendants Contents: Thermometer, clinical, oral (1 piece); plastic sheeting, 3'x 7' (1 piece); gloves (1 pair); hinge type soap dish (1 piece); surgical scissors, 5 1/2" (1 pair); forceps, haemostat, straight Kelly's (1 pair); sponge holding forceps (1 pair); instrument tray with lid (1 piece); pocket weighing scale, Salter type (1 piece); soap, 135 mg (1 piece); cord ties, - 50 - Annex 3 Page 5 of 8 4/packet (1 packet); apron, plastic (1 piece); Terramycin eye ointment (1 piece); flashlight with batteries (1 unit); hand brush, nylon bristles (1 piece); cotton, 25 mg (6 pieces); bag, black leatherette (1 piece); suction bulb syringe, reusable (1 piece). Users: Trained traditional birth attendants for home deliveries. 3. Obstetrical Kit for Midwives Contents. Carrying bag (1 piece); sphygmomanometer, aneroid with cuff (1 piece); stethoscope (1 piece); straight scissors, 8 1/2 (1 pair); kidney basin, 600-800 ml. (1 piece): soap container (1 piece); soap (1 piece); suction valve, rubber (1 piece); plastic sheet, 3/4 yard (1 piece); instrument tray, 4"x 8" (1 piece); flashlight, with 2 batteries (1 unit); thermometer, rectal (1 piece); thermometer, oral (1 piece); sponge (instrument) forceps (1 pair); sponge forceps, 8", round nose (1 pair): forceps, Kelly's (1 pair); hand towels (2 pieces); baby spring-type scale, 5-25 kg gradation (1 piece); sterile gauze pack (1 pack); absorbent cotton, 6/pack (1 pack); surgical hand brush (1 piece); plastic apron (1 piece); plastic sheeting (2 pieces); gloves (1 pair); plastic bags, sealable for dirty linen (2 pieces); glass bottle, 500 ml. with screw top (5 pieces); Terramycin ophthalmic ointment (1 tube); tape measure, plastic (1 piece); suture, catgut, with needle, sterile package (4 pieces); anesthetic, local (1 ampule); antiseptic solution (50 ml.); Vitamin K (1 amp.); medicine glass, plastic (1 piece) Users: Midwives 4. Obstetric Emergency Kit Contents: Dextrose (1 liter IV bag); vacuset (1 unit); butterfly gauge No. 19 (1 unit); oxytocics (2 amp./l amp.); analgesic (1 amp.) Users: Trained midwives, doctors, public health nurses at RHU, maternity homes, lying-in clinics and district/provincial hospitals. Selection Criteria for Facility Upgrading Provinces 1. Provinces were selected on the following basis: (a) high level of maternal deaths; (b) high maternal mortality ratio (more than 1.4 maternal deaths/1,000 live births); poor provinces (President's priority list). Provincial Hospitals 2. The causes of maternal deaths are often directly related to the need for interventions beyond primary health care solutions and facilities. The first-referral level obstetric hospital is therefore needed to provide these services. The essential obstetric functions at the first referral level are: (a) to perform cesarean section; (b) to give an anesthetic; (c) to give blood transfusion; (d) to carry out vacuum extraction (delivery technique); (e) to - 51 - Annex 3 Page 6 of 8 carry out section curettage to incomplete/septic abortion/miscarriage; (f) to insert intra-uterine devices; (g) to perform tubal ligation or vasectomy; and (h) neonatal special care. 3. These functions will require: (a) a provincial hospital with a fully operational obstetrics unit, including labor room, delivery room, operating room, septic room, isolation room, examination room, nursery for intensive neonatal care, reception and triage area, recovery room, sterilizing room, adequate water, sanitation, and electricity, and infrastructure; and (b) a laboratory capable of supporting blood bank and essential laboratory tests for emergency obstetrics. 4. The final selection of provincial hospitals will be based on the following criteria: (a) facility to which the rural health midwives, and rural health doctors can directly refer; (b) need for upgrading of obstetric facilities measured against a standard list of needs for this facility in order to provide quality, safe, and essential first-referral level facilities; (c) physical location of the facility; and (d) overall condition of the facility. District Hospitals 5. The essential obstetric functions would be the same as for the provincial hospitals, which would require: (a) a district hospital with a fully operational obstetrics unit, including a labor room, delivery room, operating room, septic room, isolation room, examining room, nursery for intensive neonatal care, reception and triage area, recovery room, sterilizing room, and adequate water, sanitation, and electricity; and (b) a laboratory capable of supporting blood bank and essential laboratory tests for emergency obstetrics. 6. Final selection of District Hospitals will be based on the following criteria: (a) 25-bed capacity or greater; (b) facility to which the rural health midwives and rural health doctors can directly refer, which is a maximum of 2 hours via local transportation-distance from the majority of the rural population; (c) need for upgrading of obstetric facilities measured against a standard list of needs for this facility in order to provide quality, safe, and essential first-referral level facilities; (d) physical location of the facility; and (e) staff available to support 24-hour intensive nursing observations and care as well as to provide 24-hour emergency surgical care. The minimum staff allocation required is that of a 25-bed district hospital with 4 doctors, 6 nurses, and 8 to 12 trained midwives. Rural Health Units 7. The RHU is the closest full-time staffed facility providing primary health care within a community. These facilities have at least a rural health midwife at all times on call. RHUs provide the following services: (a) - 52 - Annex 3 Page 7 of 8 primary health care; (b) minor surgery, e.g., wound dressings, suturing; (c) antenatal and postnatal care; (d) family planning; (e) management of common infectious diseases; and (f) counseling. 8. Issues that presently compromise the quality of services provided at these facilities include: (a) lack of privacy for clients when requested; (b) poor management of sterile conditions; (c) poorly maintained facilities and equipment; (d) lack of essential equipment, drugs and supplies; (e) lack of reliable and clean sources of water and power; and (f) poor sanitation facilities for clients especially needed for women undergoing internal examination and for antenatal clients. 9. The project will upgrade the facility in order to increase its capacity to provide acceptable, safe and quality women's health services. This will include: (a) repair existing infrastructure such as roof, ceiling, guttering, paintwork (internal and external); (b) connection to local electricity source, if available; (c) water supply; (d) sanitation facilities; (e) private physical examination and counselling space; (f) storage capacities for essential drugs and equipment; and (g) observation area. 10. Selection of rural health units will be based on the following criteria: (a) enough allocated staff to be able to provide 24-hour on-call service for obstetrical care by a rotated RHU staff person being within 15 minutes of the RHU and at a site that the community can locate readily; (b) physical location of the facility; and (c) population served. Barangay Health Stations 11. The BHS is the health post where the rural health midwife may base her work, and from where she may serve one to three barangays. The BHSs provide the following services: (a) primary health care; (b) antenatal and postnatal care; (c) family planning; (d) management of common infectious diseases; and (e) counseling. 12. Issues that presently compromise the quality of services provided at these facilities include: (a) lack of privacy for clients when requested; (b) poor management of sterile conditions; (c) poorly maintained facilities and equipment; (d) lack of essential equipment, drugs and supplies; (e) lack of reliable and clean sources of water and power; and (f) poor sanitation facilities for clients especially needed for women undergoing internal examination and for antenatal clients. 13. The project will upgrade the facility in order to increase its capacity to provide acceptable, safe and quality women's health services. This will include: (a) repair existing infrastructure such as roof, ceiling, guttering, paintwork (internal and external); (b) connection to local electricity source, if available; (c) water supply; (d) sanitation facilities; (e) private physical examination and counselling space; and (f) storage capacities for essential drugs and equipment. 14. The selection of barangay health stations will be based on the following: (a) population served, generally BHSs that can serve 3 to 5 barangays; and (b) in close proximity to an RHU that is upgraded. - 53 - Annex 3 Page 8 of 8 Lying-in Clinics 15. The lying-in clinic will be a safe birthing center for rural areas. This model is well tested in the urban settings, but has not been widely tried in rural areas. The need for this facility is three fold: (a) women's preference as a safe and clean option for a normal birth away from home but not in a hospital; (b) for easier access of the midwife to obstetrical cases in large population or geographically difficult areas; and (c) for women whom the midwife is concerned cannot have a safe delivery in the home due to physical conditions of the location. 16. The lying-in clinic offers a bed in which to rest for a few hours before returning home post-partum, and for post-partum counseling regarding mother and child care, family planning and other aspects of women's health. They also provide an opportunity for the midwife to supervise TBA deliveries and in-service training. They will also serve as a transfer point for stabilizing a woman prior to transfer if she is suffering from an obstetrical complication. 17. The RHUs that will be upgraded to provide lying-in services will be selected based upon: (a) allocated staff able to provide services on a 24-hour basis for women; (b) location in areas that are easily reached by the majority of the population; (c) location to provinces and districts with facilities that will be upgraded to first-referral level obstetrical service capacity. 18. The upgrading will consist of: (a) a three-bed labor/post-delivery room; (b) a delivery room; (c) a toilet and bathroom; (d) piped water; and (e) electricity. Equipment that is supplied to all the RHUs (for midwife staff) will be located also in this facility. Maternity Waiting Homes 19. The project will test the effectiveness and acceptability of maternity waiting homes in the rural parts of the Philippines; if successful, the initiative can then be promoted as a community activity. Maternity waiting homes are facilities in the style of local housing. They provide pregnant women with a temporary residence where they can be observed prior to delivery. Women who use the facility can be accompanied by a family member and can prepare their own food, as in their own homes. While in residence, the pregnant women can be more closely monitored by the first-referral level obstetric facility and can be quickly admitted at the onset of labor, at the first sign of any complications, or if an unanticipated complication arises. 20. The facility addresses the following problems regarding early management of obstetric complications: (a) that women who are identified as high-risk pregnancies do not like to stay for long periods of time in a hospital--away from family members, in unfamiliar surroundings and where they believe sick people should be; and (b) that women who may need intervention should be able to be quickly transferred to the hospital at the onset of labor or a problem, in remote areas this is not possible. To be effective, therefore, maternity waiting homes need to be either on the grounds of or very close to the first-referral level facility. - 54 - Annex 4 Page 1 of 2 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT List of Drugs. Reagents and Medical Suplies for Other Women's Health Services Family Planning Drugs Quantities 1. Pregnancy Test 76,300 2. Lidocaine 2% 5ml/vial 166,300 3. Providone Iodine 10% solution 2,700 4. Midazolan 5 mg/apl 305,000 5. Pethidine 50 mg/ml 30a vial 20,300 6. Mefenamic Acid 500 mg/amp 1,220,200 7. Naloxone HCL 0.4 mg/amp 2,100 8. Chorhexidine Gluconate 4% solution, 4 liters 3,300 Supplies Quantities 1. Surgical Gloves 22,200 2. Gauze Pads, 4"x 4" non-woven, 200 pcs/pack 1,800 3. Syringes (10 ml) 332,500 4. Needles (G23) 27,500 5. Plaster 27,500 6. Surgical Blades - #15 27,500 - #3 305,000 7. Butterfly Needles (G21) 305,000 8. IV Set (Adult) 305,000 9. Syringes (5 ml) 305,000 10. D5LR 305,000 11. Plain Catgut 184,700 12. Chromic 20 Sterile 305,000 Reproductive Tract Infections/Sexually Transmitted Diseases Drugs Quantities 1. Miconazole Nitrate, 200 mg.vag. 1,309,700 2. Metronidazole, 500 mg.tab. 4,939,200 3. Doxycycline, 100 mg.tab. 5,544,000 4. Ceftriazone, 250 mg. vial 630,000 5. Bezathine Penicillin 1,008,000 - 55 - Annex 4 Page 2 of 2 Reproductive Tract Infections/Sexually Transmitted Diseases (cont.) Laboratory Supplies Quantities 1. Cover Slip, box 10,500 2. Slide, box 10,500 3. Dropper 490 4. Cx Swab 1,050,000 5. Darkfield - 50 ml. oil 2,100 - slide, box 2,100 - oil immersion lens 500 - light source (client) 2,100 6. RPR - tube 210,000 - high intensity lamp 70 7. FTA-ABS - flourescence microscope assembly 70 - pipette 210,000 - water bath 70 8. Trichomon - Medium 42,000 - Plating Swab 250 Cervical Cancer Supplies and Reagents (Pap Smears) Quantities 1. Spray Fixative, 100 ml can 12,500 2. Cytocolor Kit 1,250 3. Mounting Medium, 500 ml can 1,250 4. Slides, frosted end, 100/box 12,500 5. Cover slip - 24 x 56 mm, 100/box 12,500 - 24 x 40 mm, 100/box 12,500 6. Gloves, 1 dozen/box 9,300 - 56 - Annex 5 Page 1 of 2 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Information, Education and Communication Sub-component 1. The information, education and communication (IEC) sub-component of the Women's Health and Safe Motherhood Project ultimately aims for change in the behavior of women in ways that will safeguard their health. The project strategy is to launch a thematic campaign prior to campaigns directed to specific target audiences. The thematic campaign would aim to raise the general awareness of women about health issues, and lay the groundwork for increasing knowledge and changing attitudes and behaviors. Specific campaigns will then be directed to four key audiences among the primary targets, to promote the adoption of audience-specific behaviors, namely: Target Audience Key Behaviors 1. Women in Union Safe motherhood, proper nutrition for pregnant and lactating women, prevention and treatment of reproductive tract infections/sexually- transmitted diseases 2. Older Women Screening for early detection of cervical cancer 3. Adolescents Proper nutrition; delaying sexual activity; negotiations skills relevant to social interaction; if sexually active, behaviors relevant to reproductive health concerns 4. Special Audiences For victims of domestic violence, seek counselling and obtain support from health workers or the community 2. The campaigns, while directed to the primary targets (the women themselves) are also expected to reach two other types of audiences: secondary targets, i.e., groups or persons who exert an influence on health behavior of women, such as their partners; and tertiary targets, i.e., those in positions of authority who can influence the enactment of policies, programs, laws and regulations to provide an enabling environment for the new behavior to take root. Specific messages directed to the secondary and tertiary audiences will also be developed, as needed. 3. The project will develop and utilize the following communication support materials: (a) mass media materials, including radio and television plugs, and print ads with the same message concepts as the broadcast spots; (b) print media, including mini-magazines and adult "komiks," which are the most widely-read printed materials in the country, as well as the traditional brochures, flyers and posters; and (c) other materials, including training/teaching materials and videos for health care workers. - 57 - Annex 5 Page 2 of 2 Sample IEC Messages Maternal Care a Seek early care when pregnant a Why pre-natal and post-natal care are important and where to receive such care " Danger signs in pre- and post-natal period, and what to do * Elements of a safe delivery a Nutritional needs of adolescent girls and women a Nutritional needs of pregnant and lactating women * How a community can support a pregnant woman a How a community can support an obstetrical emergency " First aid for obstetrical emergencies a How to negotiate for care " Responsible parenthood Family Planning a Family planning is a health intervention a Family planning promotes safe motherhood and child survival a Range and characteristics of family planning methods a Where to get family planning services a What to do if problems arise * How to negotiate with partners regarding contraceptive use " Responsible sexual behavior Reproductive Tract Infections a What RTIs are and what causes them a Why it is important to seek early care a What are the complications of RTIs a How to prevent RTIs a How to manage RTIs a Using medication for RTI management a How to negotiate with partners Cervical Cancer " The signs of cervical cancer a What a Pap smear is " When and how often women should have Pap smears a Where to go for Pap smears Violence Against Women " It is a problem: don't hide it, don't accept it a Where to go for help a Legal rights - 58 - Annex 6 Page 1 of 9 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Description of Training for Health Care Workers A. Traditional Birth Attendant (Hilot): Basic Course 1. For 30 to 70.% of women in the country, a traditional birth attendant (TBA) is the prime attendant at delivery. The aim of working with TBAs in the Women's Health and Safe Motherhood Project is to ensure that the TBAs do not cause nor contribute towards maternal mortality nor morbidity through unsafe practices, and refer early and appropriately to higher level services when needed. 2. There are approximately 40,000 TBAs in the country, approximately 500 per province and one to three per barangay. It has been estimated by the Department of Health (DOH) that 75% of these have already been trained in safe delivery practices by the DOH through, among others, a project funded by UNICEF and the Australian International Development Assistance Bureau (AIDAB). This training was matched with the supply of a safe delivery kit in 100% of the cases. A 10% drop-out rate (due to death, migration, other causes) was estimated. 3. The project will train a total of about 13,750 TBAs. The training will be based upon the curriculum developed, tested, implemented and reviewed by the UNICEF-AIDAB supported project. Trainee materials, curriculum and materials prototypes are available and will be reviewed. This review will mainly be to design an integration of family planning information (in order to facilitate the role of the TBA as a motivator, counsellor and support person for contraceptive users and potential users), and referral of women with other women's health issues to the nearest Rural Health Unit or higher facility. The TBAs will also be trained specifically regarding the use of the safe delivery kit and its maintenance and care. 4. The TBA training module will contain, at a minimum, the following information: - introduction to family planning methods - interpersonal communication skills and counselling - the need for and sources of pre- and post-natal care - safe delivery practices (e.g., hand washing, clean area for delivery, no internal examinations, not to push down on the uterus, other aspects of infection control) - early danger signs during antepartum period and where to refer - early danger signs during labor and where to refer - danger signs during the postpartum period and where to refer - obstetrical first aid (e.g., elevating a woman's legs, keeping an eclamptic woman quiet and restful) - referral practices - how to support women using family planning and iron supplementation - use of the home-based mothers record - 59 - Annex 6 Page 2 of 9 5. At present this training is undertaken by the rural health midwife (RHM). In order to address the need to improve the quality of the training, the RHM and the Rural Health Doctor will be trained (see below) in their own courses on how to train and support TBAs. This training will be randomly checked for quality by provincial and regional trainers and/or training contractees. The training will take 2 days at the Rural Health Unit level to complete. B. Barangay Health Worker 6. There are about 300,000 barangay health workers (BHWs) in the country, approximately 4,000 per province or 1 BHW per 20 families (although some reports indicate that only 50,000 BHWs are active). It has been estimated through the UNFPA and Family Planning Services of the DOH that 20% of these have already been trained in family planning support and counselling; however none have received training in safe motherhood or women's health. 7. Under the project, all BHWs will be trained. The training will be based upon a curriculum developed, tested, implemented and reviewed by the DOH. It will be designed to be broadcast over provincial radio, in local dialects, in a three-month cycle of short (half-hour) lessons, that may be accompanied by a low literacy sheet to follow during the program. It may also feature a "write-in" spot where BHWs have the opportunity to seek advice from a regional or national health officer about specific problems they are having in the implementation of their work. BHWs will be informed about the program through the RHMs, rural health doctors and public health nurses. 8. Negotiations will be conducted with the Philippine Information Service and the Provincial Radio and Rural Announcers Federation to gain free or reduced air time. Experience with use of radio for BHW training was successfully tested in one province about 15 years ago, and has been used by other sectors. Distance learning on such a large scale will be an innovation in the country, but it is hoped that it will provide a cost-effective means of reaching a volunteer labor force with a very high turnover. It will also inform the community who may listen to the program to understand what they can expect from the program (thereby acting as a community level supervision of their worker) and educate them about their health and health behaviors. 9. The content will include, at a minimum: - what and where the services for a pregnant woman are - what family planning is and where services are - how the community can support a pregnant woman and the BHW role - how to talk to and counsel your clients - what reproductive health is, and common problems for both women and men - what reproductive tract infections (RTIs) and sexually-transmitted diseases (STDs) are - what the danger signs of pregnancy are - what the danger signs of cancer afflicting women are - the importance of breastfeeding - what to advise women who are victims of violence - 60 - Annex 6 Page 3 of 9 C. Rural Health Midwives 10. There are approximately 13,500 RHMs in the country or approximately 140 per province (10,914 are on the local government unit (LGU) payroll as a result of devolution, with the rest due for absorption by the LGUs in 1995). It has been estimated that, through existing program efforts of the DOH supported by UNICEF, AIDAB, UNFPA and USAID, 100.% of these will have been trained in a Basic/Comprehensive course in family planning provision (for pills, condoms and intrauterine devices) as well as in counselling and interpersonal skills. However none have received training in injectable contraceptives (except for 10 provinces in 1994), essential obstetrics care or obstetrical first aid for emergency cases, nor, except for some minimal content in the Basic/Comprehensive course, on reproductive tract infections or cancers afflicting women. It has been estimated that there is a 10% drop-out rate among this cadre; however, the aforementioned donors will provide the Basic/Comprehensive course to any new midwives during the period 1994-99. 11. The project will train a total of about 14,850 RHMs (including new recruits). The training will be based upon a curriculum developed, tested, implemented and reviewed by the DOH, modularized and designed to be taught in a competency-based fashion, with the major emphasis being on skills training. Training models as well as clients will be utilized in this training. In addition to the traditional forms of didactic learning, various self-directed learning packages using interactive teaching methods appropriate to the setting (e.g., tapes, slides, videos) will be utilized. In addition, videotaping trainee practices will be explored for feedback and review. The use of these innovative teaching methods will lay the groundwork for the RHMs being involved in distance learning and continuing education activities also to be developed and implemented under the project (Section P below). 12. The modules will be adaptations of existing training materials or available modules. The aim of the training would be to teach women's health as an integrated package, and thereby support and encourage a more holistic and appropriate approach to the provision of services. In the provinces where family planning training has already been provided, a special refresher module will be provided. 13. The course content will include, at a minimum, the following: (a) Basic clinical examination skills (refresher training for most) - reproductive history taking - general physical examinations (especially pulse, blood pressure, oedema) - pelvic examination including determination of pelvic size (for obstetrical assessment) - pelvic anatomy (location of the tubes, uterine size and shape and surface, condition of the fornices, ovarian size and condition, condition of the abdominal cavity - vaginal examination (including presence of any infection, lacerations, fistula, other pathology) - cervical visualization (color, condition, presence of any pathology) - proper method of insertion of specula - 61 - Annex 6 Page 4 of 9 - specula examination; external genitalia examination, including presence of any pathology - ecto- and endo-cervical smears for cultures, slides and Pap smears - universal precautions (sterile techniques, infection control, worker safety (b) Interpersonal skills - counselling: family planning; maternal care; pre- and post-testing for RTIs/STDs; compliance with treatment regimes; emergency situations; domestic difficulties; breastfeeding, aspects of antenatal and post-natal services - information provision: face-to-face; group; audience specific; use of visual and print aids - referral - specific counselling on indications and contraindications regarding different family planning methods, side effects and health benefits, assisting a woman/couple in method selection (c) Clinical skills - inserting and removing an IUD (refresher skill) - taking an endo- and ecto-cervical smear - giving injectable contraceptives - giving tetanus toxoid - oral and parenteral dispensing of oxytocic drugs after delivery of the placenta - suturing perineal lacerations to control bleeding - setting up, inserting and managing the giving of intravenous fluids during obstetrical emergencies (including fluid balance) - management of a normal delivery including use of a partogram, assessment of progress through fetal health sounds, cervical dilatation, monitoring of contractions - provision of antenatal care (refresher skill) - use of RTI algorithms, including ability to undertake a wet mount slide microscopic examination, the KOH Whiff test, and pH test for RTIs - appropriate prescribing practices including rational use of drugs (d) Management skills - how to be a TBA supervisor, including scheduling of time, use of a supervisory checklist, responses to findings (refresher skill) - how to record information, including filling in forms, how to use the data to follow trends and quality of services - how to manage stocks and supplies, including inventory, storage, projections, ordering - how to manage the referral system - how to manage one's own supervision - infection control, including cleaning, sterilization, contingency measures, e.g., making reuse of gloves a safe practice in shortage conditions (refresher skills) - how to mobilize the community (refresher skill) - how to schedule workload and time - how to delegate - how to identify and meet one's needs for assistance - 62 - Annex 6 Page 5 of 9 (e) Training skills - how to provide "updates" to community level workers (refresher skill) - how to train TBAs 14. The RHM course will be 21 days in duration, with 75% direct contact time and 25% guided self-directed learning. In addition to structuring the course on targeted competency levels, it will also include trainer assessment of on-the-job competency by setting tasks for the trainee to follow after the direct course, and following the provider into the field. The trainer will be the provincial-level health official who will be trained as a master trainer (Section M below) along with at a project-contracted midwifery trainer. D. Rural Health Doctors 15. Rural health doctors (RHDs) work in Rural Health Units. They are usually recent graduates, and stay only an average of three to five years. There are over 2,000 RHDs in the country, or approximately 14 to 15 per province. It has been estimated by the DOH that 75% of RHDs have already been trained in family planning provision (for pills, condoms and intrauterine devices) and in counselling and interpersonal skills. However none of them have received training in injectable contraceptives, essential obstetrics care and first aid for emergency obstetric cases, reproductive tract infections or cancers afflicting women. 16. The training of this cadre will basically be the same as that of the RHM. However, because of previous experience where joint training has caused problems, the RHDs and RHMs will be trained separately. E. Public Health Nurses 17. There are approximately 11,000 public health nurses (PHNs), or approximately two to three in each Rural Health Units. This cadre consists of fully-trained nurses with midwifery training who are permanently stationed at the Rural Health Unit. They provide clinical services and supervise the RHMs. Most of them have been trained in family planing and interpersonal communication skills. 18. The training for PHNs will be basically the same as for the RHDs and RHMs, but will be trained separately from them. F. First-Referral Level Doctors 19. The training for first-referral level doctors will be a six-month residential course in obstetrics and gynecology (ObGyn). The training will be conducted at fifteen Regional Medical Centers of the DOH which have received accreditation from the Philippines Obstetrics and Gynecological Society (POGS) and the DOH to train in post-graduate obstetrics for specialist training and rural doctors. There will be one trainee per six months per facility. Preceptors (clinical tutors) shall be assigned at each of these facilities specifically for this program; this is likely to be the Senior Resident at each of these facilities. The preceptors will be attend annual training and - 63 - Annex 6 Page 6 of 9 feedback workshops in Manila to review progress, materials and evaluations of the program. 20. The existing six-month training program will be strengthened by POGS, the DOH and technical adviser to be provided under the project. This strengthening shall result in: - definition of competencies and desired performance levels - curriculum and materials for trainees and trainers - training programs and manuals - trainee logbook and assessment materials - preceptor orientation materials - locum scheme (where the doctors in training will be covered for the six-month absence by a DOH-provided locum with ObGyn training) 21. The skills required included the following: (a) Surgical Skills: - repair of high vaginal and cervical tears - laparotomy - repair and surgical treatment of uterine rupture - ectopic pregnancy - placental removal (retained placenta) - management of incomplete and septic abortions - surgical treatment of sepsis (b) Medical skills - augmentation of labor - intravenous total dose of iron - medical treatment of sepsis - treatment of shock - management of severe hypertension and eclampsia - blood transfusion - vacuum extraction (Ventouse extraction) - low cavity forceps - fluid balance management - management of medical problems during pregnancy (c) Delivery skills - normal delivery - management of breech and other abnormal presentations - use of the partograph - physical assessment of the progress of labor - antenatal and postnatal checkups (d) Other clinical skills - management of reproductive tract infections (simple and complicated) - management of contraindications and side effects of family planning use - provision of family planning, including all temporary methods and bilateral tubal ligation (minilaparotomy technique) - counselling and interpersonal communication skills - 64 - Annex 6 Page 7 of 9 - cryotherapy management of dysplastic changes on the cervix - local and regional anaesthesia for obstetrics - obstetrical anaesthesia and management of a nurse technician (e) Management skills - Infection control - Training of obstetric surgical team - conduct of maternal mortality reviews and other quality assurance activities - supervision of physical environment of the ObGyn ward - team work G. Obstetrical Nursing Team at First-Referral level Hospital: 22. The training for the obstetrical nursing team will be two days in duration and held in the hospital where the nurses work. It will be provided by the resident doctor upon his/her return from the six-month ObGyn training. The resident doctor will have received training in how to train these staff and the materials with which to do so. 23. The content of this refresher training will include, at a minimum, the following: - nursing of the eclamptic/severely pre-eclamptic patient - fluid balance - post-operative management of patients - surgical scrubbing and infection control - physical environmental management - obstetrical first aid H. Support staff of the ObGyn Ward 24. The support staff of the ObGyn ward (orderlies, reception and triage staff) will be provided an orientation of three hours duration at the hospital in which they work. It will be conducted by the resident Doctor upon his/her return from the six-month training course in ObGyn. Its content will include obstetrical first aid (how to transport a woman with an obstetric emergency), how to counsel the woman and her family, and where to direct them. I. First-Referral Level Laboratory Staff 25. These staff will be trained at the Regional Training Centers and Regional Medical Centers on RTIs, management of a blood bank, cervical ecto- and endo-cervical smears, and good laboratory practices to support the activities of the maternal care, RTI and cervical cancer activities of the project. This training will be conducted by pathologists at the regional level. Test slide kits will be available for the training. It will be a residential course of six days duration. J. Cytotechnicans 26. Training for cytotechnicians will be six days in duration, specifically on the management of a cytology lab for both Pap smears and - 65 - Annex 6 Page 8 of 9 biopsy (cervical) samples. Additionally, training on good laboratory practice will be included. This training will be conducted by the pathologists at the regional level. Test slide kits will be available for the training. It will be a residential course of Eix days duration. K. Pathologists 27. Training will be provided to pathologists at each of the Regional Medical Centers as well as from up to 10 provincial hospitals that will be part of the RTI and cervical cancer expansion activities of project. The training shall be conducted in Manila for six days. The training shall be conducted by POGS and technical adviser provided under the project. It will include refresher training in cervical pathology and RTIs as well as blood bank management, quality assurance activities for laboratories, and good laboratory practices. They will also receive instruction on training of the cytotechnicans and the laboratory technicians at the regional level. L. Obstetrician/Gynecologists 28. Training will be provided to ObGyn doctors at each of the regional medical centers as well as from up to 10 provincial hospitals that will be part of the RTI and cervical cancer expansion activities of the project. The training shall be conducted in Manila for six, and shall be conducted by POGS and technical adviser provided under the project. It will include refresher training in cervical pathology and RTIs, and training in quality assurance activities, including mortality reviews and observational studies. M. Preceptors 29. Preceptor training will be held in Manila for two days. Two senior resident staff from each of the 15 accredited Regional Medical Centers will receive instruction specific to teaching the six-month resident training program in ObGyn. As these staff are already master trainers, they will basically be oriented to the strengthened approach of the project. This training shall be conducted by POGS and a technical adviser to be provided under the project. N. Provincial-Level Trainers 30. Members of the Provincial Training Task Force will be trained as trainers by the national and regional training teams, and by technical advisers and training contractees. This training shall be a two-weeks residential course at the regional level. Training will be conducted in the principles of integrated training, competency-based training, adult learning, innovative training methodologies and self-directed learning skills. Materials will be provided for them based upon these principles and specifically for the conduct of the integrated women's health training for rural health unit staff. There shall be competencies (both end-of-training and on-the-job) defined for this training. 31. In addition to the actual face-to-face training for the two weeks, the trainers shall supervise the first round of training by these provincial trainers, providing guidance and on-the-job in-service training. - 66 - Annex 6 Page 9 of 9 32. The training shall be skills-based, and utilize the techniques which the trainers should, in turn, use for their training. Video cameras will be used in this training to playback, as a training technique, their practice training sessions as well as their counselling sessions. Additionally, they will be taught video camera techniques (turning the camera on and off) to enable them to use a tripod mounted camera for interpersonal communication skills training of the rural health unit staff. 0. National and Regional Master Trainers 33. National and regional master trainers will be provided a 30-day training course in Manila by training advisers to be provided under the project. The course shall provide refresher training on instructional design, teaching methods, teaching equipment use and maintenance, adult learning, self-directed learning, training of trainers. Additionally, it shall introduce the master trainers to the,integrated training and competency-based training. 34. The training shall be skills-based, and utilize the techniques which the trainers, in turn, should use for their training. Video cameras will be used in this training to playback, as a training technique, their practice training sessions as well as their counselling sessions. P. Distance Education 35. Distance education will be provided for the following: - BHWs via radio, with back-up support by the RHM and limited print materials - rural health unit staff (midwives, doctors, nurses) via print media (posted every two months) - 67 - Annex 7 Page 1 of 6 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Public Financing of Health in the Post-Devolution Era 1. With the completion of the physical transfers of personnel, assets, functions and resources for the delivery of public health services from the national government to local governments in accordance with the 1991 Local Government Code, new arrangements for the financing of the public health system are necessary. In the immediate post-devolution era, a period of transition is to be expected in which, for health and economic reasons, a continued and important role for national government financing will be required to support the operation and development of the devolved public health system. The 1994 DOH Budget from a Devolution Perspective 2. From the standpoint of the central and local dichotomy inherent in thinking about devolution, the 1994 budget of the Department of Health (DOH) amounting to P17.3 billion consists of three types of expenditures: (a) About P1.28 billion is allocated to shared national functions, such as general administration at the central and regional levels, health policy development, standards and regulations, health information, health human resources development and essential national health research. The specific local impact of these activities are not easily distinguishable and thus cannot be considered as targeted subsidies to localities. (b) About P2.8 billion is allocated to inputs and activities whose benefits accrue to specific localities via spending for national health programs and projects. This includes the immunization, diarrhea, acute respiratory infections, tuberculosis, malaria, rabies, primary health care, environmental health and community health programs as well as general purpose drugs and medicines. These are properly considered as targeted subsidies to local governments. Considerable grant resources flowing outside the DOH budget also finance activities whose benefits accrue to specific localities. (c) About P3.3 billion is allocated to inputs and activities whose benefits also accrue to specific localities through the operation of retained national health facilities and through direct financial assistance of devolved health facilities. Local Government Budgets Based on 1993 Apropriations 3. Based on the 1993 budget appropriations, the following can be said about local government financing of health functions: - 68 - Annex 7 Page 2 of 6 (a) In accordance with the Local Government Code, provinces have appropriated largely for hospitals, municipalities for rural health centers and barangay health stations, and cities for a mixture or hospitals and health centers. (b) For provinces and municipalities, the cost of devolved health functions as they had been set before devolution by the DOH was the main determinant of their respective allocations. For these local government units (LGUs), the pre-devolution costs were such that they could not easily ignore them. For cities and barangays, which are not saddled by large transferred costs of devolved health services, their allocations for health can be presumed to be in closer accord with local preferences. (c) For provinces and municipalities, the costs of health services represent a significant portion of their total revenues. For all provinces, the total costs transferred from DOH represent about 29% of their total 1993 share of the Internal Revenue Allotment (IRA). For municipalities, the cost of devolved health functions amount to 13% of their total IRA share. This compares with 1.3% for cities, and 0% for barangays. (d) For provinces and municipalities, their 1993 (and probably 1994) spending for health are expected to accommodate and feature gradual adjustments, downwards or upwards, from their pre-devolution levels towards levels more in accord with local preferences and capabilities. For barangays and cities, the adjustment process to fit health spending to local preferences is likely to move faster. Role of Central Financing Under Devolution 4. Without any policy intervention, the prospect is that LGUs would finance their newly-accepted health functions in accordance with their local health needs, resources (their own revenues and their share in IRA) and the stock of health service capabilities transferred to them; meanwhile, the national government would finance only retained national functions. However, a policy integrating central with local spending can be a better alternative to separate and purely autonomous central and local public spending. There are four main categories of reasons why central spending for some local functions in some localities should be undertaken on efficiency and equity grounds: (a) Devolution as specified contains inherent inequalities. First, the pattern of local subsidies represented by retained national health facilities allow certain localities to benefit from national spending more than others.- Second, the pattern of local subsidies represented by the distribution of devolved assets and capabilities For example, the province of Camarines Sur obtains the benefit of national government spending for the regional hospital located in Naga City, which is not as easily utilizable by the people of other provinces in the region. - 69 - Annex 7 Page 3 of 6 allow certain localities to benefit more than others. Central spending for public health programs can help correct the inequities in the distribution of devolved facilities and in the flow of national subsidies for retained facilities. (b) Devolution as specified poses certain technical constraints to more efficient allocation and utilization of resources for health. First, the structural break between provinces which are responsible for financing hospitals (hence curative care) and the component municipalities which are responsible for financing community health services (hence preventive and promotive care) poses a barrier to rational province-wide resource allocation and utilization. Municipalities may under-provide for prevention, and provinces may end up spending more and more for treatment and cure. Municipalities may also end up spending more for health care needs if provinces under-provide for medical care. Provinces or municipalities may free-ride on each other or may duplicate their efforts. The local allocation of central spending for public health programs would allow provinces and municipalities to alleviate this structural break in area-wide health operations. Second, local preferences in health program priorities may not be in accord with national priorities. Certain health programs have large inter-jurisdictional externalities which may not be sufficiently internalized in local government decision-making.l/ Localities may over-provide for lumpy expenditures like medical centers more properly utilized by larger populations than those of the investing localities. Other localities may free-ride by not spending on certain services and encouraging their population to utilize other localities' provisions. Program allocation of central government spending for localities can help assure adequacy for total program spending (national, provincial and municipal). (c) The third reason for national financing of some localities' health functions involves transitional difficulties. Localities may not yet have sufficient information to make the best decisions about health. Central government financing of public health programs can assist in improving the information markets in health via technical assistance and training where appropriate. Another transitional difficulty involves the progressive absorption of the devolved personnel and facilities into the local government system. Aside from the unrest that can be caused by a cutback or For example, provinces like Pangasinan and Iloilo obtain benefits from hospitals transferred to them which may not be available to provinces that did not inherit such infrastructure. For example, high immunization levels in one town may not sufficiently protect it from epidemics if immunization levels in a neighboring town are low. - 70 - Annex 7 Page 4 of 6 redeployment of the stock of resources transferred from the national government, there is also the need to avoid permanent adverse effects of possible mistakes in actions. Personnel may leave and it may be difficult to recruit replacements. Facilities may run down and it may be difficult to rebuild them. Central government financing can cushion the adjustment process in fitting the devolved infrastructure with the local needs and financing capabilities. (d) The devolved health system could increase ability-to-pay disparities among localities. The pattern of national revenue sharing as well as the pattern of local tax base potentials are not in accord with the pattern of health needs. Some of the areas in greatest need for health services may be those areas with the least capacity to finance them. Central government financing for public health programs can be used for partially alleviating these disparities. The sizes of local populations as well as the local burdens of health care for the poor vary considerably among LGUs. The large minimum fixed requirements of public health care provisions will tend to burden the smaller localities. In addition, the public burden of care for the poor will tend to be greater on those localities with a larger proportion of poor households in their population. Small provinces with large poor populations would have greater difficulties. Central government financing of local health functions can be used to partially alleviate these types of disparities. Policies for Health Project Financing 5. In the context of implementing the proposed Public Investment Plan of the DOH, the following principles would guide the financing of health projects: (a) The projects to be included in the investment pipeline would be addressed to the priority areas for public health intervention. (b) The total cost of the projects would be within the medium-term and annual investment ceilings of the DOH in accordance with the overall fiscal program of the government. (c) The design, allocation and implementation of the projects shall be in the context of strengthening the operation of the devolved health system and encouraging local autonomy and self-reliance in achieving national health goals. (d) The features of the financing provided to health projects should contribute to improving the efficiency and equity of the health sector. 6. Consistent with the above principles, the following policies would apply: - 71 - Annex 7 Page 5 of 6 (a) Having determined the need for the proposed investment project, the policy objective of the DOH relative to project financing is to obtain an adequate level of investments in its priority areas. The overall size of the projects in terms of physical quantities as well as total costs will be driven by national health goals and targets. Investment priorities would be articulated within the overall budget ceiling of the DOH. While the DOH will endeavor to obtain the least- cost financing of its proposed investments, its primary goal would be to obtain an adequate level of investment. The DOH would be tasked with the decision regarding project size and timing, while the Department of Finance and the National Economic Development Authority would decide on the sources of the financing (revenues, grants or loans) given overall fiscal objectives, opportunities and constraints. (b) The national public investment projects in health will typically involve expenditures for the DOH-retained functions as well as expenditures for devolved functions. Investments in devolved functions are necessary because (i) these functions involve basic health services which are currently underfunded, leaving substantial unmet needs, (ii) these functions are not efficiently handled by autonomous financing of local governments nor by insurance, direct payments of households and employers, (iii) these functions have large externalities and spillovers which cross local jurisdictions, (iv) additional spending by the central government could induce more rational spending by LGUs, and (v) fulfilling these functions would have a large future impact in improving the overall quality of human resources, reducing future costs of care, and alleviating poverty and its effects. (c) The national public investments on some devolved health functions in some localities would be provided to these localities on a grant basis, regardless of the nature of their financing sources. If the national government has decided to undertake a public investment project by obtaining financing, it should not compromise the utilization of these resources by the target localities by having them bear the burden of the financing costs. Structuring the central-local financing terms to mirror the source of financing would effectively alter the price to the localities of certain functions financed under less than grant terms. The probability that localities would opt out of these projects or part of the projects would increase, thereby compromising the technical integrity of the project investment. (d) However, while public investment funds for health would be provided on a grant basis, they would be provided on the condition that LGUs bear part of the cost of the investments. The investment resources available to some localities for some functions on a grant basis would be differentially "priced" in terms of the required cost shares for these investments. The extent of cost sharing would be determined in order to cover the requirements for (i) providing Philippine government counterparts in project financing, (ii) - 72 - Annex 7 Page 6 of 6 undertaking institutional reforms necessary for project implementation, (iii) sustaining project recurrent costs beyond the project life, and (iv) achieving local fiscal reform in LGU financing of health services. (e) In general, the basis for allocating project resources would be on need, while the basis for required cost shares would be ability and willingness to pay. (f) In general, local governments will absorb the government's cost share for non-recurrent costs, except in localities that are destitute, in which case the DOH could absorb the share of these costs. (g) Since a large proportion of public investment projects in health are in the category of incremental recurrent costs, the national government would bear the burden of some recurrent costs. This would include, for example, the cost of vaccines and malaria supplies (for reasons of externalities), introduction of new drugs as part of a new and improved treatment protocol (for reasons of technology promotion). Localities would bear the burden of recurrent costs in their devolved functions, including personnel, travel, per diems and basic supplies. For certain other recurrent costs, the national government would initially bear the burden that shall eventually be borne out by local governments or households. This would include, among others, contraceptives (due to low contraceptive prevalence), drugs for tuberculosis (due to high levels of prevalence and transmission,as well as their high cost), micronutrient supplements (as an initial emergency measure, given the high levels of deficiencies). Annex 8 Page 1 of 6 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Decision Support Models for Central-Local Financing of Public Investments in Health: Conceptual Framework and Application Introduction 1. In financing public investments under devolution, decisions have to be made about: (a) how to allocate total project investments among the various localities; (b) how much of the project investment costs will be borne by the locality and by the national government; and (c) how investments will be phased over the project period. 2. To assist the national and local governments in reaching agreement on the above questions, three decision support models are proposed: (a) resource allocation model, which contains the criteria, indicators and formula for distributing total project investments among localities; (b) cost sharing model, which contains the criteria, indicators and formulas for setting the total target share of project investment costs to be borne by local governments; and (c) project phasing model, which contains the criteria, indicators and formulas for setting annual project expenditures and corresponding cost shares of local governments in order to achieve the agreed upon resource allocation and cost share totals determined by the first two models. 3. The purpose of the models is to provide central and local governments with technical guidelines for negotiating resource allocation, cost sharing and project phasing agreements whose overall outcomes would: (a) contribute to incremental improvements in the equity and efficiency of the devolved public health system; (b) create the necessary financing conditions for successfully implementing national health projects; and (c) encourage the reconciliation of national and local goals and constraints. - 74 - Annex 8 Page 2 of 6 Description of the Models Resource Allocation Model 4. In general, resource allocation would be based on the basis of need. Project resources would first be allocated between inputs for national functions and inputs for devolved local functions. The total inputs for devolved local functions would be subject to the resource allocation model. Project resources to be distributed to localities would then be divided into those items whose local distribution can and cannot be determined by design, i.e., where specific indicators of need (prevalence of the disease, lack of facilities, severity of the problem, etc.) are available and can be used to allocate resources. Those items not pre-determined by design would be subject to a resource allocation index. 5. The resource allocation index for determining the recommended claim of each locality on project inputs yet to be distributed incorporates measures and indicators of need according to the following principles: (a) Localities with the poorest health or demographic status (as indicated by such measures as infant mortality, maternal mortality and contraceptive prevalence rates) should, in general, receive more of the project investments intended to address these problems. (b) The share of the national health or demographic problem contributed by each locality (as indicated by such measures as the proportion of national infant or maternal mortality or birth rates accounted for by the locality) would be considered. In some cases, the localities with the greatest contribution to the problem should get the most resources. In others, the localities with the greatest success in solving the problem should get most of the resources. Whether the allocation should finance the solution of failures or reward the demonstration of success would be determined based on the policy goals, behavioral assumptions, determinants of performance and the nature of the investments. 6. The totality of resource allocation decisions would be the sum of the allocations by design and those obtained by utilizing the resource allocation index. The resulting allocations by locality may be modified in two ways: (a) The Department of Health (DOH) may want to set the level of incremental project investments by locality within a framework of rationalizing all central resources benefitting localities. The incremental project resources allocated could be adjusted in order to equalize the totals of all localities. (b) On the basis of specific program needs, project resources could be allocated to fill the gaps in program requirements by locality. The resources provided by the government and other donors for the program would be estimated and the project resources could be allocated to fill the gaps for meeting program goals. -75 - Annex 8 Page 3 of 6 Cost Sharing Model 7. On the assumption that the totality of resource allocation decisions are satisfactory to national and local governments according to their policy, program and project goals, the share of the local government in project costs would be negotiated as a separate matter. While resource allocation would be based on need, cost shares would be based on ability and willingness to pay for meeting this need. 8. Since the project resources are being provided to localities on a grant basis, the cost shares are the localities' expenditure counterparts in the project. The specific shares of specific localities would be estimated on the basis of a cost-sharing index, which would incorporate the following general principles: (a) Localities that are richer should bear a larger share of the project costs than those which are poorer. (b) Local government units (LGUs) that spend less for health relative to their total revenues should bear a larger share of the costs than those with a higher poverty burden. (c) Localities with a lower absolute poverty burden (lower share of the national population that is poor) should bear a larger share of the costs than those with a high poverty burden. (d) LGUs with a lower fiscal burden for health (i.e., the costs of devolved health functions as a percentage of revenues) should bear a larger share of the costs than those with a higher fiscal burden. (e) LGUs receiving higher per capita DOH subsidies for health should bear a larger share of the costs than those receiving lower per capita subsidies. 9. The cost shares, as determined by the index, would be applied to the resources allocated to each locality, and the total cost shares generated would be summed up. Individual cost shares may have to be modified according to demands of the following considerations when applied to the resulting total: (a) Higher cost shares may need to be generated if total cost shares are short of project requirements. (b) Higher cost shares.may need to be generated if the demands of adequate local project implementation cannot be directly financed by project resources. Project Phasing Model 10. Project resources will be expended on an annual basis, and project resources will flow through multiple channels: the DOH budget for the loan proceeds and the national government counterparts, direct flows of the grants, and LGU budgets for the local cost shares. Total resource allocations per locality and the corresponding local cost shares thus need to be translated -76- Annex 8 Page 4 of 6 into a scheme for progressively capturing the project life targets in the annual budgets of the DOH and the LGUs. 11. The goal of the project phasing scheme is to ensure that, by the end of the project, each locality would have received its corresponding project resources and have provided its corresponding cost shares. Proposed Resource Allocation and Cost Sharing Indicesl' 12. Table 1 on the following page describes the inputs, outputs, constraints and basic computation procedures of the three decision support models for resource allocation, cost sharing and project phasing. As noted earlier and in the table, the required inputs for the first two models include indices for resource allocation and cost sharing. Such indices have been developed for the application of the models to the Women's Health and Safe Motherhood Project. Resource Allocation Index 13. The resource allocation index is intended as an overall measure of women's health status and of health services delivery. Two alternative indices have been developed. The first includes the following indicators: total population, population density, maternal mortality rate, infant mortality rate and contraceptive prevalence rate for modern methods. The second index uses a poverty measure as a substitute for maternal and infant mortality, due to concerns raised about the reliability of these mortality data at the provincial level; this poverty measure is the percentage of the population living below the subsistence level. 14. While the specific indicators and the weights assigned to each are yet to be agreed upon, the preliminary structure of the indices, the proposed weights and the underlying assumptions are summarized in Table 2 on the next following page. Cost Sharing Index 15. The cost sharing index is intended as a measure of provinces' ability to pay and of inter-province equity. The proposed index includes the following indicators: per capita income, percentage of revenues spent for health, the percentage of the population living below the subsistence level, the provinces' fiscal burden for health, and per capita government subsidy for health. The fiscal burden for health defined as the ratio between the total DOH costs for devolved functions and the increase of the Internal Revenue Allotment between 1992 and 1993 (which was supposed to cover the costs for devolved functions). 16. While the specific indicators and the weights assigned to each are yet to be agreed upon, the preliminary structure of the index, the proposed weights and the underlying assumptions are summarized in Table 3 on the next following page. 1" Details are provided in M. Enache, Resource Allocation and Cost-Sharing in the Women's Health and Safe Motherhood Prolect Using A Decision Succort Software, June/July 1994. Table 1. RESOURCE ALLOCATION, COST SHARING AND PROJECT PHASING MODELS: INPUTS, OUTPUTS, CONSTRAINTS AND COMPUTATION Kodel Inputs Outputs Constraints Computation Resource Total resources (costs) to Resources to be Measures of spread and/or The resource allocation index is computed Allocation be allocated for functions allocated to each restrictions: as the standardized value of the composite and cost categories which individual LGU of the weighted criteria (variables). have not been determined by - minimum spending level design (per capita or total) The resources allocated to each individual LGU are computed by using linear Resource Allocation Index - maximum spending level transformations of the index according to criteria (variables) (per capita or total) resource allocation scenarios. Direction of each - number of bottom- Scenarios are user-defined and based on variable's contribution in ranked LGUs to be variations on policy inputs or constraints the index subsidized imposed to the model. Iterative computer algorithms would be used where adjustments Level of importance are necessary. attributed to each variable (weights) Cost Total resources allocated Individual LGU shares Measures of spread and/or The cost sharing index is computed as the Sharing to each individual LGU of the allocated restrictions: standardized value of the composite of the resources weighted criteria (variables). Cost Sharing Index criteria - minimum and maximum (variables) cost shares proposed The cost shares of each individual LGU are computed by using linear transformations of Direction of each - minimum and average the index according to the cost sharing variable's contribution in cost shares proposed scenarios. the index - maximum and average Scenarios are user-defined and based on Level of importance cost shares proposed variations on policy inputs or constraints attributed to each variable imposed to the model. Iterative computer (weights) - total allocation algorithms would be used where adjustments constraints are necessary. Project Individual LGU shares of Phasing over the Measures of spread and/or The phasing over the project life of Phasing allocated resources project life of restrictions: individual LGU or central government shares individual LGU and of allocated resources are computed by Central government's shares central government - the annual percentage using linear transformations of the shares of allocated resources shares of allocated spread proposed (as percentages or absolute numbers) determined as a residual of resources according to a project phasing scenario. LGU shares - minimum, maximum and average annual Scenarios are user-defined and based on percentage proposed variations on policy inputs or constraints imposed to the model. Iterative computer - subsidize/non-subsidize algorithms would be used where adjustments '0 policy inputs are necessary. 0 O 1 0 - 78 - Annex 8 Page 6 of 6 Table 2. PROPOSED RESOURCE ALLOCATION INDICES: INDICATORS, WEIGHTS AND ASSUMPTIONS INDICATORS WEIGHTS ASSUMPTIONS Alternative 1 Population 1 More populous provinces may have economies of scale Population Density 1 Higher density provinces may have economies in health service delivery Maternal Mortality Rate -2 Major indicator of women's health care needs Infant Mortality Rate -3 Major indicator of health care needs Contraceptive Prevalence Rate 2 Measure of fulfilled health need Alternative 2 Population 1 More populous provinces may have economies of scale Population Density 1 Higher density provinces may have economies in health service delivery Percent Subsistence Population -4 Poverty has a major impact on women's health care needs Contraceptive Prevalence Rate 2 Measure of fulfilled health need Table 3. PROPOSED COST SHARING INDEX: INDICATORS, WEIGHTS AND ASSUMPTIONS INDICATORS WEIGHTS ASSUMPTIONS Per Capita Income 2 Richer LGUs should bear a larger share than poorer LGUs Percent Revenues Spent on Health -1 LGUs that spend less for health (of revenue) should bear a larger share Percent Subsistence Population -4 LGUs with lower poverty levels should bear a larger share Fiscal Burden -1 LGUs with a lower fiscal burden for health should bear a larger share Per Capita Subsidy 2 LGUs with higher per capita government subsidy for health should bear a larger share - 79 - Annex 9 Page 1 of 8 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Project Management and Implementation Arrangements A. Organizational Structure of the DOH for the Project 1. The Department of Health (DOH) will provide overall technical and managerial direction for project implementation as well as undertake direct implementation of nationally-retained functions. The DOH Undersecretary-Chief of Staff will serve as the National Project Director, reporting to the Secretary of Health. The Office of Special Concerns (OSC) will have overall responsibility for the project, and the Assistant Secretary for Special Concerns will serve as Project Coordinator, reporting to the Project Director. Day-to-day coordination of project activities would be delegated to a Project Management Office (PMO) for the Women's Health and Safe Motherhood Project (WHSMP), which will be established in the OSC and will be headed by a full- time Project Manager. The PMO will be responsible for coordinating with four groups of DOH managers. 2. Group One consists of the units of the Office for Management Services (OMS), headed by an Undersecretary. These units will prepare all finance, budget and accounting documentation for action by the Project Director. They will prepares the communications to be sent by the Project Director to the Department of Finance (DOF) regarding releases of funds to DOH implementing units as well as local government units (LGUs) implementing the project. 3. Group Two consists of program managers for Family Planning, Women's Health, AIDS/STDs and Nutrition, whose units will generate guidelines to be followed by LGUs implementing the project and will undertake technical supervision through the regional field health offices. 4. Group Three consists of the managers for the functions of infrastructure, procurement and logistics, information, education and communication (IEC), training and management systems, and research and evaluation, whose units will generate guidelines to be followed by participating LGUs as well as undertake actual implementation activities. 5. Group Four consists of regional directors, who will provide field assistance to participating LGUs, adapt project guidelines to regional conditions, and undertake implementation of region-wide activities such as training, IEC campaigns and supplies distribution. 6. These managers will perform their functions for WHSMP using their respective staff within the regular structure of the DOH, but where the project is concerned, will be under the supervision of the Project Director. - 80 - Annex 9 Page 2 of 8 B. Functions of the Project Management Office 7. The PMO will consist of 13 contractual staff funded by the project, and will perform the management and coordination functions described below. Pre-Implementation Phase (a) Launch the project and orient national, regional and provincial staff (b) Recruit staff (c) Plan for first year of implementation (d) Become familiar with procedures of all involved donor agencies (e) Coordinate the establishment of management structures consistent with donor and Government agreements (f) Establish financial flow and reporting mechanisms (g) Monitor progress of pre-implementation activities (h) Take advance action on procurement and consultant recruitment (i) Coordinate donor mission visits Annual Project Budget Proposal (a) Formulate guidelines to estimate annual project ceiling: - determine projected annual expenditure based on project costs - provide initial indications of amounts to managers of project components - assemble an initial indicative annual project budget (b) Propose annual project budget (c) Assist Project Director in negotiating final annual project appropriation during the budget preparation and authorization phases (d) Upon arrival of project budget ceiling, prepare annual work and financial plan - Annual Work and Financial Plan (a) Assemble the inputs necessary for managers of project components to draft a plan and budget for their respective components: - set initial ceilings per component and per expense category based on supporting papers of proposed budget - determine status of obligations per component, based on inputs of OMS - 81 - Annex 9 Page 3 of 8 - identify activities/items/components that are likely to be re-planned based on implementation experience (b) Design procedures and forms to be used in the preparation of component plans and budgets (c) Draft, obtain Project Director approval and disseminate guidelines on the preparation of component plans and budgets (d) Assist managers of project components in preparing their respective plans and budgets (e) Design procedures, mechanisms and guidelines for the review and integration of component plans and budgets: - propose a committee to conduct review (for approval of Project Director) - propose criteria and guidelines for conduct of review (for the approval of the Project Director) - assist in conduct of review proceedings - document comments, recommendations and results of review proceedings - summarize the results of review for approval by Project Director - prepare and facilitate issuance of final decisions on the outcome of the review for the information of all concerned (f) Assist managers of project components in revising their respective plans and budgets in accordance with the outcome of the review (g) Coordinate with OMS in transcription of the component plans and budgets into the required forms prescribed by the Department of Budget and Management (DBM) for work and financial plan (h) Assist OMS in the preparation, submission and follow-up of the Work and Financial Plans with DBM (i) Assist OMS in the revision or provision of additional documentation as required by DBM for approval of the Work and Financial Plans and subsequent release of budget (j) Work with OMS for budget release and dissemination of copies of release documents to the managers of project components Funds for Project Activities (a) In coordination with OMS, prepare guidelines for initial funds release via one or all of the following: - use of available LGU funds to be reimbursed by WHSHP funds - use of available DOH funds to be reimbursed by WHSMP funds - use of other available Government funds by DOH or LGUs to be reimbursed by WHSMP funds - 82 - Annex 9 Page 4 of 8 (b) In coordination with OMS, process disbursement transactions: - assist LGUs and DOH units in generating proper statements of expenditures (SOEs) for project activities - collect and consolidate these SOEs - prepare application forms for withdrawal of donor funds - document application forms for withdrawal of donor funds - liaise with concerned donors on replenishment (c) In coordination with OMS, process reimbursements of disbursements: - prepare instructions to pay project expenditures of DOH and LGUs - monitor releases to project components - assist LGUs and DOH units in sustaining the flow of activities, funds and documentation Technical Assistance Activities (a) Prepare a consolidated technical assistance plan for the year: - collect all technical assistance requirements in the component plan - consolidate/package technical assistance requirements into possible contracting modules - prepare a schedule of technical assistance contracting and implementation (b) Assist managers of project components in the development of Terms of Reference and Scope of Work for required technical assistance (c) Utilize contracting approach based on donor guidelines as applied to specific requirements/circumstances (d) Assist managers of project components in undertaking the contracting for technical assistance (request for proposal, review of proposal, preparing contract documents) (e) Coordinate with all DOH units involved in contracting (Legal, OMS, Commission on Audit (COA), others as needed) (f) Assist manager of project components in monitoring contractor performance, submission of outputs and documentation of satisfactory performance (g) Coordinate with OMS in facilitating the release of payments to contractors based on authorization of component managers and Project Director (h) Monitor all technical assistance contracts and facilitate termination, amendment, extension or addition according to recommendations of the managers of project components with approval of Project Director - 83 - Annex 9 Page 5 of 8 Guidelines for LGU Implementation (a) Prepare draft Project Implementation Agreements (PIAs) and specific negotiation issues for each province (b) Prepare draft agreements for each province to negotiate with cities and municipalities involved in the project (c) Calculate total provincial package and cost-share arrangements for all provinces (d) Assist Project Director, program managers, functional managers and regional directors in identifying and preparing essential guidelines for LGU implementation of the project (e) Assist Project Director and Regional Directors in undertaking negotiations of PIAs for each province (f) Document all negotiations between DOH and provinces (g) Assist province in preparing initial project plan and budget (h) Through the regional field health offices, maintain communication with LGU regarding the status of project implementation Coordinating Central Procurement (a) Request managers of project components to prepare initiating documents for procurement (b) Review request against budgetary authorities and restrictions (c) Assist the Procurement and Logistics Service (PLS) in managing procurement: - assist in organizing technical committee to write specifications and undertake review of offers - participate in bid administration (issuing bid documents, conduct of bidding, awards) - monitor the review, evaluation and award - keep managers of project components informed on status of procurement (d) Assist managers of project components in preparing plan for utilizing procured items: - preparing the distribution list for approval by Project Director; - arranging the distribution; and - documenting the receipt and use of items. - 84 - Annex 9 Page 6 of 8 (e) Ensure that procurement documents are reviewed and approved by concerned agencies (managers of project components, PLS, donors, other authorized units or offices) (f) Facilitate resolution of procurement issues (complaints of losini bidders, extension of delivery dates, non-acceptance of deliveries, non-release of contract documents form legal or COA, obtaining approval of various units) by monitoring, coordination, reporting to Project Director, and recommending action by concerned officials Monitoring of Project Implementation (a) Prepare quarterly physical accomplishment reports: - collect information on day-to-day implementation from all implementing units; - conduct quarterly consultative meetings or implementation - summarize reports and recommendations for Project Director's information and action (b) Prepare inputs for preparation of monthly and quarterly financial reports of OMS: - collect monthly obligations and disbursement by all project implementing units - consolidate reports according to project formats (c) Prepare and submit quarterly and annual reports required by Government oversight agencies and donors (d) Serve as secretariat of donor's review missions (e) Respond to queries and complaints relative to project implementation (delayed releases, disputes in implementation, confusion about guidelines) (f) Follow-up action by concerned officials necessary for project implementation (g) Report to Project Director all issues, developments and concerns regarding project implementation requiring decision and action (h) Undertake the implementation of any project component or activity which the Project Director decides should be managed directly by the PMO C. LGU Organization Each Provincial Government will establish their respective WHSMP implementation organization. This will typically feature the provincial health officer serving as the WHSMP implementation officer, reporting to the Governor and supported by other provincial officers as necessary. - 85 - Annex 9 Page 7 of 8 D. Summary of Key Implementation Roles 1. Project Director - Decides on/approves project implementation strategies, plans, budgets and activities 2. Project Coordinator - Supervises PMO 3. PMO - Performs all day-to-day management and coordination functions necessary to support project implementation 4. OMS - Performs all budget, accounting and financial management functions necessary for project implementation, in accordance with DOF 5. Designated Managers of Project Components - Prepare all technical guidelines on the implementation of the component by LGUs - Implement project activities as assigned 6. Regional Directors - Assist LGUs in organizing project implementation in the locality - Interprets project guidelines at LGU request - Provides technical and administrative assistance to LGU in project implementation - Communicates LGU concerns on project implementation to Project Director/Project Coordinator - Provides ceiling for WHSMP project in its annual appropriation - Requests releases of WHSMP funds based on DOH work and financial plans - Provides WHSMP funds to all implementing units based on work plans - Disburses WHSMP funds based on DOH authorization - Prepares financial reports for DOH transmittal to donors - Receives releases of project proceeds - 86 - Annex 9 Page 8 of 8 1. Governor/Mayor - Signs PIA on WHSMP participation - Establishes WHSMP implementing organization - Designates WHSMP implementing officer - Approves annual work and financial plan on WHSMP implementation - Delegates project implementation authorities to appropriate officials 2. WHSMP Implementing Officer (Generally Provincial/City/Municipal Health Officer - Directs implementation of WHSMP activities in the LGU - Prepares plans and budgets - Approves implementation activities Implementation Schedule 1995 1996 1997 1998 1999 ID Task Name tr4 tr1 tr2 tr3 tr :K 4tr 1tr 2Qtr 30tt 4Otr 1tr 2Otr I tr 3 r 2 MOBILIZATION AND PROJECT LAUNCH 9 COMPONENT 1: SERVICE DELIVERY 10 Sub-component 1: Family Planning 11 Programming and Budgeting 19 Civil Works 20 RHUs 21 Recruitment of Consultants 32 Document Preparation 35 Prequalificatlon 38 Bid Tendering 45 Year 1 Inplemenation as 74 Year 2 Implementation 103 Year 3 Implementation 133 BHS 134 Recruitment of Consultants 146 Document Preparation 148 Prequalification 151 Bid Tendering 158 Year 1 Implementation 187 Year 2 Implementation 216 Year 3 Implementation 246 Procurement 247 Equipment (ICB) 276 Furniture (LCB) Page 1 of 10 Philippines - Women's Health and Safe Motherhood Project Implementation Schedule 1996 1996 1997 1998 1999 ID Task Name Qtr 4 Otr 1LOtr2 Qtr3 Qtr It tr 2 Qtr 3 4lOtr 11 tr 21Qtr3 Qtr4 Otr 11Qtr 2r 3Qtr 4 t 1tr2 Otr3 Qtr 4 309 Supplies (WB, ICB) 366 Minilap Kits and Drugs (KfW, LCB) 403 Staff Training 414 Sub-cornponent II: Maternal Care 411 Progranwning and Budgeting 416 Needs AssessmentiPlanningfTargetting 430 Prograrning 437 Foreign TA 438 Procurement 451 Contiact Extension 458 Local TA 45s Procurement 471 Contract Extension 482 Pilot Programs 483 Pilot Partographs 488 Pilot DOKs 493 Pilot Food Fortification 493 Pilot Walking Blood Bank 503 Social Marketing 509 Micronutirients 614 Civil Works S1 Provincial Hospitals B16 Consultant Recruitment a28 Document Preparation Page 21 of 10 - аэ • Аппех 10 ь !� w �ь ь м � а � 01 01 �ь ь .............................. .......................... ......................._....... ....................... ....................... ................................. .............. ............... . ... ............. ь А b � � b j b � у . .. . ... .................................. ............................. ........ ....._......................................... ...................................... .................. ........................... � � b � � � � � � � у � � � ь � а� ................................................. ........ .. . _ . ........................... ........................ ............ ................. ... . . . .. . .............................. . � � /] г'C,�j iд b . . b О ' b � . - •� iл � � � � у � � ............................................................................................................................................... .. .........._....................................... ................. а � � ь Л � С'. � 'J Т 1 6� С с'а с�. 2 � � � .. и в■� ♦ F � м r� �уΡ� � F � м м v � � � � � � � � � � � � М и � � � � � � � �УΡ И А Н � М д � tl tl 1� � 1а0 У � � � n А А � � • q �в • У � А Philippines Women's Health and Safe Motherhood Project Implementation Schedule 1 1995 1 1996 1 1997 1992 1 1999 ID Task Name Qtr 4lQtr i Joy 2ptr Nqtr 41Qtr 1 10tr 21Qtr 310tr 4[Qtr I lQtr 2JQtr 3ptr 4 "t, 16tr 210tr 310tr 4 944 BHSz 946 Consultant Recruitment 96T Document Preparation 960 Prequaliftcation 963 Bid Tendering 970 Year I Implementation 999 Year 2 Impletnentation 1028 Year 3 Irnplementation 1057 Yew 4 knplementation 1086 Yew 6 Impliamentation 1116 Lying4n COnics 1117 Consultant Recruitment 1129 Document Preparation 1132 Prequalificsfion 1135 Bid Tendering 1142 Year I ImplemmAntion 1171 Yew 2 Implementation 1200 Yew 3 Implenvtntation 1229 Yew 4 Implementation 1258 Year 5 Implementation 1288 Maternity Waking Homes 1289 Consullant Recruitment 1301 Document Preparation 1304 Prequalification Page 4 of 10 Philippines - Women's Health and Safe Motherhood Project Implementation Schedule 1995 1996 1997 1998 1999 ID Task Nane 6tr4 tr 1 Qtr 2 Qtr3 tr 4 Otr 1lQtr2 Qtr3 Otr4 Otr i tr 2JQtr 3 tr4 Qtr 1Qtt 2 Qtr 31Qtr 4 tr 1Qtr2 tr 3tr4 1307 Bid Tendering 1314 Year 1 trnplementation 1343 Year 2 rnplementation 1372 Year 3 Inplementation 1401 Year 4 Irplementation 1430 Year 5 Irnplementation 1460 Procurement 1461 Equipment (CB) 1490 Furniture (LCB) 1619 Transportation (ICB) 1648 Micronutrients (ICB) 1696 Medical OB, Midwifery and TBA Kits (KW) 1637 Emergency OB Kits (ICB) 1684 Disposable OB Kits (ICB) 1731 HBMR Forms and Protocols 1760 Quality Control 1768 Sub-Component III: RTis/STDs 1769 Programming and Budgeting 1768 Foreign TA 1788 Procurement 1739 Drugs (KfW, ICB) 1823 Office Equipment (LCB) 1842 Reagents and Supplies 1377 Annual Budget Preparation Page 5 of 10 Philippines - Women's Health and Safe Motherhood Project Implementation Schedule 1996 195 1997 199 1999 ID Task Name Qtr 4 tr I tr 210tr3 tr 44tr I t 2ttrr 2t Ortr I tr3 r4t 1 Qrr Qtrtt 3 Otr34 1171 Year 2 1884 Year 3 1890 Year 4 ; 1h Yaw 4 189 Year 5 1902 Sub-Component IV: Cervical Cancer 1903 Progranoning and Budgeting 1318 Local TA 1937 Procurement (Cryotherapy Machines) 197 Procurement (Supples) 1988 Annual Budget Preparation 1987 Year 2 1998 Year 3 2006 Year 4 2014 Year 5 2023 COMPONENT I: INSTITUTIONAL DEVELOPMENT 2024 Sub-component 1: Training 2021 Prograrining and Budgeting 2033 Management Training 206 Service Delivery Training 2078 Equipment Procurement 2097 Library Iprovement 2136 Training (AIDAB) 2137 Institutional Strengthening 2133 Training Management System Page 6 of 10 Pllilppines - wonen s tean anu 3ae ivionei uou ri jut Implementation Schedule 1995 1996 1997 1998 1999 ID Task Nane _tr4 trI 1Otr2 tr3 t4 1 ttrI t2 tr 3tr 40tr I tr 2IQtr3 Qtr4 Qtr 1 tr 2IQtr 3]Qtr 4 tri tr 2 tr3 tr4 2151 Competency Based Training 2160 integrated Modules for Health Care Workers 2168 Training of Trainers (CenterlReglonlProvince) 2169 Center and Regional Trainers Contracted 2174 Provincial Trainers Contracted 2173 Basic In-Service Training 2180 First Referral Level Doctor Training 2137 Rural Midwives Training 2194 Rural Health Doctors Training 2201 Rural Public Health Nurses Training 2203 Traditional Birth Attendants Training 2216 Hospital Nurses Training 2222 Lab Technicians Training 2229 Cytotechnicians Training 2236 Pathologists Training 2243 HEPOs Training 2250 Gynecologists Training 2257 Distance Learning 225 Orientation for DOH Staff 2262 Key Personnel Training 2267 Existing Experience in Philippines 2270 Develop Operational Plan and Costs 2274 Develop Learning Modules 2282 Train Provincial Supervisors Page 7 of 10 Philippines - Women's Health and Safe Motherhood Project Implementation Schedule 1995 1998 1397 1993 1999 10 Task Name QIr 4tr 1Otr 2 tr3 tr 4 tr 1Otr 2 Otr 3IQ Otr I Qtr 2IOtr 3 Qtr 4 Qtr 1Otr 2JOtr 31Qtr4 tr I tr 2Otr 3Qtr 4 2236 Pilot Distance Learning (3 Provinces) 2293 Distance Learning Expansion 2299 Develop BHW Radio Education Program 2312 BMW Radio Program Expansion (27 Provinces) 2317 Distance Learning for First Referral Level Doctors 2326 Pilot Distance Learning (3 Provinces) 2332 Distance Learning Expansion 2338 Project Management Training 2339 Develop Outcome Evaluation IF 2340 Bsellne Survey 2348 Evaluation Survey 2364 Management Structure for Project knplementation 2362 Sub-component H: IEC 2363 Programming and Budgeting 2371 Qualtative and Quantitative Research 2372 KAP of Specific Target Audiences 2377 Conwmunication Planning 2381 Materials Development and Pre-testing 2332 Print 2386 RadiatTV 2390 Training Videos for Negotiation Skis 2393 Launch of Interventions 2396 Annual Thematic Campaign 2398 First Campaign Page 8 of 10 Implementation Schedule 1995 1996 1997 1998 1999 ID Task Narne Qtr4 Qtr 1 Qtr2 Qtr3 Qtr4 Qtr 1lQtr2 Qtr3 Qtr4 Otr 11Otr 2jQtr 3 tr 4jQtr 1[Qtr 2jQtr 3jQtr 4 tr1 tr2 tr3 Q 4 2399 Second Campaign 2402 Third Campaign 2405 Fourth Campaign 2408 Topic Specific Campaigns 2409 Round 1 2410 Adolescents 2415 Women In Union 2420 Older Women 36+ 2425 Special Audiences (Victims of Domestic Violence) 2430 Round 2 2431 Adolescents 2436 Women In Union 2441 Older Women 35+ 2446 Special Audiences (Victims of Domeatic Violence) 2451 Round 3 2452 Adolescents 2457 Women in Union 2462 Older Women 35+ 2467 Special Audiences (Victims of Domestic Violence) 2472 knpact Evaluation 2481 Sub-Cornponent III: Logistics 2482 Programming and Budgeting 2490 Procurement (Equipment) 2491 ICS Procurement Process Page 9 of 10 Philippines - Women's Health and Safe Motherhood Project Implementation Schedule 1991 1996 1997 1998 1999 ID Task Name Qtr4 ptr tr2 tr 3 tr4 O tr2 tr3 tr 4 k tr tr3 O tr tr 2tr3Qtr4 ht 1r 2 2617 Procurement (Delivery Vans) 2618 ICB Procurement Process 2637 Civil Works 2638 Warehouse Renovation (Year 1) 2668 Warehouse Renovation (Year 2) 2638 Warehouse Renovation (Year 3) 2628 Warehouse Renovation (Year 4) 2663 Sub-Component IV: Project Management 2659 Programmoing and Budgeting 2667 Procurement (Equipment) 2668 ICB Procurement Process 2687 Local TA (KW) 2709 COMPONENT III: COMMUNITY PARTNERSHIP 2710 Programming and Budgeting 2718 First Year Projects 2727 Second Year Projects 2736 Third Year Projects 2745 Fourth Year Projects 2764 Fifth Year Projects -- 2763 COMPONENT IV: POLICY & RESEARCH 2764 Planning and Programming 2772 Research Grants Page 10 of 10 - 97 - Annex 11 Page 1 of 10 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Project Monitoring Indicators 1. The monitoring indicators for the Women's Health and Safe Motherhood Project intend to capture the progress and impact of three different but related aspects of: (a) World Bank financing of specific inputs and activities as part of an integral project; (b) multi-source financing of the whole project within the Women's Health and Safe Motherhood Program of the Department of Health; and (c) broader support of the Government's program. 2. The indicators will be defined, measured and reported as part of a process that is linked with the day-to-day details of Government's management and execution of the Bank-financed elements, the whole project and the overall program. They would provide signals of underlying processes, factors and determinants of project performance and impact which can be monitored during project implementation. 3. The indicators will focus on tracking and measuring the efficiency of implementing the project as designed. Persistent failures to meet targeted norms may lead to a re-design of the project. In most cases, however, shortcomings observed through the indicators would be correlated with failures to execute a sound design. 4. Key indicators selected to monitor and evaluate overall project implementation progress and results are described in Part A below. Part B provides a detailed list of input, process, outcome and impact variables against which each of the project components would be assessed. A. Key Indicators 1. Loan Disbursement Rate (semi-annual; Bank financing-specific), defined as the cumulative amount of proj ict expenditures incurred by the Government and withdrawn from Loan proceeds as a percentage of the total Loan amount. Actual disbursements would be measured against the projected disbursement schedule (Annex 14). 2. Physical Accomplishment Rates (quarterly; project-wide scope), defined as the cumulative quantity of physical accomplishments attained by the project expressed as a percentage of total physical targets. This would include facilities constructed or rehabilitated, and equipment, drugs and medical supplies procured. Actual accomplishments would be measured against the agreed upon physical implementation schedule. 3. Project Milestone Indicators (annual; project-wide scope). Actual accomplishment of project milestones would be measured against the agreed upon project implementation schedule. Milestones would include signing of the Project Implementation Agreements with Local Government Units, employment of - 98 - Annex 11 Page 2 of 10 consultants and delivery of key outputs, conduct of training of health workers and other staff, and establishment of community partnerships. 4. Service Availability Indicators (first, third and fifth years of project; program-wide scope), defined as the proportion of total public health facilities capable of delivering women's health services, where such services are regarded as available in a first-referral hospital, rural health unit or barangay health station when such facility has all the required facilities, equipment, trained staff and supplies to deliver maternal care, family planning, reproductive tract infection/sexually transmitted disease, or cervical cancer services. Service availability would be expressed in terms of accumulated annual percentages of public facilities with available women's health services, and would be compared to a baseline determined at the start of the project. 5. Access to Service Indicators (first, third and fifth years of project; program-wide scope), defined as the proportion of the population residing within a set distance in terms of normal travel time of a first- referral hospital, rural health unit or barangay health station capable of providing women's health services (as defined in para. 4 above). Service access would be expressed as a proportion of the population with access to service, and would be compared to a baseline determined at the start of the project. 6. Risk Reduction Indicators (first, third and fifth years of project; program-wide scope), including: (a) the proportion of women contracting puerperal infections (i.e., occurring during childbirth or immediately thereafter) among the total number of diagnosed pregnancies. The end-of-project target would be a reduction by 25%; and (b) the proportion of low birth weight babies among newborns (as an indicator of pregnancy-related risk to infants as well as of maternal health and nutritional status). The end-of-project target would be a reduction by 10%. 7. Indicators for Geographic Disaggregates: Percentage of target provinces meeting the norms for physical accomplishment, service availability and access to service (as defined in paras. 2, 4 and 5 above). - 99 - Annex 11 Page 3 of 10 B. Detailed Indicators by Project Component Component Indicator aternal Care Input Number of facilities upgraded and equipped: - hospital obstetric wings - rural health units - barangay health stations Number of facilities constructed and equipped: - lying-in clinics - maternity waiting homes Number of medical centers and teaching hospitals equipped Percent of hospitals capable of performing cesarean sections Number of kits procured and delivered: - midwifery kits - traditional birth attendant kits - emergency obstetric kits - safe home delivery kits Quantities of micronutrient supplements procured and delivered: - iron/folate - Vitamin A - iodine Quantities of tetanus toxoid vaccines procured and delivered Number of health care providers trained in maternal care and staff-months of training by type of provider and training Proportion of health care providers able to provide emergency obstetric services by type of provider Number of staff and staff-months of technical assistance provided by specialization Number of home-based maternal records printed and distributed Process Prenatal Care Proportion of pregnant women who received: - 2 doses of tetanus toxoid immunization - any prenatal care from trained health care provider by type of provider - at least 3 prenatal care visits - prenatal care before 20 weeks and/or after 38 weeks - 100 - Annex 11 Page 4 of 10 Component 'ndicator Process Prenatal Care (cont.) Average months pregnant at first prenatal visit Mean/median number of antenatal visits Percent of births where client received full complement of prenatal care services Mean waiting time for services at health facility Percent of women with prenatal complications (e.g., bleeding, fever, convulsions) Delivery and Post-natal Care Percent of: - births attended by trained health care provider by type of provider - women with complications during labor and delivery by type of complication - women who were referred for management of complications - women with post-partum complications by type of complication Rate of Cesarian sections Place of delivery by age, parity, educational level and source of prenatal care Proportion of women who received postnatal care from trained health care provider by type of provider Maternal Nutrition Proportion of pregnant and lactating women who received/completed micronutrient supplementation regime: - iron/folate - Vitamin A - iodine Outcome Proportion of women with access to prenatal care Percent of women who were referred and received effective management according to protocols/standards for: - pre-natal complications - complications during labor and delivery (including appropriate indications for forceps, vacuum extraction or cesarean sections) - post-partum complications Incidence of: - tetanus (maternal and newborn) - low birth weight - prematurity - 101 - Annex 11 Page 5 of 10 Component Indicator Outcome Maternal Care (cont.) Percent of postpartum infections acquired in a hospital or health facility Percent of women satisfied with treatment received Proportion of pregnant and lactating women who are: - moderately or severely anemic - Vitamin A deficient - iodine deficient Impact Decline in: - maternal mortality ratio - maternal mortality rate - lifetime risk of death - infant mortality rate - perinatal mortality rate Family Planning Input Number of health facilities upgraded and equipped: - rural health units - barangay health stations Number of minilaparatomy kits procured and delivered Quantities of drugs and medical supplies procured and delivered Number of health care providers trained in family planning and staff-months of training by type of provider and training Proportion of health providers able to provide family planning services by type of provider Process Number of women who receive contraceptive counselling Percentage of women who receive contraceptive counselling after a pregnancy Number of voluntary surgical contraception (VSC) procedures performed Outcome Percentage of women with access to family planning services Unmet need for contraception Number of unintended pregnancies Percent of women satisfied with services received - 102 - Annex 11 Page 6 of 10 Component Indicator Impact Family Planning (cont.) Increase in contraceptive prevalence rate for modern methods Decline in total fertility rate RTIs/STDs Input RTI/STD algorithms and syndromic approach curriculum developed and field tested Number of health care providers trained in RTI/STD management and staff-months of training by type of provider and training Proportion of health care providers able to diagnose, treat or refer for treatment RTIs/STDs by type of provider Number of staff and staff-months of technical assistance provided Quantities of drugs,reagents and medical supplies procured and delivered Process Proportion of: - women diagnosed as having an RTI/STD - women diagnosed with an STD who complete the prescribed treatment - partners of women diagnosed with an STD who report for testing - partners of women diagnosed with an STD who complete the prescribed treatment Number of women who received RTI/STD counselling when presenting for pregnancy-related or family planning services Outcome Proportion of women with access to RTI/STD management services Number of untreated RTIs/STDs Number of RTI/STD complications Number of iatrogenically-induced RTIs/STDs Percent of women satisfied with services received Impact Decline in: - incidence/prevalence of RTIs - proportion of total infertility rates attributable to RTIs - 103 - Annex 11 Page 7 of 10 Component Indicator Cervical Cancer Input Number of cryotherapy machines procured and delivered Quantities of drugs, reagents and medical supplies procured and delivered Number of health care providers trained in cervical cancer management by type of provider and training Proportion of health care providers able to provide Pap smears, cervical biopsies, hysterectomy and cryotherapy by type of provider Number and staff-months of technical assistance provided Process Percentage of women over 35 years who have had at least one Pap smear Number of cases detected Number of cervical biopsies performed for suspicious lesions Number of cryotherapy procedures performed for early invasive cancer Number of simple and radical hysterectomies performed Outcome Proportion of women with access to cervical cancer management services Percent of women who received effective cancer treatment according to protocols/standards Impact Decline in: - incidence of invasive cancer - deaths due to cervical cancer IEC Input Formative research (focus groups/surveys) Communications planning Materials development/production Process Duration and frequency of radio and television plugs by message area Frequency of print ads by message area - 104 - Annex 11 Page 8 of 10 Component Indicator Process Information, Education and Communication (cont.) Number of print materials produced and distributed by message area Number of other materials (training/teaching materials and videos for health care workers) produced and distributed Number of special events conducted by theme/target audience Outcome Increase in knowledge about women's health conditions and practices contributing to improved health by target audience and message area Changes in attitudes and health behavior by target audience and message area Training Input Number of staff and staff-months of technical assistance provided Needs assessment and training plans Training curricula, methodologies and materials Teaching models and equipment Process Number and duration of workshops/courses by type of training Number of trainees Quality of training (to be measured through observational studies of trainers; review of training materials; simulated training sessions for trainers; on-the-job trainer evaluation; pre- and post tests for each training course, including end-of- course competency and on-the-job competency assessment of knowledge and skills; trainee and supervisor interviews) Outcome on-the-job competency levels in the following skills (to be measured through observation of on-the-job practices; knowledge tests; interviews with trainees, supervisors, clients and communities; simulated clients): - clinical - diagnostic - counselling - interpersonal communication - history-taking - referral practices - 105 - Annex 11 Page 9 of 10 Component Indicator Outcome Trainina (cont.) Acceptability of training (to be measured through observational studies; trainee interviews; evaluation questionnaires) - trainee attendance and completion rates - trainee satisfaction and interest - employer (DOH and LCU) acceptability - trainer acceptability Logistics Input Number of warehouses upgraded/constructed and equipped Number of delivery vans procured and delivered Number of computers and related hardware procured Logistics information system software procured Number of logistics staff trained and staff-months by type of training Number of staff and staff-months of technical assistance provided by specialization Process Implementation of systems (structures, personnel, procedures) for: - procurement, including commodity forecasting, commodity procurement scheduling, requisition, bidding and ordering, and random sampling for drugs - distribution from the center to provinces/cities to municipalities/barangays - storage and materials handling, including warehousing and inventory - logistics information system, including stock pricing, ordering status, inventory control, demand analysis, supplier performance and distribution verification Number and duration of workshops/courses by type of training, number of trainees, and quality of training Outcome Timeliness and accuracy of procurement of commodities (drugs, reagents and other medical supplies) Timeliness and accuracy of distribution of commodities Adequacy of handling and storage of commodities Timeliness and accuracy of logistics information On-the-job competency levels and acceptability of training of logistics staff - 106 - Annex 11 Page 10 of 10 Component Indicator Community Partnerships Input Training, including gender training, project planning and management, community organizing, monitoring and evaluation, and IEC on women's health and family planning Provincial teams to assist in community organization Grants for community projects Process Number of partnerships established by type of partnership Number of community projects by type of project Outcome Basic health indicators of participating communities Research Input Technical assistance Process List of studies finalized Terms of reference agreed upon Technical assistance contracts signed Outcome Completed studies Policy and program recommendations WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Expenditure Accounts by Component - Basa Cos (US$ '000) Serv Dv OHer Wamens Halth institutional Deveopment PolcyI Maternal Family Cervical Projct Conmnunity Operations Cam Planning RTis/STDs Cancer Training IEC Log~stics Management PartnershIps Research Total L inveulmsnt Costs A. Civi Wors 11,747.4 1,108.6 - - - - 2,612.0 - - - 15,468.0 8. Fumiture - 124.5 - - - - - - - - 124.5 C. Equpmet 8,091.7 560.3 7.0 69.8 568.8 14.0 660.9 80.0 - - 10.052.5 D. Vehics - - - - - - 1,944.0 60.0 - - 2,004.0 E. Iniial Medcal Supples a 31,791.6 - - - - - - - - - 31,791.6 F. Meclalb - - - - - 4,142.9 - - - - 4,142.9 G. Consultant Servces Foreign 293.0 - 45.0 - 1,672.7 50.0 645.0 117.6 2,000.0 - 4,823.3 LocaJ 3,162.0 86.5 - 15.0 1,499.7 1,849.7 662.0 - - - 7,274.9 Subtotal Constant Servces 3,455.0 86.5 45.0 15.0 3,172.3 1,899.7 1,307.0 117.6 2,000.0 - 12,098.2 H. Training oversesTraining - - - - 196.0 - 144.2 - - - 340.2 Local Training 1,981.0 ----- 8,885.0 77.1 275.4 - -- 11,218.5 Subtotal Trairnig 1,981.0 - - - 9,081.0 77.1 419.6 - - - 11,558.7 1. Grants - - - - - - - - 9,800.0 - 9,800.0 J Studies - - - - - - - - - 957.2 957.2 Total~nvesm.ntCost 57,066.7 1,879.8 52.0 84.8 12,822.1 6,133.7 6,943.5 257.6 11,800.0 957.2 97,997.5 R. Recurrent Co~s A. Drugs - 2,384.8 8,469.0 1,799.6 - - - - - - 12,653.4 B. Mdica SuppIes/Merals - 1,647.8 302.6 24.7 - - - - - - 1,975.2 C. Sa ooria - - - - 996.2 - 868.3 364.3 - - 2,228.8 D. Maintenance Faclliles Maitnace 584.3 26.7 - - - - - - - - 611.0 vehcle Ma~ienance - --------- 1,911.61-6- - 1,911.6 Subtotal Maintenance 584.3 26.7 - - - - 1,911.6 - - - 2,522.6 E. Other Operang Cost 257.5 - - 378.2 1,541.1 218.6 - 625.0 - - 3,020.4 Total Recurrent Costs 841.8 4,059.4 8,771.6 2,202.5 2,537.3 218.6 2,779.9 989.3- - 22,400.4 To~a BASEUNE COSTS 57,908.5 5,939.2 8,823.e 2,287.3 15,359.4 6,352.3 9,723.4 1,246.9 11,800.0 957.2 120,397.9 PhysicalConungencies 2,773.8 267.3 334.4 114.4 107.5 317.6 486.2 59.9 472.0 47.9 4,980.9 m Prce Contngencies 5,631.7 754.3 624.0 275.8 526.4 938.3 1,353.1 62.2 728.0 171.4 11,065.2 TotalPROJECTCOSTS 66,314.0 6,960.7 9,782.1 2,677.4 15,993.4 7,608.2 11,562.6 1,369.0 13,000.0 1,176.5 136,443.9 ./ ADB xpndiure account iclucing obetrck Idt (drugs) wad fncronumns. bl lrc-jdss broernet time for telrwision and radio IEC spats, and puhartnn of IEC mteials. PHILIPPINES WOMENS HEALTH AND SAFE MOTHERHOOD PROJECT Expmnditue Accouns by Components - Totals including Coningencies (Us$ 000) Ofm wmm's HeulUh ndt*iuonal Development Poicy/ Matrnal Fmly Cervical Proct Connuinity Operations Care Planning RTIsIsTDs Cancer Training IEC Logistics Managm~nt Patnerships Research Total L keene t Cots A. CtA Wod 13.545.5 1,294.1 - - - - 3,044.2 - - 17,883.8 B. Fumure - 146.5 - - - - - - - - 148.5 C. EqUpment 8,872.1 618.3 7.5 77.1 573.7 16.8 746.9 88.0 - - 11,000.4 D. Vehice - - - - - - 2,132.6 66.0 - - 2,198.6 E. IM Medcal Supp la 36,857.7 - - - . - - - - - 36,657.7 F. M & - - - - - 4,961.9 - - - - 4,961.9 G. Con@ultant service Freign 337.8 - 47.9 - 1,672.7 59.9 717.9 126.7 2,203.4 - 5,166.3 Local 3,648.0 102.6 - 16.3 1,576.9 2,215.4 809.5 - - - 8,366.6 Subotal Consultat Servics 3,983.8 102.6 47.9 16.3 3,249.5 2,275.3 1,527.3 126.7 2,203.4 - 13,532.9 H. Trmig~ OvmTranng - - - - 196.0 - 155.0 - - - 351.0 Lod Trainng 2,284.2 ----- 9,357.3 92.4 339.1 - -- 12,073.0 Subotal Training 2,284.2 - - - 9,553.3 92.4 494.1 - - - 12,424.0 1 Grats - - - - - - - - 10,796.6 - 10,796.6 J. Stu..m - - - - - - - 1,176.5 1,176.5 TotalnvestmtCots 65,343.4 2,161.4 55.4 93.4 13,376.6 7,346.4 7,945.2 280.7 13,000.0 1,176.5 110,779.0 IL Recur~nt Cots A. Dnjp - 2,637.5 9,336.2 2.064.3 - - - - - - 14,038.0 B. Mecal SuppIes/Matedals - 2,125.9 390.4 31.9 - - - - - - 2,548.2 c. sad HNora - - - - 1,064.2 - 1,120.8 400.7 - - 2,585.6 D. Mainimnce Fa~m Mawtenance 673.7 35.9 - - - - - - - - 709.6 Vehicle Mnteance - --- --- - 2,496.7 -- - 2,496.7 SubtotalMa~ntenace 673.7 35.9 - - - - 2,496.7 - - - 3,206.4 E. Other Operaing Cos 296.9 - - 487.9 1,552.6 261.8 - 687.5 - - 3,286.7 TotalRcurrnt Cots 970.6 4,799.3 9,726.7 2,584.1 2,616.8 261.8 3,617.5 1,088.2 - - 25,664.9 cm Tota PROJECT COSTS 66,314.0 6,960.7 9,782.1 2,677.4 15,993.4 7,608.2 11,562.6 1,369.0 13,000.0 1,176.5 136,443.9 0 m ADB opmndu~ account ic1udg mi s (drugs) and crna . % Irc'ide brandat time for t~eln and rdo EC spot , and pubicaon of IEC materialh. PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Project Components by Year -- Base Costs (US$ '000) 1995 1996 1997 1998 1999 Total A. Service Delivery 1 Maternal Care 6,065.9 11,950.4 16,0720 15,663,7 8,156.5 57,908 5 2. Other Women's Health Family Planning 200.8 1,544.5 2,118.4 1,2587 8168 5,939.2 RTIs/STDs 52.0 1,754.3 2,631.5 2,631.5 1,754.3 8,823.6 Cervical Cancer 15-0 510.3 660.7 660 7 440.5 2,287.3 Subtotal Other Women's Health 267.8 3,8091 5,410.7 4,550.9 3,011.6 17,050.1 Subtotal Service Delivery 6,333.8 15,759.5 21,482.6 20,214.6 11,168.1 74,958.6 B. Institutional Development 1. Training 1,749.2 3,097.0 3,805.9 3,507.4 3,199.9 15,359.4 2. IEC 297.8 1,849.6 1,997.0 2,013.2 194.6 6,352.3 3. Logistics 1,023.2 4,341.U 2,027.1 1,388.3 943.9 9,723.4 4. Project Management 384.9 256.7 209.6 197.9 197.9 1,246.9 Subtotal Institutional Development 3,455.1 9,544.3 8,039.6 7,106.7 4,536.3 32,682.1 C. Community Partnerships 2,360.0 2,360.0 2,360.0 2,360.0 2,360.0 11,800.0 D. Policy/Operations Research 95.7 191.4 287.2 287.2 95.7 957.2 Total BASELINE COSTS 12,244.6 27,855.3 32,169.4 29,968.5 18,160.1 120,397.9 Physical Contingencies 506.6 1,152.4 1,330.8 1,239.8 751.3 4,980.9 Price Contingencies 809.9 2,216.1 2,999.6 3,083.5 1,956.1 11,065.2 Total PROJECT COSTS 13,561.1 31,223.8 36,499.8 34,291.7 20,867.5 136,443.9 F- 0 N'.) PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Project Components by Year - Costs Including Contingencies (US$ '000) 1995 1996 1997 1998 1999 Total A. Service Delivery 1. Maternal Care 6,931.0 13,650.2 18,385.8 17,958.9 9,388.1 66,314.0 2. Other Women's Health Family Planning 216.4 1,734.2 2,479.0 1,509.5 1,021.7 6,960.7 RTIs/STDs 55.4 1,907.2 2,897.9 2,936.7 1,984.8 9,782.1 Cervical Cancer 16.3 565.6 760.3 789.1 546.2 2,677.4 Subtotal Other Women's Health 288.1 4,206.9 6,137.2 5,235.3 3,552.7 19,420.2 Subtotal Service Delivery 7,219.1 17,857.2 24,523.0 23,194.2 12,940.8 85,734.2 B. Institutional Development 1. Training 1,757.3 3,177.7 3,943.7 3,698.5 3,416.2 15,993.4 2. IEC 356.7 2,215.3 2,391.8 2,411.2 233.1 7,608.2 3. Logistics 1,102.2 4,872.8 2,461.0 1,798.6 1,328.1 11,562.6 4. Project Management 422.3 281.0 230.3 217.6 217.6 1,369.0 Subtotal Institutional Development 3,638.4 10,546.9 9,026.8 8,125.9 5.195.1 36,533.2 0 C. Community Partnerships 2,600.0 2,600.0 2,600.0 2,600.0 2,600.0 13,000.0 D. PolicylOperutions Research 103.6 219.8 350.0 371.6 131.5 1,176.5 Total PROJECT COSTS 13,561.1 31,223.8 36,499.8 34,291.7 20,867.5 136,443.9 O PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Expenditure Accounts by Years - Base Costs (US$ '000) Foreign Exchange 1995 1996 1997 1998 1999 Total % Amount 1. Investment Costs A. Civil Works 1,780.6 3,895.9 4,900.5 3,716.2 1,174.7 15,468.0 50 7,744.5 B. Furniture 12.4 49.8 62.2 0.0 0.0 124.5 20 24.9 C. Equipment 1,885.1 2,636.2 2,934.5 2,170.5 426.3 10,052.5 87 8,695.4 D. Vehicles 60.0 1,944.0 0.0 0.0 0.0 2,004.0 87 1,749.6 E. Initial Medical Supplies la 2,637.2 5,992.5 8,560.6 8,777.2 5,824.2 31,791.6 79 25,157.5 F. Media lb 31.4 1,174.3 1,350.0 1,555.7 31.4 4,142.9 20 828.6 G. Consultant Services Foreign 1,247.4 1,285.2 1,143.9 611.2 535.6 4,823.3 90 4,336.0 Local 1,238.3 1,960.9 1,697.9 1,448.3 929.4 7,274.9 10 727.5 Subtotal Consultant Services 2,485.7 3,246.1 2,841.8 2,059.5 1,465.0 12,098.2 42 5,063.5 H. Training Overseas Training 247.8 54.8 13.1 13.1 11.4 340.2 90 306.2 Local Training 475.5 2,192.9 3,004.8 3,063.3 2,482.0 11,218.5 8 905.1 Subtotal Training 723.3 2,247.7 3,017.9 3,076.4 2,493.4 11,558.7 11 1,211.3 1. Grants 1,960.0 1,960.0 1,960.0 1,960.0 1,960.0 9,800.0 20 1,960.0 J. Studies 95.7 191.4 287.2 287.2 95.7 957.2 20 191.4 Total Investment Costs 11,671.5 23,337.8 25,914.7 23,602.7 13,470.7 97,997.5 54 52,626.6 II. Recurrent Costs A. Drugs 0.0 2,530.7 3,796.0 3,796.0 2,530.7 12,653.4 95 12,009.2 B. Medical Supplies/Materials 0.0 395.0 592.6 592.6 395.0 1,975.2 0 0.0 C. Salanes/Honoraria 107.9 522.8 537.6 537.6 522.8 2,228.8 0 0.0 D. Maintenance Facilities Maintenance 58.4 117.9 180.4 185.6 68.7 611.0 0 0.0 Vehicle Maintenance 0.0 356.4 453.6 550.8 550.8 1,911.6 0 0.0 Subtotal Maintenance 58.4 474.3 634.0 736.4 619.5 2,522.6 0 0.0 E. Other Operating Cost 406.8 594.7 694.5 703.1 621.3 3,020.4 0 0.0 Total Recurrent Costs 573.1 4,517.5 6,254.7 6,365.7 4,689.4 22,400.4 54 12,009.2 0 > Total BASELINE COSTS 12,244.6 27,855.3 32,169.4 29,968.5 18,160.1 120,397.9 54 64,635.8 Physical Contingencies 506.6 1,152.4 1,330.8 1,239.8 751.3 4,980.9 54 2,674.0 Price Contingencies 809.9 2,216.1 2,999.6 3,083.5 1,956.1 11,065.2 48 5,264.7 Total PROJECT COSTS 13,561.1 31,223.8 36,499.8 34,291.7 20,867.5 136,443.9 53 72,574.5 al ADB expenditure account including obstetric kits (drugs) and micronutrients. b/ Includes broadcast time for television and radio IEC spots, and publication of IEC materials. PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Expenditure Accounts by Years - Totals including Contingencies (US$ 000) 1 199 96 1997 1998 1999 Total I. Investment Costs A. Civil Works 2,009.4 4,479.8 5,731.5 4,308.5 1,354.5 17,883.8 B. Furniture 13.5 57.2 75.8 0.0 0.0 146.5 C. Equipment 2,010.6 2,884.1 3,228.7 2,402.4 474.7 11,000.4 D. Vehicles 66.0 2,132.6 0.0 0.0 0.0 2,198.6 E. Initial Medical Supplies la 3,040.8 6,909.7 9,870.9 10,120.6 8,715.6 36,657.7 F. Media lb 37.6 1,406.5 1,616.9 1,863.3 37.6 4,961.9 G. Consultant Services Foreign 1,328.9 1,369.4 1,218.1 681.7 588.2 5,166.3 Local 1,398.4 2,246.2 1,962.2 1,683.3 1,076.5 8,366.6 Subtotal Consultant Services 2,727.3 3,615.6 3,180.3 2,345.0 1,664.7 13,532.9 H. Training Overseas Training 254.4 59.0 13.1 13.1 11.4 351.0 Local Training 524.2 2,328.6 3,211.6 3,315.6 2,693.1 12,073.0 Subtotal Training 778.6 2,387.6 3,224.6 3,328.7 2,704.5 12,424.0 1. Grants 2,159.3 2,159.3 2,159.3 2,159.3 2,159.3 10,796.6 J. Studies 103.6 219.8 350.0 371.6 131.5 1,176.5 Total Investment Costs 12,946.7 26,252.2 29,438.0 26,899.5 15,242.6 110,779.0 II. Recurrent Costs A. Drugs 0.0 2,749.3 4,181.0 4,240.1 2,867.6 14,038.0 B. Medical Supplies/Materials 0.0 459.4 737.3 788.9 562.7 2,548.2 C. Salaries/Honoraria 115.8 574.6 612.5 636.6 646.1 2,585.6 D. Maintenance Facilities Maintenance 67.4 135.9 208.5 215.8 82.0 709.6 Vehicle Maintenance 0.0 414.4 564.4 733.3 784.6 2,496.7 Subtotal Maintenance 67.4 550.3 772.9 949.1 866.6 3,206.4 E. Other Operating Cost 431.3 638.0 758.1 777.6 681.7 3,286.7 Total Recurrent Costs 614.4 4,971.6 7,061.8 7,392.3 5,624.8 25,664.9 Total PROJECT COSTS 13,561.1 31,223.8 36,499.8 34,291.7 20,867.5 136,443.9 a/ ADB expenditure account including obstetric kits (drugs) and micronutrients. b/ Includes broadcast time for television and radio IEC spots, and publication of IEC materials. PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Project Components by Financier (in US$ '000) ADO AIDAB EC KfW IBRD Government Total Amount % Amount % Amount % Amount % Amount % Amount % Amount % A. Service Delivery 1. Matemal care 46,662.7 70.4 - - - - 6,516.8 9.8 - - 13,134.4 19.8 66,314.0 48.6 2. Other Wonen's Health Services - - - - - - 7,591.7 39.1 8,195.9 42.2 3,632.6 18.7 19,420.2 14.2 Subtotal Service Defvery 46,662.7 54.4 - - - - 14,108.5 16.5 8,195.9 9.6 16,767.0 19.5 85,734.2 62.8 B. nsitutional Development 1.Trainig - - 10,553.2 66.0 - - - - 2,636.7 16.5 2,803.5 17.6 15,993.4 11.7 2. IEC 6,229.2 81.9 - - - - - - - - 1,379.0 18.1 7,608.2 5.6 3. Logistics - - - - - - 6,167.4 53.3 5,395.3 46.6 11,562.6 8.5 4 . P r * Mc t a ia g e m e n t 1 ,1 0 8 .1 8 0 .9 - - - 1 2 6 .7 9 .3 - - 1 3 4 .2 9 .8 1 ,3 6 9 .0 1 .0 SubtotalinsttutionalDeveopmnent 7,337.3 20.1 10,553.2 28.9 - - 126.7 0.3 8,804.1 24.1 9,711.9 26.6 36,533.2 26.8 C. Community Parnersps - - - - 13,000.0 100.0 - - - - - - 13,000.0 9.5 D.PolicylOperatiosResearch - - - - - - - - 1,000.0 85.0 176.5 15.0 1,176.5 0.9 Total PROJECT COSTS 54,000.0 39.6 10,553.2 7.7 13,000.0 9.5 14,235.3 10.4 18,000.0 13.2 26,655.5 19.6 136,443.9 100.0 0q PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Procurement Plan for IBRD-Financed Items Estimated IBRD Financing % To Be Implemented Total Cost Amount by Year Method of Expenditure Category/Item US$ '000) % US$ '000) 95 96 97 98 99 Procurement Major Activities 1. Civil Works LCB Appoint architect, prepare documentation, Renovation of Rural Health invite bids, award contract, supervise works Units (72) and Barangay Health Stations (72) 1,294 70 906 10 40 50 - - Warehouse Construction 1,297 70 908 10 50 40 - - Warehouse Rehabilitation 1,032 70 722 25 25 25 25 - 2. Goods Furniture for RHUs/BHSs 146 70 102 10 40 50 - - LS Invite quotations, evaluate, purchase Medical Equipment RHUs/BHSs 387 80 305 10 40 50 - - ICB, LCB Advertise, prepare documentation, invite bids, award contract Cryotherapy Machines 77 90 69 100 - - - - IS or DC Invite quotations and evaluate or negotiate, and purchase Computer Equipment RTI Service 8 90 7 100 - - - - LS Invite quotations, evaluate, purchase Logistics Information System 601 80 481 - 40 30 30 - ICB Advertise, prepare documentation, invite bids, award contract Training Equipment 78 100 78 100 - - - - IS, LS Invite quotations, evaluate, purchase Warehouse Equipment 124 70 87 70 30 - - - LCB, IS, LS Advertise, prepare documentation, invite bids, award contract Vehicles Fork Lift Truck 18 100 18 100 - - - - IS or LS Invite quotations, evaluate, purchase Delivery Vans 2,133 100 2,133 - 100 - - - ICB Advertise, prepare documentation, invite bids, award contract Drugs and reagents 6,677 100 6,677 - 20 30 30 30 ICB,LCB,IS,DC Advertise, prepare documentation, invite bids, evaluate and negotiate multi-year contracts 3. Services Consultant Services Cons. Selection Short-list, [01, TORs and draft contract, selection Architect 103 70 72 30 30 30 10 - Women's Health 64 90 58 100 - - - - Training 374 100 374 5 25 25 25 20 Logistics 1,527 90 1,375 25 25 25 15 10 Studies 1,177 85 1,000 10 20 30 30 10 Training Women's Health 2,185 100 2,185 - 25 25 25 25 Logistics 494 90 445 25 35 15 15 10 Total 18,000 - 115 - Annex 14 PHILIPPINES WOMEN' S HEALTH AND SAFE MOTHERHOOD PROJECT IBRD Disbursement Schedule and Profile Estimated IBRD Disbursements Disbursement Profile a/ IBRD Piscal By Semester Cumulative Cumulative Cumulative Semesters from Year/Semester ---- in US$ million ---- as % of total as t of total Approval Date 1995 1st 2nd 0.0 0.0 0 0 1996 1st 0.5 0.5 3 3 1 2nd 0.7 1.2 7 3 2 1997 lt 1.0 2.2 12 6 3 2nd 1.2 3.4 19 14 4 1998 1st 1.6 5.0 28 22 5 2nd 1.9 6.9 38 30 6 1999 1st 2.1 9.0 50 42 7 2nd 2.2 11.2 62 50 8 2000 let 2.4 13.6 76 62 9 2nd 2.4 16.0 89 74 10 2001 1st 2.0 18.0 100 82 11 2nd 86 12 2002 1st 94 13 2nd 100 14 A! Population, Health and Nutrition (PHN) Sector, East Asia and Pacific (RAP) Region. Disbursement Graph 100 70 6 0- 50- 30 20 >10- 0 1995 1996 1997 1998 1999 2000 2001 2002 [BRD Fiscal Year 8 Appraisal Estimate EAP PHN Profile - 116 - Annex 15 Page 1 of 2 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT IBRD Supervision Plan 1. IBRD Supervision Input. The staff input indicated in the table on the following page is in addition to regular supervision needs for the review of progress reports, procurement actions, supervision report preparation and correspondence (estimated for this project to require six staff-weeks per year throughout project implementation). 2. Borrower's Contribution to Supervision. (a) Annual work plans and budgets for the project would be prepared by each central and regional DOH office responsible for implementing specific project activities, and each participating local government unit (LGU). The plans and budgets of the central and regional offices would be reviewed by the appropriate technical and financial staff of the DOH and the Project Management Office (PMO). The plans and budgets of the LGUs would be reviewed by the regional field offices, agreed upon with the DOH, and included in the Project Implementation Agreements governing LGU participation in the project. The PMO would consolidate the plans and budgets of the LGUs, the central and regional DOH offices into an overall annual project plan. (b) Semi-annual progress reports would be prepared by the PMO in a format to be agreed upon with IBRD during the project launch mission. The reports would (i) include a concise, narrative section describing major project achievements and problems encountered, and (ii) utilize a simple, tabular account to show details of actual accomplishments compared to agreed upon plans. The initial progress report would be due on December 31, 1995, with succeeding reports due on June 30 and December 31 of each year until project completion. The reports would constitute the basis for the semi-annual project performance reviews to be conducted by the Government and IBRD. (c) Monitoring and reporting of implementation progress in accordance with the annual plans would be the responsibility of the PMO, with inputs from the DOH technical services and regional field offices. The PMO would also be responsible for organizing annual workshops to review implementation progress with LGUs, which would be timed to support the annual updating of operational plans and budgets. (d) The PMO would be responsible for coordinating arrangements for supervision missions, and for providing information required by missions. Mission briefings upon arrival and wrap-up meetings would be presided by the Project Director or a designated representative. (e) The PMO would prepare and submit to IBRD within six months of the Closing Date a final evaluation report on the project and a plan for the future operation of the completed project. - 117 - Annex 15 Page 2 of 2 3. Field Supervision Plan Approximate Staff Input Dates Activity (staff-weeks) 05/95 Project launch/initial supervision mission 6 11/95 Semi-annual review mission 4 05/96 Semi-annual review mission 4 11/96 Semi-annual review mission 4 05/97 Semi-annual review mission 4 11/97 Semi-annual review mission 4 05/98 Mid-term review mission 8 11/98 Semi-annual review mission 4 05/99 Semi-annual review mission 4 11/99 Final supervision/ICR mission 8 Note: ICR - Implementation Completion Report (a) Semi-annual reviews of project performance would be normally be held in May and November of each year to assess progress in project implementation. (b) A comprehensive mid-term review would be completed by June 30, 1998 to determine any need for modifications to the design and implementation targets of all project components. Particular attention would be given to accomplishments or difficulties encountered with the implementation of devolution-related strategies. (c) Each IBRD supervision mission would: (i) require at least two weeks in the field; (ii) require the services of specialists in women's health and project management/implementation on a regular basis; and (iii) review progress of procurement and civil works, financial statements and disbursements, Loan covenants, and the implementation of technical assistance and training activities. Specialized skill requirements would be added to the missions according to needs identified by previous supervision missions and would include, among others, the following: specific areas of women's health (maternal care, family planning, reproductive tract infections/ sexually transmitted diseases, cervical cancer, breast cancer, violence against women), life cycle approach to service delivery, information, education and communication, training, logistics, research, computerized project management, and monitoring and evaluation. (d) At least one of the two semi-annual reviews would be held jointly with all of the project's cofinanciers, who would provide both general supervision and additional specialized skills. - 118 - Annex 16 Page 1 of 2 PHILIPPINES WOMEN'S HEALTH AND SAFE MOTHERHOOD PROJECT Selected Documents Available in the Proiect File 1. Department of Health. Investing in Equity in Health: Proposed Ten-Year Public Investment Plan for the Health Sector (1994-2004). Prepared for presentation to and approval by the NEDA Board. January 1994. 2. Department of Health. Women's Health and Safe Motherhood Project: Project Proposal. July 1994. 3. Department of Health. Women's Health and Safe Motherhood Project: Project Implementation Plan. December 1994. 4. Galvez-Tan, J. (Undersecretary and Chief of Staff, Department of Health). Notes on the Women's Health and Safe Motherhood Project. June 1994. 5. Development Academy of the Philippines, Project Development Institute. Women's Health and Safe Motherhood Progra (in three volumes: Main Report, Organization and Management Study, Annexes). July 1993. 6. Asian Development Bank. Report and Recommendation of the President to the Board of Directors on a ProDosed Loan to the ReRublic of the Philipines for the Women's Health and Safe Motherhood Project. October 1994. 7. Program Development and Review Branch, Australian International Development Assistance Bureau. PhiliRoines - Integrated Women's Health Training Proiect. Feasibility/Design Study: A Sub-Comonent of the Women's Health and Safe Motherhood Project. April 1994. 8. Whittacker, M. Philipines Women's Health and Safe Motherhood Project: Interim Report of the Technical Assistance Mission (HIV/STD/RTI Specialist [of AIDAB1). January 29 - February 5, 1994. 9. Philippines Women's Health and Safe Motherhood Project: Sexually Transmitted Diseases and HIV/AIDS. October 1993. 10. Women's Health and Safe Motherhood Project. Cancer Component. October 1993. 11. Kabalikat ng Pamilyang Pilipino Foundation, Inc. Women's Health and Safe Motherhood Project [Information, Education and Communication Sub-component). June 1994. 12. Clark, M., B. Alano, H. Khajehpour, R. Gutteridge. Philiopines Women's Health and Safe Motherhood Project: Logistics Report. July 1994. - 119 - Annex 16 Page 2 of 2 13. Alano, B. Private Contractual Arrangements for the Department of Health Logistics System; A Feasibility Study. August 1994. 14. United Nations Fund for Population Activities. Contraceptive Requirements and Logistics Management Needs in the Philippines. 1993. 15. United States Agency for International Development. USAID Population Assistance Strategy. 1993-1998: A Formula for Success. June 1993. 16. Department of Health. Managing Health Services: Post-Devolution Perspectives and Strategies. Prepared for roundtable discussions among representatives of the DOH management and international donor organizations at the Asian Development Bank. September 1993. 17. Taguiwalo, M. Background Paper on the Public Financing of Health in the Post-Devolution Era. June 1994. 18. Taguiwalo, M. Three Decision Suport Modules in Central-Local Financing of Public Investments in Health, Manila, June 1994. 19. Taguiwalo, M. Recommendations on Implementing the Women's Health and Safe Motherhood Project Under the Conditions of Devolution. February 1994. 20. Taguiwalo, M. Women's Health and Safe Motherhood Project: Issues in Central-Local Cost Sharing. February 1994. 21. Enache, M. Resource Allocation and Cost-Sharing in the Women's Health and Safe Motherhood Project Using A Decision Support Software. Report presented to the Department of Health. June/July 1994. 22. Guanzon, R. Development and Testing of the Comprehensive Health Care Agreement. Report completed under the auspices of the United States Agency for International Development (USAID, Manila), Health Finance Development Project, and the UPecon Foundation. May 1994. 1BRD 26566 � iao is. i�и PHILIPPINES CLA551FiCAT10и OF PROViNCES �/ОМ L�: г S �""� EALTf'"{ AN � вyAOMiNisтaAтivEaEOioNS SAFE MOTHERHOOD PROJECT 1 aocos v1 wesтEaииsдrAS в�"°� SERVICE DELIVERY COMPONENT 1 1locos None :Эl3 А41о^ �п' 2 1locos 5о� Зс+ Соwг Туре о4 5ervice З lo Uпiоп 4() qnhque BATANES 4 Pongos�nan 4 1 11а1о � CORD��LERAADмw�STRATwE 4? 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