Philippines - Population Project

Report No. 333a-PH FILE COPY CIRCUIATING COPY Report No. 333a-PH IIQ BE RETURNED TO REPORTS DESK Philippines Appraisal of a REPORTN T Population Project WITHIN 7ON E W E?EP May 22,1974 Population and Nutrition Projects Departrment Not for Public use Document of the International Bank for Reconstruction and Development Intemational Development Association This report was prepared for official use only by the Bank Group. It may not be published, quoted or cited without Bank Group authorization. The Bank Group does not acLept responsibility for the accuracy or completeness of the report.  CURRENCY EQUIVALENT U.S. $1.00 - P 6.78 P1.00 = US$ 0.147493 P1 million = US$ 147,493 A. ABBREVIATIONS ASI - Asian Social Institute BHS = Barrio Health Stations CHEC ' Community Hospital and Health Center DOH = Department of Health DSW Department of Social Welfare FPEO - Family Planning Evaluation Office FPOP = Family Planning Organization of the Philippines IEC = Information, Education, Communications IMCH - Institute of Maternal and Child Health IPPF International Planned Parenthood Federation IUD = Intra-Uterine Device KAP - Knowledge, Attitude, Practice MCC = Medical Care Commission MCH/FP = Maternal and Child Health/Family Planning MIES = Management-Information and Evaluation System NEDA - National Economic Development Authority NMPC = National Media Production Center OHEPT = Office of Health Education and Personnel Training PCU = Project Construction Unit POPCOM = Comnission on Population RHU = Rural Health Unit RPC = Responsible Parenthood Council of the Philippines RTC = Regional Training Centers UNFPA = United Nations Fund For Population Activities UP = University of the Philippines UP-IMC = University of the Philippines - Institute of Mass Communications UPPI = University of the Philippines Population Institute B. DEFINITIONS Birth Rate = Annual births per 1,000 population Death Rate = Annual deaths per 1,000 population Age-Specific Fertility Rates = Set of 6 or 7 rates obtained dividing the number of annual births to mothers in each age interval from 15 to 44 or 49 years, by the corresponding female population in the same age interval.  B. DEFINITIONS (Contd) General Fertility Rate - Annual births per 1,000 women 15-44 years. (It is a more refined index than the Birth Rate, al- though less refined than the Age Specific Fertility Rates since it conceals variation according to age.) Total Fertility Rate - It is the sum of age-specific birth rates, each mult;iplied by 5 (usual age interval in years). It is interpreted as births per woman or per 1,000 women. It is a more effective measure than the general fertility rate, since it takes into account age distribution of mothers. Infant Mortality Rate - Annual deaths of children aged less than one year, per 1,000 live births. Midwife - Auxiliary health worker with 18 months of training in a Midwifery School, after secondary studies. Midwife/Community Health Worker = Midwife with an additional 4-month course in community health work (this category will be started with this project). Rural Health Unit (RHU) 3 Health center usually staffed with one or two doctors and nursing staff for provision of out- patient health and family planning services in municipalities under 50,000 population. Barrio Health Station = Center, staffed with a midwife, which is satellite to an RHU. Family Planning Clinic = Health Center or any private or public health outpatient outlet which may be used exclusively or partially to render family planning services.   PHILIPPINES: BASIC DATA 1972 2 Area (in thousanp d km ) .............................. , ********.................... 300 Density (per km 2,. 3 Density per arable land (km2) ..................................... 761 Population (in millions) .. . ............. ...... . 39.0 Birth Rate (per 1,000) ... ...................... 40* Death Rate (per 1,000) ,000).. ....... ...... 10* Infant Mortality Rate (per 1,000) .. 80* Rate of Natural Increase (per 1,000). . . 3.0* Total Fertility Rate ............. . . ... . 6.4* Age Structure (Z) Under 15 yearsears......... 43* 15-64 yearsears........... . ............. 53* 65 years and overr.... . . . ...... O4* Women 15-44 years (in millions). 8.8* Proportion Married (1960) ..........................,.,.,......... 62%* Percentage of Rural Population .67* Literacy Rate (%) .. 83* Unemployment Rateate.. ....... 0. 8% Population Per Physician ..... . ........ . ......... 2,819 Population Per Hospital Bed. 657 Family Planning Acceptors (in thousands) ....... .................. 441 Dependency Ratio (1970). 0.87 GNP (in US$ millions at 1970 market prices) .... .8,468 GNP Per Capita (1971) US$ .. ..240 *Population data from 1970 Census; rates apply to intercensal period 1960-70.   PHILIPPINES APPRAISAL OF A POPULATION PROJECT Table of Contents Page No. SUMHARY AND CONCLUSIONS ..............., ............. i-iv INTRODUCTION .......* * o******** *.............. *........ . .... 1 I I. DEMOGRAPHIC ANALYSIS ...... ........................ 1 III. THE NATIONAL FAMILY PLANNING PROGRAM ............ . 4 A. Organization and Administration ........... 4 B. Program Performance . ......... .o.. . . ........... . . . . . 6 C. Research and Evaluation ...................... 8 D. Program Financing .. ......................... 8 IV. HEALTH SERVICES IN RELATION TO FAMILY PLANNING ... 9 A. Rural Health Units .... . ... ...... .. 9 B. Puericulture Centers *..... 10 C. Family Planning in Hospitals ... 10 D. The Philippine Medical Care Commission ..... 10 E. Health Manpower .............. ............. 11 V. THE PROJECT .......................... .o...... 14 A. POPCOM's Project Component ............. ...... 14 B. Rural Health and Family Planning Service Component - Departments of Health and of Social Welfare.. 16 C. Regional Training Center ................. . . 19 D. Direct Project Assistance to the Department of Health .......................... .... o ... 21 VI. PROJECT COST, FINANCING, DISBURSEMENT, AND IMPLEMENTATION .23 A. Cost ...... .......... .. 23 B. Proposed Financing ................ o .......... 25 C. Procurement ................................ 25 D. Implementation ....... ........................ 26 E. Sites .......... o .......................... 26 F. Disbursements ........ ......................... 27 VII. PROJECT JUSTIFICATION ........ o. - ...... o ....... 28 VIII. RECOMMi&IDATIONS ................ o ........_...... 29  Table of Contents (Continued) ANNEXES 1. Demographic Analysis 2. Training In Family Planning 3. Agreement Between The Government~ Of The Philippines And The UNFPA On IEC Component 4. Rural Health Units S. Midwifery Education 6. Total Project Cost By Donor Agency 7. Illustrative Terms Of Reference For Facilities Evaluation Study 8. Civil Works 9. Non-Construction Project Component Costs 10. Disbursement Schedule MAP IBRD 10813 - Philippines Population Project This report is based on the findings of an appraisal mission which visited the Philippines in March-April 1973 and a special civil works mission which completed appraisal of construction components in July-August 1973. The first mission consisted of Mrs. M.N. Maraviglia (Population Specialist, Mission Chief), Dr. L.S. Sodhy (Public Health Specialist, Deputy Mission Chief), Mr. J. Burfield (Architect), Mr. J. de Vries (Economist), and Mr. R. Cuca (Demographer) from the Bank; and Miss M. Zapenas (WHO), Mr. A.V. Shianmugan (UNESCO) and Ur. J.E. Lundeberg (Institutet for sjukhusplanering, Stockholm, Sweden) as consultants for nursing, communications and architecture, respectively. The second mission was formed by Mr. D. Shoesmith and Mr. L. Nield (Architect/Planners, Consultants) and Dr. T.I. Kim from the Bank. Mr. Zaidan led both missions during the first week. This report was prepared by Mrs. M.N. Maraviglia incorporating the contributions of several mission members in particular sections.  PHILIPPINES APPRAISAL OF A POPULATION PROJECT SUMMARY AND CONCLUSION i. This report describes a population project in the Philippines for which a Bank loan of US$25 million is proposed. The project's main objec- tive is to assist the Government of the Philippines in strengthening its population program and expanding it into the rural and semi-rural.areas where almost 70% of the population lives. Extended coverage of the family planning program is essential in order to enhance the possibility of a moderately fast decline in fertility, which would result in a population of nearly 79 million in the year 2000, compared to 102 million if fertility remains at the present level. The project would be implemented by the Commission on Population (POPCOM), the Department of Health (DOH) and the Department of Social Welfare. It would strengthen the coordinating and monitoring capacity of POPCOM to direct the program and would increase the outreach and effectiveness of the Departments of Health and Social Welfare to render family planning services to rural and poor people. To this end, the project includes the reorganization of POPCOM and assistance to the Department of Health to establish a rew system of health delivery in rural and semi-rural areas; buildings will be financed for 205 Rural Health Units and 11 Regional Training Centers. Additional reoriented midwifery personnel will be assigned to implement the new service system. ii. The Republic of the Philippines is experiencing a high population growth rate of about 3% per year. If the high birth rate (40 per 1,000) and the low death rate (10 per 1,000) continue at current levels, the present population of more than 40 million would double in about 20 years. At present, about half of the national investments must be devoted to absorbing the population increase. The prospect of further mortality reductions makes the need for fertility decline even more urgent. iii. The concept of family planning has been spread by private voluntary groups since the mid-fifties. Their activities increased considerably in the 1960s with financial help from foreign agencies. In February 1969, President Marcos by an Executive Order established the Commission on Population to formulate policy and program recommendations in the population field. In 1970, family planning became official policy and POPCOM started to act as the official coordinating body of some 25 agencies engaged in population and family planning activities. Under Martial Law, POPCOM's functions have been stressed by the Government through recent Presidential decrees. iv. Data on program performance indicate an impressive increase in the number of new acceptors, from 43,000 in 1968 to about 440,000 in 1972-73 (about 8% of all married women). As of June 1973, there were over 2,100 clinics belonging to some 25 organizations. Of this number, 1,500 clinics were under three institutions, one of which was the DOH with 1,273 clinics. All methods  - ii - of fertility control, except abortion, are available through the family planning program; however, there is a preference for oral contraceptives. Although the program performance so far has been encouraging, much more needs to be done to achieve sustained long-term fertility decline, which would bring the total fertility rate down to 60% of its present value by the year 2000, and would result in an average annual growth rate of population close to 2%, instead of the present 3%. v. The administration of this considerably expanded program will call for changes, reorientation and reinforcement in several fields of activity including organization and management, logistics, training, service procedures, manpower utilization and program evaluation. The project will be implemented by the POPCOM, the Department of Health and the Department of Social Welfare, with the participation of other private and Government institutions as required. Its inputs have been selected to enable the extension of family planning services and motivation programs; they will: (a) Strengthen the coordinating capacity of the POPCOM, including new Regional Offices, to conduct the population program; (b) Extend and reinforce the rural health and family planning delivery system of the Department of Health (both facilities and manpower); {c) Provide health and family planning training to Government Personnel, emphasizing new procedures of health and family planning service delivery using paramedical staff, through 11 new Regional Training Centers of the Department of Health; and (d) Provide direct assistance to the Department of Health through salary support and advisory services for organization of training, the statistical system, new RHU procedures and logistics and supplies distribution. vi. The Government has made a number of organizational changes within the POPCOM, some of which will be executed as components of this project. The latter include a new Information, Education and Communications (IEC) Division, a new Training Division and eleven POPCOM Regional Offices. Re- current expenditures for the IEC Division will be financed by the UNFPA for four years. Initial financing for the Regional Offices and four-year financing for the Training Division will be provided by the USAID. vii. The Department of Health's role in this project will consist of establishing a new approach to health and family planning service delivery and public outreach using auxiliary personnel (midwives) to serve effectively the rural and small urban areas where about 70% of the population live. The  - iii - project will provide new buildings for 205 Rural Health Units (RHU), staff housing for remote areas, 11 new Regional Training Centers, vehicles, and equipmer.. Although buildings represent a large proportion of total project cost (aEiout 65%), the outstanding characteristic of the DOH component is the new health and family planning service approach. Technical assistance and salary support given through the project to some innovative parts of this program will be significant in terms of the volume of activity which they will generate and their influence on the national family planning program. This includes financing on a declining basis for the salaries of 2,400 ad- ditional midwives for family planning and community health work. viii. The proposed new system will be built upon the principle that the locus of health and family planning services and administration in each municipality of 10-50,000 population should be a RHU known as Type A. This RHU (158 of which will be built through this project) will be located in the "poblacion" (generally the largest barrio) to care for the immediate popu- lation of about 15,000. Barrio Health Stations (BHS) (existing or to be provided by Government outside of this project) would form satellites to the RHU and each would take care of about 5,000 people. BHSs would be manned by a new cadre of midwives retrained through the project in the Regional Training Centers. Also, 47 Type B Rural Health Units for municipalities with 5,000 to 10,000 population will be built through the project. In all new and existing DOH facilities advice and services on all family planning methods approved for the national family planning program will be offered to the public. ix. The evaluation of the national family planning program will continue to be carried out mainly by the POPCOM through a Management Information System (MIS) Unit and an Evaluation Unit which operate as part of POPCOM's Planning Division, with UNFPA financing. The DOH Project components will be evaluated by the statistical services of the DOH and by a Facilities Evaluation Study to be initiated in July 1976. Both DOH activities will be financed through this project. x. Availability of physicians and paramedical personnel in the Philippines is seriously affected by emigration to developed countries (particularly to the USA) and by uneven distribution within the country. There is an urgent need for effective measures to prevent the massive out- flow of health manpower. Measures to this effect were discussed with the Government during negotiations. xi. The POPCOM will coordinate the work of the national agencies participating in the execution of the project. A Project Construction Unit (PCU) will be established in the Department of Health, headed by a Director, who will be assisted by a Project Architect. Supporting staff and additional professional services drawn from the public and private sectors will also be provided as necessary.  - iv - xii. The Loan includes retroactive financing in the amount of $350,000 from May 1, 1974, for preliminary engineering and architectural work and to set up the Project Construction Unit. xiii. Contracts for civil works, furniture, equipment, vehicles and spare parts required for the project which are over US$70,000 will be awarded on the basis of the Bank's Guidelines for International Competitive Bidding. Contractors for civil works will be prequalified and notices of invitation will be inserted in national newspapers and circulated to the embassies of member countries represented in the Philippines. For contracts under US$70,000 equivalent the GOP may follow its normal procurement procedures, provided that the aggregate cost of the goods to be procured in accordance with this procedure shall not exceed US$200,000. Domestic manufacturers of furniture, equipment and vehicles will be accorded a margin preference equal to 15% of the CIF costs of competing imports. xiv. The loan will finance 50% of total project costs. Parall_1 financ- ing from UNFPA will be provided for 1% and from the USAID for 1% of the total project cost. The GOP would finance the remaining 48%. xv. Disbursements would be made for 100% of total techn,ical assistance and the CIF cost of imported vehicles and equipment or the ex-factory cost of domestically produced vehicles. For civil works and recurrent costs, a fixed percentage of expenditures (39%) would be disbursed so that the loan wotuld cover 50RO/ of total proiect costs. On an annual basis the loan will finance 90, 70, 50, 30 and 30% of certain salaries and other re- current costs incurred in years I through 5 respectively (equivalent to 39% of such costs during the period). The Commission on Audit of the GOP will audit the accounts and financial statements of the DOH related to the project, at least annually, and will furnish to the Bank certified copies of such statements, no later than four months following close of fiscal year.  I. PITRODUCTION 1.01 A Bank population sector mission visited the Philippines from February 21 to March 23, 1973 to undertake an in-depth assessment of the population program, at the Government's request. The findings of the mis- sion were presented in a Population Sector Review report (No. 91-PH). The proposed project is based on the results of the sector review and on a Government re-examination of the national family planning program undertaken in late 1972. Bank missions appraised the project in March-April 1973 and helped further prepare the project in July-August 1973. Through the stages of project development there was close coordination, both at headquarters and in the field, with other agencies involved in supporting the program, in particular USAID and UNFPA. Also, the missions worked in close contact with WHO, to ensure that Bank and WHO activities in the Philippines are comple- mentary and reinforcing. 1.02 The project was developed to respond to the country's need to achieve sustained fertility reduction in the next two-and-a-half decades. Although the performance of the femily planning program so far has been encouraging, the success of the Philippines' population program will depend, in the long run, on its ability to reach the rural population with family planning advice and services. The proposed project would complement the assistance received by the Government from USAID, UNFPA and other donors for the operation of a program geared to cause a moderately fast decline in fertility. If fertility is to decrease to 60% of the present levels by the year 2000, over 25 million births would have to be averted during that period. This level of fertili-fy decline would result in a population close to 79 million by 2000, which is almost double the number currently inhabiting the country, but some 23 million lower than the total which would result if fertility remains at the present levels. The project would contribute to this decline through two main components. First, it would strengthen the coordinating capabilities of the Commission on Population. The second component would be mainly implemented by the Department of Health and would assist in bringing family planning services to the rural population, without whose participation the stated fertility decline would not be achievable. II. DEMOGRAPHIC ANALYSIS 2.01 The demographic problem of the Philippines is mainly one of very rapid growth resulting from sustained high fertility and declining mortality. Its population has grown from 7.6 million in the first census taken this century (1903), to about 40 million at present. Population growth accelerated considerably after the Wlorld War II period. While it had taken 33 years for the population to double between 1903 and 1936, the doubling period prior to  - 2- the 1970 census was only 24 years. The average annual rate of growth of about 3% in the decade 1960-70 places the country's population among the fastest growing in the world. The following table gives evidence of these trends: Average Annual Year Population Growth Rate (millions) (%) 1903 7.6 1918 10.3 2.0 1939 16.0 2.2 1948 19.2 2.1 1960 27.1 2.9 1970 36.8 3.0 2.02 According to national studies, 1/ the birth rate has been almost constantly high (over 45 per 1,000) in the last 70 years, while mortality (with the exception of the war years) has ber<n constantly decreasing. Esti- mates based on the censuses of 1960 and 1970 indicate a birth rate of 40 per 1000 and a death rate of 10 per 1,000 population and a total fertility rate of 6.4 per woman in ages 15-49 years. However, infant mortality is still high (probably around 80 per 1,000 live births) and the emphasis on maternal and child health programs in coming years will undoubtedly contribute to increased life expectancy. The prospect of further mortality reductions makes the need for fertility decline even more urgent. The main reasons for this are inadequate food supplies, scarce employment opportunities and the desirability of providing satisfactory education and health services to the total population as soon as possible. Because of the high rate of popula- tion growth, about half of national investm-nts must be devoted to absorbing the population increase. 2.03 Although there are some indications of fertility decline in urban areas, these are offset by the persistent trend of increasing fertility in the rural areas. The national crude birth rate was estimated to be 43.4 to 45.6 in 1960 and preliminary census results for 1970 give indications that currently it may be only slightly lower, around 40 per 1,000. 2.04 Persistently high fertility patterns outside the industrialized areas of Manila and Southern Luzon appear to indicate that voluntary birth limitation is not significantly practiced among couples living in smaller towns and cities classified as "urban". In 1970, around 70% of the popula- tion of the Philippines was living in rural areas and this points to the magnitude of the task ahead. 1/ Demographic indicators used in this report have been obtained mainly from reports and publications prepared by the University of the Philippines Population Institute.  - 3 - 2.05 The population of the Philippines is young, with about 45% under 15 year, of age, a reflection of the high fertility level. The dependency ratio 1/ was 0.87 in 1970, a high value which implies the need for heavy expenditures in services, particularly in education and health care. 2.06 Two illustrative population projections have been prepared for this report to show alternative trends in the next three decades under the following assumptions of fertility decline: Projection A: almost constant fertility; Projection B: modetately rapid decline in age-specific fertility rates to 80% of the 1970 level by 1975, and 60% by 2000. 2.07 In both projections, life expectancy at birth is assumed to increase from 56 for males and 60 years for females in 1970, to 65 and 69 years, respectively, in the year 2000. Projection A estimates the population trend in the absence of a national family planning program, and measures the efforts that would be required in terms of family planning users and births averted to achieve a fertility decline similar to that illustrated by Projection B. The alternative population projections are as follows: Population Projections (millions) A. Constant B. Moderately Birth Rate Death Rate Growth Rate Year Fertility Fast Decline A B A B A B 1970 36.8 36.8 40.0 40.0 10.2 10.2 3.0 3.0 1980 50.7 47.9 41.5 32.9 8.1 7.7 3.3 2.5 1990 71.6 61.8 42.2 32.6 7.0 6.9 3.5 2.5 2000 101.9 78.9 40.9 28.9 6.1 6.5 3.5 2.2 2.08 These estimates provide only a range of possibilities, yet they serve to underline the serious implications of delays in reducing fertility. The assumption of constant fertility up to the year 2000 gives an upper limit of almost 102 million persons in that year. The lower population trend (79 million in 2000) would be accomplished if couples practiced family limitation to the extent of averting over 25 million births during the next 26 years. This would only be possible if the family planning program is successful and if there are fairly basic attitude changes toward procreation. The project is addressed to the need to increase the effectiveness of the family planning program both as an instrument of communication and motivation and for the provision of contraceptive services. 1/ Population under 15, plus the group 65 years and over, divided by population aged 15-64. A lower ratio means a smaller burden for "producers." In developed countries this ratio hovers around 0.5.  III. TIE NATIONAL FAMILY PLANNING PROGRAM A. Organization and Administration The Commission on Population (POPCOM) 3.01 The family planning program in the Philippines is conducted by some 25 different organizations with varying degrees of participation. This is the result of progressive involvement of private organizations, local author- ities, external agencies and, recently, the Central Government. Government and private agencies have contributed significantly to the total national effort, but an urgent need was felt for coordination and direction of acti- vities. The establishment of the Commission on Population (POPCOM) in the Office of the President through an act passed by Congress in August 1971 (Republic Act 6365) was in response to this need. The act was amended by Preside-atial Decrees No. 79 and 166 dated December 8, 1972 and March 31, 1973, respectively. The composition of the Board of Commissioners is now as follows: Secretary of Education and Culture, Secretary of Health, Secretary of Social Welfare, Dean of the University of the Philippines Population Institute, the Director-General of the National Economic and Development Authority (NEDA) and two members from the private sector with the necessary expertise in the field of population planning and who are not recipients of Population Commission program funds, appointed by the President of the Philippines for the term of three years. 3.02 Significant changes introduced by the recent amendments are: (a) a larger representation from the Government in the Board; (b) representation of NFDA through its Director, thus enabling the Commission to work directly with the highest level of national planning; (c) a more active role in pro- posing studies and policy related to specific population goals. 3.03 The Office of the Executive Director has a staff of some 70 persons. The Executive Director is assisted by a Deputy Director and, under the recent reorganization, Associate Directors, each responsible for one of following divisions: Administration, Finance Logistics, Operations, Planning, IEC and Training. A Management Information System has been recently establish- ed within the Planning Division; this Division is also responsible for evalu- :ion and research. 3.04 At the time of the Bank missions, POPCOM did not have field staff; its only visibility at the regional and provincial levels were occasional visits from the Central staff, but this was evidently not enough to allow for effective program coordination on a country-wide basis. The 11 regional POPCOM offices recently established will fill this gap.  -5- The Department of Health (DOH) 3.05 Since the private organizations and many of the provincial govern- ments are providing family planning services through out-patient clinics in the larger urban areas, the Department of Health is giving emphasis to the development of family planning services in the small urban centers, barrios and rural wreas and to the establishment of postpartum motivational programs in its hospitals. More recently (mid-1973) the concentration of the Govern- ment on rural health services has sharpened with particular emphasis on the barrio level. This will facilitate considerably the expansion of the family planning program of the Department of Health. 3.06 Within the Department of Health, the National Family Planning Office is in charge of overall planning, administration, coordination and evaluation of the DOH family planning program. There are currently about 1,300 Rural Health Units providing clinical and educational family planning services, although the administrative and physical conditions of these units will need upgrading to assume the additional tasks of the family planning program. 3.07 The Department of Health is also involved in training medical, paramedical and promotional personnel for the family planning program through the Office of Hlealth, Education and Personnel Training (OHEPT) with head- quarters in Manila and seven Regional Training Centers. 3.08 Another branch of the DOH currently involved in the family planning program is the Bureau of Health and Medical Services. This office is re- sponsible for the implementation of a maternity-centered family planning project for 25 designated training hospitals. The program is operating in 15 of these hospitals and in the remaining 10 it started on July 1, 1973. This activity is funded by UNFPA and UNICEF, with technical assistance from WHO. As part of the larger commitment recently signed with the UNFPA, addi- tional financial assistance would be available, depending on the results of an evaluation now under way, to extend the project to introduce maternal and child health and family planning services into 100 additional government hospitals with 25 to 100 beds each. Other Participating Government and Private Agencies 3.09 When the Government became involved in the population issue around 1969-70, various private and semi-private groups and several local and provincial governments were already working on programs designed to encourage fertility decline. Notable among those private agencies which carried out pioneering work in this field are the Institute of Maternal and Child Health (IICH), the Family Planning Organization of the Philippines (FPOP) and the Responsible Parenthood Council (RPC). Some 20 other agencies are active in this field. Hlowever, they operate mostly in urban areas and the task of reaching the rural and remote regions with family planning advice and service will remain mostly the responsibility of Government clinics.  -6- 3.10 In the field of Communications, several institutions have con- tributed to the family planning program, carrying out projects financed mainly by U'SAID and UNEPA. These include the Population Information and ducation Office within the National Media Production Center; the Institute of Mass Communications of the University of the Philippines; and the Depart- ment of Education which is carrying out a family life education program in public schools. The Responsible Parenthood Council and the Asian Social Institute are currently considering new communications projects. The Depart- ment of Social Welfare is strengthening its program of family education and counselling for responsible parenthood through social work methods. B. Program Performance 3.11 There were over 2,100 family planning service outlets (or clinics) in the Philippines as of June 1973, operating under some 25 different organi- zations. Of this number, however, over 70% belonged to three agencies (DOH, IMCH and FPOP). The services offered by these clinics varied widely, from full-time to one-afternnon-a-week sessions. All methods of contraception listed in the table below are made available in these clin.cs to couples desirous of spacing, limiting or preventing pregnancy. 3.12 Recent auditings and reviews of the family planning program's ser- vice statistics have revealed serious deficiencies in the system, caused by over-reporting of acceptors by clinics and reporting of women transferring from one clinic to another, as new acceptors. The breakdown of new acceptors by method is presented below as an indication of the general trends in program performance: New Acceptors Fiscal Year Adjusted for (April to IUD Over-reporting and/a March) Pills Insertions Rhythm Other Total Clinic Transfers - (thousands) 1969-70 52,100 17,400 10,000 10,700 100,200 89,200 1970-71 122,400 50,600 34,100 16,500 223,600 204,000 '071-72 ^51,200 72,800 52,100 36,000 412,100 343,800 1972-73 311,400 82,400 58,000 107,300 559,100 440,800 I'ercent 1972-73 55.7 14.7 10.4 19.2 100.0 /a Source: Commission on Population, Year-End Report (January-December 1972) 3.13 According to the estimates in the last column of the above tables, in the past four years there has been a four-fold increase in the number of new acceptors, from almost 90,000 in 1969-70 to 441,000 in 1972-73. -Pi acceptors represented mr re than half of the acceptors in 1972-73; this proportion has been increasing since the early years of the program.  - 7 - 3.14 In a national acceptor survey 1/ carried out by the Population Institute (University of the Ohilippines), it was found that about one-third of the acceptors in the sample lived in "barrios" or rural communities; since more than two-thirds of the eligible women lived in these areas in 1970, this result indicates under- representation of rural women in the program. Over 40% of the acceptors lived in chartered cities, although the corresponding proportion of eeligible women in those cities was only 20%. The proportions of acceptors by method and place of residence were: Percent Locality Total Pills IUDs Rhythm Other City 42.4 37.4 55.2 34.0 47.1 Town (poblacion) /a 23.4 25.1 16.1 32.3 24.3 Town (barrio) /a 34.2 37.5 28.7 33.7 28.6 Total 100.0 100.0 100.0 100.0 100.0 Sample: 1,838 1,007 529 232 70 /a "Poblacion" is the seat of the municipal government and "barrios" are rural settlements belonging to a given municipal- ity (town). 3.15 In general, the scope of the program is growing and rightly so, since increased efforts will be needed to achieve the long-term fertility decline goals. The recent achievements, in program volume, however encouraging, should not give rise to premature optimism. It is evident from the survey results thiat there are several operational aspects of the program that need attention and proper handling by the management. The following aspects, pointed out in the Bank's sector report, are particularly relevant. These include: a. the existence of a large number of family planning service agencies with very low performance; b. a more favorable clinic distribution to reach large sectors of the rural population, with low economic status and little education achievement who are less likely to practice family planning inde- pendently of the program; c. the extension of clinic services to a daily basis in the Department of Health RHUs and hospitals; and d. education/information/communication efforts parallel to the extension of clinic services suggested in (b) and (c) including field workers for face-to-face motivation (mainly reoriented midwives and social welfare workers as well as other Government field personnel which may be trained in family planning). . 1/ Laing, John E., Selected Response Distributions from the 1972 National Acceptor Survey; Manila, February 1973.  C. Res4arch and Evaluation 3.16 Population research in the Philippines has been a function of the tniversities. The University of the Philippines Population Institute (UPPI) created in 1964 is the principal center of demographic training and research in the country. Other various universities have also been active in popula- tion research. In February 1970 the Family Planning Evaluation Office (FPEO) was created as part of the UPPI through a contract with the University of Chicago, under USAID financing. 3.17 The purpose of the FPEO was to set up an evaluation system for the family planning program. This office developed a sound basis for the national record-keeping system working together with the National Computer Center and also carried out several special studies and surveys, within the limitations of scarce national professional expertise in this field. In August 1973 super- vision of the record-keeping system and routine reporting was shifted from the FPEO to the POPCOM, with financial assistance from the UNFPA. Currently FPEO is retaining responsibility for special surveys, tabulation and analysis of the National Demographic Surveys and development of special statistical methods. Processing of all service and survey data is undertaken by the National Computer Center. 3.18 The Planning Division in POPCOM is operating the record-keeping, reporting and evaluation system of the family planning program and will assume coordinating duties for research. A Management Information System (as pro- posed by the Bank Sector mission) is now being established within the Planning Division. D. Program Financing 3.19 The population program of the Philippines relies substantially on external funds. The POPCOM, together with the National Economic Development Authority, is responsible for allocating all bilateral and multilateral funds from official sources for family planning. 3.20 USAID, which has assisted the program since its early stages, has made the largest financial contributions. It provided US$25 million in the period FY 1967-73, and appropriated US$7 million for FY 1974. For FY 1974, US$2.2, million represent inputs for commodities (including contraceptives). 3.21 In January 1972, the UNFPA signed a US$3.3 million agreement with the GOP, covering both on-going and planned projects of which about half (US$1.4 million) is for the family life education in public schools. A new agreement was signed in December 1973 through which the UNFPA has committed to the COP an additional US$6 million for programs in the next five years.  -9- 3.22 There are other donors involved in financing smaller programs. Among them, the Ford Foundation has assisted in research for several years and initially supported the University of the Philippines Population In- stitute. Ford's present annual level of assistance is in the order of US$0.2 million. The Pathfinder Fund has assisted with commodities to clinics and health centers and with various smaller projects totaling US$0.6 million in disbursements in 1972. The IPPF has been the source of funds for the FPOP with contributions of about US$0.3 million annually. The Rockefeller Founda- tion has supported biomedical research and has committed US$1.5 million over a period of ten years to finance the program costs of the Population Center Foundation Inc., built with funds contributed jointly by the GOP, the USAID, and the Rockefeller Foundation. 3.23 Budget allocations from the GOP started in FY 1971 but were minimal until FY 1973, when P5.9 million was appropriated; the budget for 1974 amounted to about P40 million of which over 70% are new budgetary inputs. IV. HEALTH SERVICES IN RELATION TO FAMILY PLANNING A. Rural liealth Units 4.01 When the Government started the national family planning program four years ago, it set as an objective the delivery of family planning services through all Rural Health Units (RHUs) and Government hospitals. At present there are about 1,500 RHUs and by June 1973 family planning services were offered in about 1,300 of them (for details, see Annex 4, para 8). However, in order to increase the scope of the RHUs to include these new services, considerable improvements are required in the physical facilities (buildings, equipment, transportation) and in the administrative arrangements and logistics of the RHUs. 4.02 The DOH recognizes that the organization of day-to-day operations of the RIUs and the respective functions of .he team members need a reassess- ment, which may result in new procedures and reassignment of functions. An operational research team assisted by WHO experts has been recently conducting a series of studies on the existing rural health services in the Province of Rizal near Manila in order to define the actual demand for health services and the ways through which existing resources in the public sector have been deployed in satisfying the health requirements of the population in rural areas. In particular, the objective of these studies is to develop alternatives to rationalize the distribution of duties among the health staff to improve performance. The team has already submitted suggestions to redistribute duties among health workers (Annex 4, Appendix 1) and in November 1973 presented a final report, manuals of procedures and training schemes. The Health Planning Unit of the DOH is already developing the rural health plan along lines suggested by these studies.  - 10 - 4.03 Only 510 RHUs out of 1,454 with data available were occupying especially designed and Government-owned buildings; the remaining RHUs were housed in municipal buildings, multipurpose halls, puericulture centers and rented private premises (Annex 4, Table 2). The large majority of these facilities are in too poor condition to provide sound clinical service to clients. (The project will finance new buildings for 205 RHUs - (paras 5.15 to 5.18). The number of Barrio Health Stations (BHS) 1/ in the country is estimated at about 4,500, although the condii:ion of the physical facilities and the staffing position is not known by the DOH. The DOH agreed during negotiations that it will carry out a survey of Barrio Health Stations in order to undertake a program of rehabilitation of and additions to these facilities to be financed by the GOP, which will complement the Bank project. Such program will be submitted to the Bank for comments within the next two years. B. Puericulture Centers 4.04 The puericulture centers are health units with the same functions as the RHUs. They were established much earlier, in 1921, by the National League of Puericulture Centers, a semi-private organization. They were created with the main objective of reducing maternal and child mortality. They were also used by the IMCH to provide family planning services since the early stages of the program. The staff should include a part-time physician, a nurse and a midwife, although personnel shortages are common. In fact, most centers are staffed only by one midwife. A revision of this ailing system is long overdue. C. Family Planning in Hospitals 4.05 Another branch of the DOH active in the family planning program is the Bureau of Health and Medical Services. This office is implementing a maternity-centered family planning project in 25 designated training hospitals, wfith funds from UNFPA and UNICEF and technical assistance from WHO. Addition- al tinancial assistance would be provided by the UNFPA to extend the project to 100 additional Govermnent hospitals with 25 to 100 beds each, starting in F' 1974-75, for a period of five years, pending evaluation of the present c.t ivities. 1). The Philippine Medical Care Commission 4.06 The Medical Care Commission (M4CC) was created by the Republic Act Ao. 6111 also known as the Philippine Medical Care Act of 1969 to gradually provide medical service for all the Filipino people. The Commission consists 1/ BHSs are health posts located in rural "barrios," usually housed in ad hoc quarters, which function only when manned temporarily by health staff from the main RHU; some have a resident midwife as permanent staff, generally paid from local funds.  - 11 - of a Chairman and seven other members, one of whom is the Secretary of Health. UInder the Community Hospital and Health Center Scheme (CHHC) the Commission conpleted ten and expects to construct another 71 5-to-10-bed hospitals in renote areas. It plans to staff them with two physicians each, one to be drawn, whenever required, from a neighboring RHU and the other from the private sector. The Commission has shown a tendency to develop a parallel health service. There are still several aspects that the two agencies--MCC and DOHl-need to clarify. These include their respective functions, staffing of CHHCs and RHUs, and administration and technical supervision of the CHHCs. The Bank mission, working in consultation with the DOH, identified the loca- tion of the CHHCs and excluded those municipalities from the list of project- financed RHUs. During negotiations, the GOP confirmed that it intends to ensure that the new CHHCs will provide space for the RHU services and will also offer family planning. E. Eealth Manpower Physicians 4.07 The availability of physicians and paramedical personnel in the Philippines is seriously affected by the emigration of doctors to developed countries (particularly the United States) and by their uneven distribution within the country, highly unfavorable to the rural areas. A recent survey shows that as of July 1970 there were nearly 13,000 physicians in the country and approximately 8,300 abroad (3,500 of them on a temporary basis). The ratio of physicians to population is 3.4 per 10,000 for the whole country and in the rural areas it is as low as 2 per 10,000. About 40% of doctors are concentrated in Greater Manila and over 65% in cities and provincial capitals (including Manila). This leaves a scarce 35% for the rest of the country. 4.08 The annual number of graduates from medical schools has declined from 1,300 in 1965-66 to 1,100 in 1969-70 due to a decision of the Philippines' medical colleges to limit enrollments. The number of physicians leaving the country yearly for the United States and Canada reached over 800 in 1970. "fore recently a small but increasing number is leaving for Australia and Western Europe. Thus, the net addition of physicians, making allowance for retirements and deaths, may not be higher than 100 per year, a net annual increase of less than 1%. This is considerably below the increase of 400 doctors per year which would be necessary only to keep up with population growth. 4.09 In order to slow down the outflow of medical (and nursing) manpower a Presidential Decree, effective January 1, 1974, makes it compulsory for all newly graduated physicians and nurses to serve for 6 months in rural areas. They are being appointed to vacant positions. The DOH will spend P16 million in the FY 1974-75 for this program, which is expected to slow down the outflow  - 12 - and motivate some young professionals to serve in the rural areas for longer periods. Also, a special allowance equivalent to 25% of the salary is already in effect as an incentive for the DOH health!staff who are assigned to hardship areas. (Through the Bank project, housing will be provided at 85 locations tor doctors and nurses or midwives as an addi.tional incentive.) Nursing Personnel 4.10 In the Philippines, nurses either hold a Bachelor of Science in Nursing degree obtained in a five-year basic collegiate program or a graduate nurse diploma granted after a basic four-year hospital training course. Their functions are the same for both categories and include nursing care and super- vision of patients, implementation of physician's orders concerning treatment and medication and community health work. 1Midwives are auxiliaries, with *18 months of training. The midwife takes care of normal childbearing women from the beginning of pregnancy to the end of the puerperium and of normal infants during the neonatal period. 4.11 According to a special study made by the Philippine Nurses Association 1/ there were 18,700 nurses in 1970 and those who passed the Board examination in that year numbered 3,000. Another 15,000 were abroad and 7,200 were inactive or not practicing nursing. Only 3,000 nurses worked in rural areas pointing to a seriously uneven distribution. Emigration is also considerable among nurses, who leave the country for the United States and Canada at a rate of 1,400 annually. It has been observed that quite a number are leaving annually for Western Europe. Since no complete information is available on emigration, it is not possible to estimate the net annual gain, although the problem of supply of nurses would appear less serious than that mentioned for doctors. Ilowever, the tendency of nurses to concentrate in urban areas is even more pronounced than for physicians. 4.12 There are no reliable estimates of the total number of midwives in the country. There were, however, nearly 19,000 names on the register as of December 1972, with no information on how many of these have emigrated, gone abroad on a temporary basis, died, retired or moved to jobs other than midwifery. Also, this number includes nurses that register as nurse-midwives after providing proof of having attended 20 deliveries or after passing the Board examination for midwives (probably 2 to 3% of all those registered). A rough estimate, taking into account all these possibilities, is that there were 3,000 midwives in the country in 1972. The Government employed about 3,500 midwives in that same year and probably 1,000 were employed by the private health sector. This estimate would leave about 3,500 midwives un- accounted for. Currently there are 32 schools of midwifery, 29 of which are private and under the jurisdiction of the Department of Education. Three Government Schools functioning under the Department of Health are located in Manila, Cebu and Butuan. There were about 400 graduates from all private schools yearly and a similar number from the three Government schools--about 1/ Philippine Nurses Association, Facts and Figures on Nursing, Manila, 1972.  - 13 - 800 in all. These rough estimates would seem to point to an adequate supply of this category of personnel. Since the project implies an increased reliance on the services of midwives, the project will stress reorientation of midwifery training to make it more relevant to family planning work in rural areas. While there may be some regional supply problems, the general situation suggests that they can be overcome by proper salary differentials or other incentives. 4.13 The difficulties in recruitment of midwives in several regions are a consequence of the uneven distribution of schools (Annex 5, Section F). About half of the 32 schools are concentrated in or around Manila (Region IV). There are no midwifery schools in Regions II and VIII and almost 70% of the total student enrollment during the period 1970-72 corresponded to schools located in Region IV. 4.14 Measures to correct this situation were discussed with the GOP during negotiations. Assurances were obtained from the GOP to the effect that it will establish, by December 1974, a special committee of representatives of POPCOM, Board of Midwifery; Department of Health and Department of Education to review the policy regarding training of midwives bo-h in the Government and private sectors, with special emphasis on the following points: a. regional distribution of schools; b. government subsidies for operation of midwifery schools in selected areas; c. role of midwives in the private sector; and d. modification of the curriculum of midwifery schools (including family planning subject matter) to make it more relevant to the work of the midwife in both private and public sector. 4.15 Also during negotiations the GOP confirmed its intention to examine, within the first two years of the project execution period, possible ways for adopting an expanded scholarship scheme for midwifery students, including a provision that they would serve in rural areas for a specified period after graduation. 4.16 There is consensus among those working in the family planning pro- gram that midwives would do a better job in motivating couples to adopt family planning methods than the present lay motivators employed by the DOH for RHUs. It is, therefore, envisaged that midwives will be increasingly used for this task instead of the lay motivators and will thus become the key health workers for the family planning program, both for rendering services and undertaking face-to-face motivation of couples. Through this project, the DOR will initiate a program for reorientation of midwives, in its Regional Training Centers, to mnake them community health workers and will sanction and recruit midwives to increase its number by 2,400 during the next five years. These midwives, initially financed through this project, vill be posted as resident staff in Barrio Health Stations and in RKUs. (The DOH plans to recruit another 2,600 midwives during the same period to accomplish an addition of 5,000 positions.)  - 14 - V. THE PROJECT 5.01 The success of the Philippines family planning program will largely depend on its ability to reach and motivate the rural population and impover- ished groups with information, advice and services. The project will comple- ment various national and external inputs and will enable the Government to extend the family planning program to small urban places and rural areas, where about 70% of the population lives. It will be implemented by the POPCOM, and the Departments of Health and of Social Welfare. The project will: a. strengthen the coordinating capability of the POPCOM and support the development of field staff to direct the family planning program; b. extend and reinforce the rural health and family planning infrastructure of the Department of Health by establishing a new system of health service delivery in rural areas (in this revised system, retrained midwives will play the key family planning role in the health team); c. support inservice training on health and family planning in the Regional Training Centers of the Department of Health, by providing new buildings for training, living accommodations for trainees and technical assistance for reorientation of midwifery and other inservice training; and d. Employ additional staff and provide equipment and technical advisory services to the Department of Health for implementing new RHU procedures and establishing of a new statistical system for evaluation. 5.02 The following sections describe the four project components relating respectively to the POPCOM, the DOH's Rural Health and family planning services, the Regional Training Centers and the direct project assistance to the Depart- ment of Health for technical services and evaluation. A. POPCOM's Project Component 5.03 The Comnission will introduce staffing and administrative changes to strengthen its effectiveness as a coordinating and monitoring body. Specifi- cally the project will: a. establish in the Commission an Information, Education and Communications (IEC) Division and a Training Division; and b. staff its 11 regional offices with additional manpower . to undertake the coordination of the family planning pro- gram at the Regional level.  - 15 - 5.04 The UNFPA will finance the recurrent expenditures of the IEC Division for the first four years (Agreement included in Annex 3). The USAID wlll pro- vide funding for the Training Division (four years) and for the first year of operations of the Regional Offices. (Agreements included in Annex 2, Appendices I and II.) The GOP will assume funding of these activities thereafter. IEC Division 5.05 In par with the other divisions of POPCOM a Communications Division will be established in POPCOM with initial UNFPA financing, with the main function of planning and coordinating all communications inputs into the popu- lation program. The implementation of communications activities would continue to be carried out by various agencies outside POPCOM. Details on the Communi- cations Division component to be finxtnced by UNFPA are included in Annex 3. Training Division 5.06 Training in family planning will continue to be conducted by five major organizations: DOH, the IMCH, the FPOP, the DSW, and the University of the Philippines. It is necessary, however, that training curricula be made uniform, and that all participating organizations adhere to the policy decisions laid down by the POPCOM. This agency will be responsible for set- ting standards, determining curricula, deciding on numbers and types of per- sonnel to be trained, and evaluating the training activities. These func- tions will be performed by a training division to be established as part of POPCOM's reorganization which will consist of an Associate Director Training, who will be assisted by training project officers for major activity areas (e.g., medical and service-related, information, education, etc.). Training assistants will be employed as the workload requires. Contractual and short- term consultants will be utilized as needed for special assignments (details. are included in the USAID agreement reproduced in Annex 2, Appendix I). Regional Offices 5.07 The activities of the POPCOM have been centralized in Manila with little visibility in the field. Under the reorganization already underway, POPCOM will have 11 Regional Offices, each headed by a Regional POPCOM Re- presentative with rank and status of Associate Director. Some of these officers have already been appointed. They are multipurpose staff with a suitable combination of university studies and administrative experience. They have or will receive training in family planning and program management. The functions of the regional POPCOM representatives are to help in the development and implementation of the regional program, help solve field problems, elicit participation from official and private sources for the family planning effort and maintain program impetus (detailed duties and responsibilities of the Regional Representatives are included the USAID agree- ment reproduced in Annex 2, Appendix II).  - 16 - Evaluatioa 5.08 The Government has created a Management Information System (MIS) within the POPCOM's Planning Division, with UNFPA financing. During negotia- etions the GOP gave assurances that it will continue to carry out the evaluation of its family planning program through the new MIS and/or through any other means and resources that may be found appropriate to cover the following functions: a. Evaluation of program efforts or inputs (personnel-years, visits, clinics, costs, etc.); b. Evaluation of intermediate results (number of acceptors, continuing users, active clients, etc.); c. Evaluation of program efficiency (relation of intermediate results to various physical or financial inputs; and d. Evaluation of effect on fertility decline. 5.09 Aside from the system of continuous data collection which is needed for this program, periodic sample surveys will be required. Essential sur- veys which will need to be undertaken include: a. Follow-up sample of program acceptors; and b. Attitude studies of family planning (through samples among the general population). 5.10 The ultimate objective of the family planning program and the project - fertility decline - can only be evaluated through accurate vital statistics. The Dual Registration System already operating under the National Census and Statistics Office is a good mechanism for obtaining vital statistics on a continuous basis - especially age-specific fertility rates -- and should receive support from the GOP, as required, to evolve into a permanent system. B. Rural Health and Family Planning Service Component - Departments of Health and of Social Welfare 5.11 The project will provide financing for strengthening and expanding the system of Rural Health Units in order to implement new procedures for the delivery of health and family planning services in small urban centers and outlying rural areas. This will include: a. Construction equipping and furnishing of 158 Type "A" and 47 Type "B" Rural Health Units (defined in paras 5.15 and 5.18), including two houses for the staff of each of 38 Type A units and one house each in all Type "B" units;  - 17 - b. Procurement of 205 jeeps, spare parts for existing and new vehicles and vehicle maintenaace; c. Employment of about 2,400 additional midwives to serve as midwife/community health workers in RHUs and Barrio Health Stations (480 midwives per year are expected to be employed during the 5-year project period) and; d. salaries for core staff in the DOR to organize implementation of RHU procedures. RiU Physical Facilities 5.12 only 510 of 1,454 RHUs for which information was available were occupying a Government owned building suitable for their specific functions. The remaining RHUs were housed in various locations such as municipal build- ings, multipurpose halls, puericulture centers and rented private premises (Annex 4, Table 2). Many of these facilities are in too poor condition to provide sound clinical services to clients. The DOH has identified 313 RHUs which need new buildings and 598 which would need rehabilitation and general repairs (Annex 4, Table 3). After reviewing the available information regard- ing population coverage, staffing patterns and expected RHU activities, the Bank mission, working in consultation with the GOP, derived the following criteria for project preparation: a. new RHU facilities would be provided through this project for municipalities with 5,000 to 50,000 population by 1983 (this group would constitute 85% of all municipalities by 1983); b. municipalities which already have a Government hospital or will have a CHHC in the future (see para. 4.06 for plans of Medical Care Commission) would not be eligible for a REU building under the project; and c. the RHUs to be built through this project would be standardized providing a type "A"' RHU in municipalities with 10,000 to 50,000 population, and a type "B" building for municipalities with 5,000 to 10,000 population (variation of the demand under type "A" would be satisfied by varying the number of Barrio Health Stations, rather than the size of the RHU). 5.13 During negotiations the GOP confirmed its intention to establish RHU functions in the facilities mentioned under (b) above, in order to avoid duplications between RHUs and other Government medical institutions. Also, during negotiations the GOP agreed to undertake a survey of Barrio Health Stations to obtain information about the physical facilities and availability of resident staff and will prepare a plan for the rehabilitation and construc- tion of Barrio Health Stations. This plan will be submitted to the Bank for examination and comments within the first two years of the project execution period.  - 18 - 5.14 The project will finance construction, furniture and equipment for 158 buildings for type "A" RHUs which will be the center for outpatient care for municipalities with 10,000-50,000 population. The proposed schedule of accommodation for type "A" RHUs incluces consulting/examination rooms for the doctor and the midwife, a treatment room, a recovery room with 2 beds, a dental room, a multipurpose room for lectures and demonstrations for public health and social welfare work, family planning, nutrition, etc. Supporting services will include a laboratory for routine tests, a botica (a small pharmacy) records, etc. Offices will be provided for public health work and one office and storage area for social workers. In 38 locations where it is difficult to attract and retain professional staff, 2 staff houses will be built for type "A", RHUs. The type "A" RHU will provide health and family planning services and, in selected locations, will also be the focus for social welfare work organized by the Department of Social Welfare; it will be located in the "poblacion" (generally the largest barrio), and will serve the immediate population of about 10,000-15,000; in addition, it will support Barrio Health Stations which will be manned by a resident midwife/ community healthtfamily planning worker serving about 5,000 population (reorien- tation of midwives is also a part of this project, para. 5.24). 5.15 No construction of Barrio Health Stations will be included in the project; they will be built by the DOH or the municipality. The Government plans to provide BHS in barrios which are within municipalities where new RHUs will be built through the Bank project, so that the new service system can operate effectively. (The combination of RHUs type "A" and satellite BHSs is the essential basis for the new system to be started through this project.) As part of the revised service procedures, the project will provide simple radio/telephone equipment which will be the link between the base RHU and the Barrio Health Stations. 5.16 An important aspect of the new rural health system will be the employment of 5,000 additional midwives/community health/family planning work- ers (salaries for 2,400 of them will be initially financed by Bank funds, on a declining basis. Para. 6.14 (c)). During negotiations the Government agreed to sanction annually about 480 midwife positions adequately distributed among the regions, during the next five years. This scheme should be closely related to any future system of Government-sponsored fellowships for midwives (para. 4.15). -,.!i The type "B" RHU has been planned to serve the needs of smaller municipalities with 5-10,000 population. The project would finance 47 type "B" RHUs. The proposed schedule of accommodation for the type "B" RHU reflects the lower demand for services in the smaller communities. Accommodation includes a consultation examination room, a treatment room and a multipurpose lecture/demonstration room. By definition this type of RHU will be located in remote and sparsely populated areas; a staff house will therefore be built.  - 19 - 5.18 The project provides funds for maintenance of the new vehicles during a five-year period. Additionally, since the fleet of vehicles of the DOH is in poor repair and transportation is essential for the rural health program, including family planning activities, the project will finance spare parts for 300 existing vehicles. This assistance will strengthen the present vehicle maintenance system of the DOH, which is also receiving financial and technical support from UNICEF. Repairs will be organized by the Regional Health Offices in the DOH workshops or in private garages under contractual arrangements. The number of vehicles needing repair was estimated through a survey undertaken by the DOH in mid-1972, at the request of the Bank mission. Ri-U Management and Clinic Procedures 5.19 An operational research team assisted by WHO experts is conducting a series of studies on the rural health service system in the Province of Rizal, to define the actual demand for health services and to ascertain how public resources nave been used to serve the people in rural areas. These studies were undertaken to develop alternatives for redistributing duties among the health staff. The team produceda final report with recommendations, along with a manual of procedures and training schemes for the workers at various levels. The Health Planning Unit of the DOH is already developing the rural health plan following those suggestions. 5.20 The project will provide the means to increase RHU efficiency through buildings, equipment, additional staff and technical assistance. To this end, the findings and recomiendations of the GOP/WHO Rizal operational research team may be used as a basis for introducing improvements in the rural health services (see Appendix 1, Annex 4 for redistribution of functions among the health team members). During negotiations, the GOP confirmed its intention to request each Regional Health Office to develop a rural health service scheme within guidelines established by the DOH. Three to four index areas will be selected for initial implementation. Testing and implementation of such service schemes should be combined with the training program of the Regional Training Centers, which will also be a part of the project. Financing for a core staff at the Central level will be provided to promote and coordinate these efforts, with the assistance of six man-months of advisory services on health delivery services (these advisory services are included in Part D of the project, para. 5.28, item b.i. and para. 5.32). C. Regional Training Centers (RTCs) 5.21 The project will provide financing for facilities, equipment, furniture and advisory services for the training program of the Department of liealth, including:  - 20 - a. Construction of aniLu equipment and furniture for 11 Regional Training Centers, for in-service health and family planning training of Government staff. Each center will have, besides teaching and administrative facilities (including audiovisual and IEC equipment) a library and living accommodation for trainees and staff, 3 minibuses and 3 jeeps (including spare parts and vehicle maintenance); b. provision of additional materials and services for about 9 workshops for staff of the Regional Training Centers includ- ing trips and travel per-diem (3 per year for about 22 trainers each during 3 years); c. Technical advisory services for OHEPT on organization and training methods (12 man-months) and for development of the midwife/community health training programs for RTCs (12 man-months); and, d. Fellowships for midwifery tutors and Public Health Nursing supervisors in RHUs (33 one-year national fellowships). 5.22 The Department of Health conducts all of its health and family planning in-service training activities through its regional training centers. The Office of Health Education and Personnel Training (OHEPT) in the Depart- ment of Health is responsible for special courses; the Regional centers are directly under the supervision of the Regional Directors. Five regional centers are functioning in Manila, Dagupan, Iloilo, Cebu and Davao. Recently, two new centers opened at Naga and Zamboanga. 5.23 The project will provide new buildings for the 11 Regional Training Centers, since none of the present facilities are suitable for the proper fulfillment of the Centers' functions. Present teaching space consists of provisional arrangements for the use of office space within the Regional Health Offices. The DOH family planning training program has encountered problems of inadequate space, lack of transportation for students to attend field classes, and a scarcity of visual aids, contraceptive kits, books and other teaching materials. None of the Centers has any provision for living accommodations for trainees. Present living arrangements are highly inade- quate and impose a burden and inconvenience on trainees. 5.24 A significant additional activity in the project-financed Training Centers will be a three-month preservice course for midwives, which will re- orient them to become community health workers in RHUs and resident staff in Barrio Health Stations. Training loads will be considerable in the next five years, with the preservice training of 5,000 additional midwives (2,400 through the project). Also, midwives currently employed in the RHUs will have to under- go this reorientation. The project will finance 12 man-months of technical advisory services to assist the OHEPT and the RTCs in curriculum development and planning of the preservice courses for midwives in community health/family planning.  - 21 - 5.25 The project includes 33 one-year fellowships (three for each Region) to be used during the first three years of the project to train graduate nurses in Public Health and administration. This training will take place in the University of the Philippines Institute of Public Health and other national training institutions, starting in September 1974 and wiln be completed within the first three years of the project. The nurses would either be al- ready on the staff of the DOH or would be subsequently employed as trainers in RTCs and as supervisors in the Rural Health Program. 5.26 Another priority activity in these centers will be training in family planning for Government personnel (both health and other staff). The present training program of the Department of Health has been substantially assisted by the USAID and will continue to receive support from this source and from the GOP. The project will provide 12 man-months of advisory services to assist OHEPT and the RTCs in administration, teaching methods, curriculum development and planning of courses. 5.27 The buildings for the RTCs will be designed on the basis of a review of the proposed curriculum and number of course participants; space utilization charts were prepared by the mission in consultation with the DOli. Seven teaching spaces will be provided producing a use factor of 64% of available time and an occupancy factor of 60-70%. Living accommodation for staff and visiting lecturers will also be provided. About 20% of the participants will have accommodations in the town. For teaching there will be two lecture rooms with projection, four seminar rooms (one of which will double as a demonstration room for family planning), one demonstration labora- tory for public health work, a library, administrative offices and a conference room. D. Direct Project Assistance to the Department of Health 5.28 There are several project components designed to strengthen func- tions of the Department of Health's capacity to undertake project coordination and evaluation. They include: a. Salaries for core staff (to be disbursed by the Bank on a declining basis - para. 6.14 (c) and equipment to undertake additional services in Health Statistics in the Department of Health; b. Technical advisory services for (i) new RHU procedures (6 man-months); (ii) logistics and supplies distribution (12 man- months); and (iii) health statistics (6 man-months); C. Study tours for 3 senior DOH nurses; and d. Facilities evaluation study and provision for future project preparation.  - 22 - Record-Keeping, Statistics a1d Evaluation 5.29 The system of record-keeping and .3tatistics in RHUs is not pro- viding regular and complete data for evaluating the activities of those units; no reliable information is currently available on operations and vital statistics. In 1971, a WHO consultant advised the Government on health service records and reports, as part of a General Health Service Develop- ment Project underway since 1969 in the Province of Rizal. The study revealed that many of those forms were redundant or useless and recomuended their re- placement by several newly designed form. An instruction manual for reporting and for a new filing and record-keeping system for RHUs, and recommendations for the reorganization of the data transmittal system were also prepared. .30 This system is not yet operating nationally; this would require organization of a new central health statistics unit and enough manpower for processing, analyzing and instructing the RHU and Provincial personnel on the new procedures for record-keeping, filing and data transmittal. Furthermore, the present system of consolidating the information from individual records at several administrative levels (i.e. REHU, Municipal, Provincial and Regional levels) before the information reaches the national office, has considerable disadvantages. 5.31 Through the present project, a reorganized office of health statistics and evaluation system will be set up in the DOH; salaries for core staff at the central level and in the regions will be financed on a declining basis to assist in the development of an improved statistical system that would be the basis for RHU performance evaluation, central data analysis, production of periodic health statistics reports and a feedback system to the RHUs, with comparative performance figures. The project will also provide six man-months of technical assistance to the DOH's reorganized health statistics office. Other Technical Advisory Services 5.32 The project also includes an adviser for one year to develop uniform inventories for supplies and medications for RHUs. The adviser would recommend arrangements for procurement, location of storage points and method and fre- quency of distribution. Six months of advisory services on health delivery for RIU new procedures are also included for Bank financing through the project 1(6ee also para. 5.20). 5.33 As part of the efforts to strengthen the central administration of the family planning program and the DOlt training programs three fellowships for two, three and five months respectively will be financed for overseas courses for the following nurse/midwives positions at the central level: (a) DOH Nursing Program Supervisor for MCH; (b) Nurse Coordinator of the Na- tional Family Planning Office and (c) the Nurse Training Coordinator.  - 23 - Facilities Evaluation Study 5.34 This project will finance an evaluation study of project facilities and programss to be initiated by July 1976, which would also serve as a basis for the design of facilities needed for further expansion of the system. The main objective of this evaluation will be to relate capital and operating costs to (a) staffing patterns and worktime, (b) facilities used for various functions, and (c) the amount of services delivered. The terms of reference for this study are given in Annex 7. VI. PROJECT COST, FINANCING, DISBURSEMENT AND IMPLEMENTATION A. Cost 6.01 Of the total project costs of P339 million (US$50 million), $US21.5 million is for the construction and equipping of physical faci- lities, US$1.4 million is for vehicles, US$0.6 million for technical assistance and studies, US$0.7 million for special equipment, and US$7.4 million for incremental recurrent costs, US$2.0 million for physical con- gencies and US$16.4 million for price escalation. 6.02 Detailed project costs, which are exclusive of taxes, are shown in Annexes 8 and 9 and summarized in the following tables. 6.03 The estimates of construction cost have been based on a cost analysis prepared (as of mid-1973) by the private sector and reviewed by the Department of Public Works. A 15% allowance has been made for provincial variations in construction cost and also for the higher cost of construction in especially remote areas (see Annex 8). A construction contingency of 10% have been allowed to cover unexpected hazards during the construction period. The cost has been updated to June, 1974 mainly on the basis of a recent NEDA issue of Economic Indicators, and future escalation has been estimated accord- ingly to 16% for construction during the second half of 1974, 19% during 1975 and 12% per annum thereafter. Annual price escalation for non-construction items was estimated as follows: for vehicles and special equipment, 15% the first year, 12% the second year and 9% thereafter; for other non-construction costs, 9% per year for the first 3 years and 5% thereafter per year during the 5-year period.  -24- PHILIPPINES Foreign A. PROJECT COST BY TYPE PhiliDpine P USS Exchange OF EXPENDITURE Local Foreign Total Local Foreign Total ComDonent I. Civil Works A. Siteworks & Construction l, RHU Type 'A' (158) 46.33 29.61 75.94 6.83 4.37 11.20 2. Housing ( 38) 2.07 1.32 3.39 0.30 0.20 0.50 3. RHU Type 'B' ( 47) 6.53 4.18 10.71 0.97 0.61 1.58 4. Regional Training Centers 18.36 11.74 30.10 2.71 1.73 4.44 Subtotal 73.29 46.85 120.14 10.81 6.91 17.72 39 B. Fees & Supervision 12.88 - 12.88 1.90 - 1.90 - C. Furniture & Equipment 7.80 5.02 12.82 1.15 0.74 1.89 39 II. Other Proiect Costs D. Special Equipment - 4.75 4.75 - 0.70 0.70 100 E. Vehicles & Spare Parts 7.80 1.36 9.16 1.15 0.20 1.35 15 F. Technical Assistance 1. Advisors - 1.29 .1.29 - 0.19 0.19 2. Fellowships 0.27 0.34 0.61 0.04 0.05 0.09 3. Special Studies 0.81 1.56 2.37 0.12 0.23 0.35 Subtotal 1.08 3.19 4.27 0.16 0.47 0.63 75 G. Incremental Recurrent Costs 1. Salary Support 43.39 - 43.39 6.40 - 6.40 2. Workshops & Trips 0.20 0.27 0.47 0.03 0.04 0.07 3. Operating Cost 6.37 - 6.37 0.94 - 0.94 Subtotal 49.96 0.27 50.23 7.37 0.04 7.41 0.5 H. Project Construction Unit 0.34 - 0.34 0.05 - 0.05 - III. Contingencies A. Physical 8.13 5.16 13.29 1.20 0.76 1.96 B. Price 1. Civil Works 59.12 35.12 94.24 8.72 5.18 13.90 2. Non-Construction 14.24 2.64 16.88 2.10 0.39 2.49 Subtotal 81.49 42.92 124.41 12.02 6.33 18.35. 35 TOT,%L PROJECT COSTS 234.64 104.36 339.00 34,61 15.39 50.00 31 B. PROJECT COST BY FUNCTIONAL CATEGORY % of Total Program Administration 2.37 0.95 3.32 0.35 0.14 0.49 1 Services 181.37 72.35 253.72 26.75 10.67 37.42 75 Training 44.61 27.05 71.66 6.58 3.99 10.57 21 Health Statistics 2.24 0.95 3.19 0.33 0.14 0.47 - Evaluatior. & Research 1.22 2.24 3.46 0.18 0.33 0.51 1 IEC 2.44 0.82 3.26 0.36 0.12 0.48 1 Project Construction Unit 0.39 - 0.39 0.06 - 0.06 - TOTAL 234.64 104.36 339.00 34.61 15.39 50.00 100  - 25 - 6.04 The foreign exchange component is estimated at US$15.4 million, which represents 31% of total project costs. It has been calculated as 39% of civil works, 58% of the cost of furniture and equipment, 26% of the cost of vehicles, and 75% of the cost of technical assistance and studies. B. Proposed Financing 6.05 The project would be financed by a Bank loan of US$25.0 million equivalent (50%) a Government contribution of US$24.4 equivalent (48.0%); the UNFPA will provide US$0.43 million (1.0%) and the USAID, US$0.51 million (1%). The Bank loan will cover 50% of the total project costs, including the foreign exchange component of US$15.3 million and local costs amounting to US$9.7 million equivalent. This Bank loan will provide some local currency financing to assist the Government in extending family planning services to the large rural sector of the population. The loan would have a term of 25 years, including a five-year period of grace. Retroactive financing for US$350,000 from May 1, 1974 will be provided to cover the salaries of the project construction unit and consultants' fees. C. Procurement 6.06 All contracts over US$70,000 equivalent for civil works, furniture, equipment, vehicles and spare parts required for the project will be awarded on the basis of International Competitive Bidding (ICB) in accordance with the "Guidelines of Procurement under World Bank Loans and IDA Credits" (October 1972). To the extent practicable, orders for civil works, and for furniture and equipment shall be grouped in lots of not less than US$70,000 equivalent. Contractors for civil works will be prequalified and notices of invitation will be inserted in national newspapers and circulated to the embassies of member countries represented in the Philippines. To make allowance for standardization and spare parts required for existing equipment, contracts not exceeding US$70,000 and in aggregate not exceeding about US$200,000 may be procured on a competitive basis in accordance with the normal pro- curement procedures of the Borrower. Domestic manufacturers of furniture, equipment and vehicles will be accorded a margin of preference equal to 15% of the c.i.f. costs of competing imports. 6.07 The Borrower will prepare and submit to the Bank for comment, promptly upon their preparation, the preliminary architectural drawings and the outline of the specifications for the buildings and facilities included in the project.  - 26 - D. Implementation 6.08 The GOP will designate its Commission on Population to coordinate the work, in respect of the project, of the Government agencies participating in its execution. A Project Construction Unit (PCU) will be established with- in the Department of Health, headed by a Director. If he were already a senior official in the Department of Health, he could serve on a part-time basis. The unit would also include a full-time Project Architect, (duties and responsibilities included in Annex 8) and supporting staff such as a project accountant and an equipment specialist, who would be seconded from other Government offices. Additional staff (such as personnel from the Department of Public Works, Transport and Communications to help in site selection) could be borrowed from other Government Departments as required. The GOP will appoint after consultation with the Bank qualified and experienced persons to serve as Director and as Project Architect of the Project Construc- tion Unit. These appointments will be conditions of loan effectiveness. 6.09 In addition, the GOP will employ a firm of executive architects and/or a firm of construction management consultants whose qualifications, experience and terms and condition of employment will be satisfactory to the Bank. (Duties and responsibilities included in Annex 8.) The major problems anticipated in the implementation phase lie in management cost control and maintaining progress of construction in the rural areas and it will not be necessary to retain consultants specializing in the design of health facili- ties. Construction management consultants are available in the Philippines and have been employed in this capacity for major projects. The executive architects will be required to retain the services of construction management consultants if both architectural and management services cannot be supplied by a single firm. Resident Clerks of Works will be appointed to provide day-to-day supervision of construction while the executive architect will provide the customary periodic inspection of work in progress. E. Sites 6.10 Site selection criteria were prepared by the, August, 1973 mission to identify and acquire actual sites. A list of locations is included in Annex 8. Government land is available in most rural areas and no special difficulties in transfer are foreseen. The DOH began selecting and acquiring sites after the August 1973 mission, and has furnished the Bank, at the time of negotiations, a list of the sites already acquired, as well as a timetable for the acquisition of the remaining sites.  - 27 - 6.11 The RHUs which make up the Bank project were drawn from a national list: of facilities requiring replacement on the grounds that they were either dilapidated or housed in buildings such as municipal halls (owned by other agencies). The criteria for selection were agreed during appraisal. Speci- fically included are the great majority of rural municipalities which fall firstly in the 10-50,000 population bracket and secondly, in the 5-10,000 bracket. 6.12 Excluded are municipalities with population less than 5,000 and those where the population will exceed 50,000 by 1983, becoming thereby "urban" rather than "rural." For those municipalities DOH is developing health delivery programs outside the Bank project. Also excluded, on grounds of duplication of service, are municipalities where there are exist- ing or proposed Government Hospitals, Emergency Hospitals or Comunity Uospitals and Health Centers (detailed criteria are described in Annex 4, para. 14). 6.13 Sites for the Regional Training Centers will generally be within the compound of Regional or Provincial Hospitals; this relationship will permit easy access to clinical demonstration material and supporting services such as food supply and laundry. Similarly, clinicians will be well placed to contribute to the teaching program. F. Disbursements 6.14 The loan would be disbursed to meet 50% of total project cost. However by disbursement categories disbursable amounts would be: (a) 100% of total expenditures for technical assistance (both local and foreign) and of the c.i.f. cost of imported vehicles, furniture and equipment or the ex factory cost of domestically produced vehicles and furniture and equip- ment; (b) 39% of total expenditures for civil works and recurrent expendi- tures, estimated to make the total loan equivalent to 50% of total project costs; and (c) On an annual basis, 90, 70, 50, 30 and 30% will be applied to annual incremental recurrent costs incurred in project years 1 through 5 respectively, so that the loan would finance 39% of such total costs. 6.15 Retroactive financing for US$350,000 is provided from May 1, 1974, for preliminary engineering and architectural work and to set up the Project Construction Unit. The Commission on audit of the GOP will audit the accounts and financial statements of the DOH related to the project, at least annually and will furnish to the Bank certified copies of such statements no later than six months following close of fiscal year. Undisbursed funds would be avail- able for cancellation. A disbursement schedule is included as Annex 10.  - 28 - VII. PROJECT JUSTIFICATION 7.01 The national population program is designed to reduce the total fertility rate by about 25% of the present level -- from 6.4 in 1970 to 4.8 in the year 2000. Over 15 million births would be averted during that period as a result of the program. Family planning practice is also ex- pected to increase outside the program, as a result of improvements in socio-economic conditions and independently of program efforts. If this effect is also included, a total of 25 million births are estimated to be averted from 1970 to the year 2000. Total fertility would then decline from 6.4 to 3.8 and total population would be close to 79 million by the year 2000, almost double the current population, but some 23 million lower than the 102 million persons which would result if fertility remained constant; and the population growth rate would be 2% per annum in the year 2000 instead of the current 3%. 7.02 The project is estimated to contribute directly to at least one sixth of the projected fertility decline of the national program -- by averting 2.5 million births between 1979 and the year 2000. This is the direct effect of the project resulting from bringing family planning ser- vices to the rural population, whose participation is essential to achieve such a fertility decline. The new RHUs, the network of Barrio Health Stations and the additional midwives will provide services to at least 7.8 million more people by 1979 than at present (or 1.6 million more women in the reproductive ages). 7.03 Other important, but non-quantifiable benefits can also be expected from the project. These result from information-education and communication activities which are expected to increase the demand for family planning services, training of family planning personnel at the regional level, tech- nical assistance for training and communication activities, continuing evaluation of the program, transportation, etc. In summary, all these ele- ments of institutional development for the POPCOM and the DOH may well be as important in improving program effectiveness and reducing population growth as is the direct effect of the project's physical facilities. 7.04 The demographic effect of the project would have important social and economic implications. A smaller number of children in the individual household means that more resources would be available for consumption and/or private savings. Living standards of the population would improve meaning more food and better nutrition for each family member, better maternal health and child care, improved opportunities for education, etc. The poorer families of the rural population are expected to be the main beneficiaries of this project. 7.05 Over the long run, a slower rate of population growth would reduce the rate of increase of the labor force. The rate of urban unemployment in the Philippines is over 12% and underemployment is known to be prevalent among the labor force. A smaller number of births would thus reduce the pressure on the labor market and, ceteris paribus, unemployment.  - 29 - VIII. RECOMMENDATIONS 8.01 During negotiations, agreement was reached between the Government of the Philippines and the Bank on the following points: (a) The GOP will sanction new positions for midwives/community health workers to be resident staff in Barrio Health Stations and RHUs, at the rate of 480 positions per year to complete a total of 2,400 new posts in five years, beginning in FY 1974/75 (para. 4.16 and 5.16); (b) The GOP will cause the Regional Health Officesto select 33 graduate nurses who will undergo one-year training in Public Health, administration and other related fields, starting in September 1974, with fellowships financed through this project; this training will be completed by 1976. The GOP will sanction positions as required, to employ these trainees as tutors in the Regional Training Centers and as Supervisors in the rural health program (para. 5.25); (c) The GOP will continue to carry out an evaluation of its family planning program under terms of reference which shall include those set forth in paras. 5.08 - 5.10. (d) The Bank will approve the qualifications, duties and responsibilities of the Director of the Construction Unit and the Project Architect and their appointments will be made in consultation with the Bank. The appoint- ments of all advisors to be used in the project over continued periods exceeding five months will also be made in consultation with the Bank (para. 6.08); (e) The GOP will cause, no later than December 31, 1974, the POPCOM, the Board of Midwifery, the Department of Health and the Department of Education to form a special commit- tee to review policy regarding training of midwives (both by Government and private schools) with special attention to matters referred to in para. 4.14 with a view to producing recommendations within the first two years of the project, which will be submitted to the Bank for comments, together with an implementation plan; (f) The Department of Health will urLdertake a survey of Barrio Health Stations to obtain information about physical facilities and availability of resident staff and will pre- pare a plan which will include rehabilitation of Barrio Health Stations;such plan will be submitted to the Bank for examination and comments within the first two years of the project period (para. 4.03 and 5.15);  - 30 - (g) Starting in July 1976, the GOP shall cause a study to be undertaken on cost, effectiveness and utilization of project facilities under terms of reference submitted to the Bank for consultation and comments; consultants for this study will be appointed in consultation with the Bank; the study will be used as a basis for formula- tion of subsequent project activities (para. 5.34); and (h) All sites for facilities to be built through this project should be acquired by the GOP promptly, as required to keep up with the schedule for civil works. 8.02 Also as recorded in minutes of negotiations, the Government confirmed that it intends to undertake the actions described in: (a) para. 4.15 Govern- ment Scholarship Plan for midwives, (b) para. 5.20 on testing and implement- ation of new service procedures in RHUs by Regional Offices; (c) para. 4.06 and 5.13 on RHUs and family planning in Medical Care Commission Hospitals; and (d) para. 5.14 on participation of social workers in the family planning actitivities of RHUs. 8.03 The following will be conditions of loan effectiveness: (a) the establishment of the Project Construction Unit (para. 6.08); and (b) the appointments of the head of the Project Construction Unit and the Project Architect after consultation with the Bank (para. 6.08).  ANNEX 1 DEMOGRAPHIC ANALYSIS Contents Page Nlo. A. Basic Demographic Data .............. 1 Censuses ............................ 1 Vital Registration .................. 1 Surveys ..................... . 0..... 1 Demographic Research Facilities ..... 2 B. Country's Demographic Background *... 2 Introduction ........*.** **.** *... * *. 2 Population Projections .............. 5 Education .. ..... ,......0.*... 6 Employment .......................... 7 C. Implications of Population Trends for Program Targets ........ . . . . . . . . . ....... 8   ANNEX 1 Page 1 of 1S DEMOGRAPHIC ANALYSIS A. Basic Demographic Data 1. Birth and death registration in the Philippines is still deficient in spite of Government efforts to improve the vital registration system. For instance, recent publications of the Department of Health indicate a birth rate of 27 per 1000 for 1968, which differs very markedly from fertility indi- cators derived from reliable analyses of the population's age structure obtained from the censuses and national surveys. Estimates based on the 1970 census, for instance, point to a birth rate of 40 per 1000 for the period 1960-70. Analysis of the present fertility situation as well as past trends are very limited due to the absence of reliable registered data. Current knowledge of the fertility levels in the Philippines is mainly contained in studies produced by the University of the Philippines Population Institute sometimes in corpera- tion with other Universities.l/ Censuses 2. The last two censuses in the Philippines were taken on February 15, 1960 and on May 6, 1970, in compliance with the United Nations expressed ob- jective of carrying out decenial censuses. The 1970 census is the sixth pop- ulation count undertaken during this century since 1903. Analysis of census data has become an important tool to ascertain mortality and fertility levels in countries with poor vital statistics. It is therefore highly desirable that especial attention be given in the Philippines to census analysis, at least with reference to the 1970 census; unfortunately, individual record files for earlier censuses have been destroyed, thus ruling out any thorough analysis of past fertility and mortality. Vital Registration 3. As mentioned above, the vital registration system in the Philippines is seriously deficient, with only between 60 to 70 percent of births and deaths being registered. Recently, a Dual Registration System has been initiated under which the existing registration system is continued and at the same time a Periodic Household Enumeration is undertaken on a sampling basis. This new system encountered some initial difficulties that have now reportedly been resolved; next year it should be possible to obtain fairly accurate vital rates from this source. Surveys 4. National Demographic Surveys (NDS) are sample surveys of households carried out every five years. One such survey carried out in 1973. Earlier NDS were undertaken in 1958, 1963, and 1968. These surveys have supplied the only direct information on marital age-specific fertility rates.  A\NNEX 1 Page 2 of 18 Demographic Research Facilities 5. There are several institutions in the Philippines carrying out re- search in Demography. The University of the Philippines Population Institute in Manila, the University of San Carlos in Cebu City and the Xavier University in Cagayan de Oro are among the institutions working in this field. The Bureau of the Census is planning to form a research team mainly to analyze the information contained in the 1970 census tapes. 6. The POPCOM4 has reorganized its executive office and is developing (with UNFPA financing) Management Information System within its new Planning Division following recommendations to plan research needs, specify research projects and support research relevant to program efforts. 7. Several foreign researchers are working in demography in the Philip- pines. Although Filippino nationals have been trained in demography both in the country and abroad in the last ten years, only a few reamin in the national universities, and those few are reportedly very much in demand form other agencies for part time work or have very heavy teaching schedules. All this prevents them from devoting adequate time to research. Low salaries have been most often mentioned as the inhibiting factor in attracting capable nationals into demographic research. The situation as stated above does not call for the creation of new demographic research insitutions, but rather for improving staff employment conditions in the existing universities. The expanded division of POPCOM mentioned above will play an important role in ascertain- ing research requirements and financially supporting those institutions to allow them to build up adequate research capacity. B. Country's Demographic Background Introduction 8. The population of the Philippines has grown from 7.6 million in the first census taken in this century (1903), to almost 37 million in 1970. Population growth accelerated considerably after the World War II period. 'Wh1ile it had taken 33 years for the population to double between 1963 and 1930, the doubling period prior to the 1970 census was only 24 years. Faster growth has been a result of a decline in mortality, brought about by improve- ments in public health, medicine and nutrition, combined with persistent high fertility. International migration has not been numerically significant to influence population growth. The average annual rate of growth of the popula- tion in the decade 1960-70 was three percent, placing the country's popula- tion among the fastest growing in the world. Estimates for the same period indicate a birth rate of 42 per 100.0, a death rate of 12 per 1000 and a total fertility rate of 6.4 per woman 15-49 years of age.  ANNEX 1 Page 3 of 18 9. A recent fertility analysis 1/ based on data from the National Demo- graphic Surveys of 1958, 1963 and 1968 throws some light into the fertility changes experienced by the population during that period. However, since only information on ever married women was provided by those surveys, the analysis is limited to that group. The rates presented there were below the actual overall fertility rates due to the exclusion of all premarital births and births to never-married women. Discrepancies are greatest for the younger age groups, where most extra marital births tend to occur. The following age-specific marital live birth rates are presented in Flieger's paper: Age at Period Childbirth 1953-58 1958-63 1963-68 Actual Age-Specific Rates 15-19 86 60 26 20-24 263 240 186 25-29 312 301 303 30-34 278 290 262 35-39 215 208 229 40-44 92 1C04 112 45-49 23 2.5 20 TFR 6.35 6.14 5.69 Rates Standardized on Proportion of Women Married 15-19 46 60 90 20-24 229 240 290 25-29 290 301 339 30-34 274 290 276 35-39 215 208 231 40-44 91 104 110 45-49 23 25 20 TFR 5.84 6.14 6.77 10. Although the direct comparison of total fertility rates of ever- married women would seem to indicate a decline in fertility, once these rates are adjusted for changes in age distribution of married women, with 1958-63 as standard population, the standardized rates show an opposite trend with a 10% increase in total fertility. As the author indicates "there were fewer married women in the younger childbearing ages in the mid-sixties than five years earlier, but these young women who were married had more children in early years of marriage than their predecesors." 11. The same paper analyzes cohort fertility for those women in the sample surveys and the conclusion is drawn that "today, as three or more decades ago, childbearing in the Philippines starts early and extends over  ANNEX 1 Page 4 of 18 the entire reproductive life span ow women. In short, traditional patterns prevail." It is further concluded that whatever fertility decline was taking place (before 1970) would appear to represent nothing more than elimination of some of the excess fertility which was a consequence of the post-war high fertility level. 12. Be regions, the total fertility rate varies from more than seven in North Mindaao and Bicol, to 4.5 in Manila, the Ilocos Region and South Western Mindanao and Sulu. According to Flieget, present regional differentials (excluding the Ilocos and Southern Mindanao) are largely due to variations in age at first marriage and post-war developments such as migration and indus- trialization. The following total marital fertility rates by period and Region were calculated on the basis of data from the National Demographic Surveys: Percent Period Changes Region 1953-58 1958-63 1963-68 1953-68 Actual Rates All Regions 6.35 6.14 5.69 -10.4 Greater Manila 5.20 4.92 4.52 -13.1 Ilocos and Mt. Provinces 4.71 4.23 4.59 - 2.5 Cagavan Valley 8.07 6.78 6.10 -24.4 Central Luzon 6.93 6.65 6.09 -12.1 Southern Luzon 6.27 5.80 5.28 -15.8 Bicol 7.14 7.38 7.13 - 0.1 Western Visayas 6.13 6.22 6.08 - 0.2 Eastern Visayas 6.25 6.23 5.97 - 4.5 - Northeastern Mindanao 6.97 7.31 7.48 + 7.3 Southwestern Mindanao 6.32 5.73 4.56 -27.8 Standardized Rates * All Regions 6.35 6.70 7.30 +15.0 Greater Manila 5.20 5.70 6.52 +25.4 Ilocos and Mt. Provinces 4.71 5.11 6.82 +44.8 Cagayan Valley 8.07 8.03 8.08 0.0 Central Luzon 6.93 7.34 8.39 +21.1 Southern Luzon 6.27 6.32 6.61 + 5.4 Bicol 7.14 7.95 8.95 +25.4 Western Visayas 6.13 6.79 8.29 +35.2 Eastern Visayas 6.25 6.79 7.52 +20.3 Northeastern Mindanao 6.97 7.80 9.13 +31.0 Southwestern Mindanao 6.32 6.07 6.04 - 4.4 * Standardized by Age and Marital Composition.  ANNEX 1 Page 5 of 18 13. It was found in this study that the regions which preserved their agricultural economic base also preserve high fertility (Central Luzon and Bicol) regardless of development. Only metropolitan Manila and Southern Luzon showed slight indications of fertility decline, which may be indicative of an inverse relation between industrialization and fertility. 14. These data would seem to indicate that voluntary birth limitation is not significantly practiced among couples and this would seem to be espe- cially the case in areas outside the industrialized cities, where about 70 percent of the population lives. 15. In spite of the decline in the crtde birth rate, high infant mortality (increasingly being considered as a probable factor acting against the desire for family limitation) is still a serious problem. The infant mortality rate estimated from the 1970 census was almost 80 per 1000 live births, or at least four times as high as in developed countries and at least double that of other developing countries of that region. Population Projections 16. Two population projections were prepared for this report to illus- trate the effect of alternative trends of fertility and mortality in the next three decades. They are presented in Table 1, together with the corresponding birth, death, natural increase and infant mortality rates. The following as- sumptions of fertility were built into the projections: Projection A: Almost constant high fertility during the period; and Projection B: Moderately rapid decline in age-specific fertility rates, to 80% of the 1970 values by 1975 and to 60% by the year 2000. 17. In both projections, life expectancy at birth is assumed to increase from 56 and 60 for males and females in 1970, to 65 and 69, respectively in the year 2000. Projection A is used here as a "maximum"' level of reference against which the efforts that would be required in terms of family size limitation will be measured. Projection B reflects up to 1975, the goals stated by the Government, which consist of decreasing the average rate of population growth to 2.5% by that year. A moderately rapid fertility decline is assumed thereafter, which would result in a total fertility rate of 3.8 children per woman in the year 2000, compared to 6.4 in 1970. 18. These estimates provide only a range or possibilities, yet they serve to underline the serious implications of delays in reducing fertility. The assumption of constant fertility up to the year 2000 indicates an upper limit of almost 102 million persons in that year. The alternative popula- tion trend would be accomplished if couples practiced family limitation, both using the program's services and independent of it, to the extent of omitting  ANNEX 1 Page 6 of 18 over 25 million births in the next 26 years. Of this number, about 900,000 births would be omitted from 1987 on as a result of declining fertility trends i.n previous years and a consequent decline in the number of women entering into reproductive ages from 1987 on. This magnitude of birth omission would only be possible if efforts through the family planning program are successful and at the same time, fairly basic attitude changes toward procreation take place fairly rapidly. Under those circumstances, the total population in the year 2000 would reach nearly 79 million, which is almost double the number currently inhabiting the country, but some 23 million lower than the upper limit mentioned earlier. 19. The alternative projections have substantial implications for sectors such as education and health and for other socio-economic aspects. Education 20. The country has achieved a literacy rate which is among the highest in South Asia. About 83% of the population 10 years and over is considered literate. Elementary education is offered free to all children and is mainly financed by the Government. For the secondary level (4 years' duration) enrollment reached 71 percent of the group 13-17 years in 1970. Higher educa- tion institutions have enrollment ratios second only to those in Canada and United States, although in the Philippines higher education is shorter in dura- tion and therefore ratios are not strictly comparable. However, according to a Bank education appraisal mission which was in the field in 1971, these quan- titative achievements have not been matched by qualitative accomplishments. The report adds that the system has become too large for the country to support and faces increasing pressures resulting from population growth. 21. The elementary school age population (6-12 years) which in 1971 was 3.7 million would almost double by the year 2000, even if projection B, which implies moderately fast fertility decline, is achieved. That group could reach as high as 9.8 million children in 2000 under a constant fertility trend. The implications of the alternative population projections for secondary school and college resources are shown below, together with the trends for the elemen- tary school age population: Population in Thousands Elementary Secondary College 6-12 years 13-16 years 17-20 years A B A B A B Year No. Z* No. %Z NO. %* No. %* No-. * No. %* 1971 3,730 3,730 1,683 1,683 1,505 1,505 1980 4,823 30 4,664 25 2,463 46 2,463 46 2,047 36 2,047 36 1985 5,293 42 4,522 21 2,724 62 2,686 60 2,548 69 2,446 63 1990 6,376 71 4,996 34 3,063 82 2,530 31 2,693 79 2,611 73 1995 8,121 118 5,696 53 3,717 121 2,804 67 3,169 111 2,540 69 2000 9,789 162 6,480 74 4,524 169 3,191 90 3,487 156 2,864 90 * Percent increase  ANNEX 1 Page 7 of 18 22. In order to keep providing free elementary education to almost all children between 6 and 12 years, by 1980, the capacity of the educational system (teachers, administrative staff and buildings and equipment) would need expansion to accommodate 25 to 30% more students. From that point in time on, the expansion needed for the educational system would differ consid- erably depending on whether the population's fertility is declining or not. For instance, by 1990 the group 6-12 years would increase by 34% or 71% de- pending on whether fertility remains constant or declines according to pro- jection B. The secondary school group (13-16 years) would be 31% or 82% larger than in 1971, also depending on the fertility trends. For the college-age group (17-20) which is also the group seeking entrance to the labor force, the effect of a decline in fertility would be noticeable only after 1990 and the differences resulting from alternative fertility trends (constant or de- clining) would be dramatic by 1995 when an increase of 69% with respect to 1971 could be expected if fertility declines, compared to a doubling of this group if fertility remains constant. Employment 23. During the 1960's the labor force in the Philippines grew at an average annual rate of 2.7%. Over the same period the population of working age grew by 3.4%, indicating a rather pronounced decline in the participation rate. The main reason for this is the increased rate of school enrollment. During the 1970's the increase in the population of working age will slow down somewhat, to about 3.1%. Due to the fact that the school enrollment rate will continue to increase, although at a slower pace than in the 1960's, the increase in the labor force over the 1970's is supposed to remain about the same, i.e., 2.7% per annum. A serious problem will arise in the 1980's, when the school enrollment ratio will not increase any further, and the growth in the labor force will start to reflect the full impact of the growth in the population of working age. A sharp increase in the rate of growth of the labor force during this and the following decades can only be prevented by increasing the effort in the area of family planning as quickly as possible. 24. The growth in employment during the previous decade at 2.5 percent per annum has not been able to keep pace with the rate of increase in the labor force, even though this last one was moderated by the increase in the school enrollment ratio. It may be assumed that the increase in the school enrollment ratio was partially a consequence of this discrepancy, as the supply pressures in the labor market induced people to extend the length of their education. A sectoral breakdown of the growth in employment, plus the prospects for its growth during the present decade, are given below:  ANNEX 1 Page 8 of 18 Labor Force and Employment- Percentage of Annual Growth Labor Force 1960-70 1970-80 1960 1970 1980 Labor Force 2.7 2.7 100 100 100 Employment 2.5 2.5 94 92 92 Agriculture 1.2 1.0 58 50 42 Mining and Manufacturing 2.3 3.0 12 12 11 Services 5.1 4.8 24 31 39 Unemployment 5.0 2.7 6 8 8 /1 Calculation from rounded figures. 25. Especially alarming is the slow growth in employment in the sector of mining and manufacturing. The employment in the mining sector grew by over 6% during the 1960's, but this sector is still rather small, employing less than 4% of the labor force working in both sectors combined. The employment in the manufacturing sector, which in a developing country should ideally grow considerably above average in order to cope with the slow growth in agricultural employment, is expected to grow only slightly faster in the 1970's, as much of the expected growth in real output can be achieved by using the present excess capacity in the manufacturing sector. Agriculture probably will not be able to absorb labor at an average rate of more than around 70,000 workers per annum, indicating a 1% growth in agricultural employment. Employment growth in the service sector, finally, is expected to drop below 5%, thus leading to a forecast of the growth in total employment during the 1970's of 2.5%. This means that unemployment will continue to increase. 26. For the 1980's, prospects are still more dim due to two factors. In the first place, as explained, the labor force will start to grow at a higher rate. In the second place, a further drop in the rate of growth of agricultural employment is expected. C. Implications of Population Trends for Program Targets 27. As pointed out in para 18, if the population of the Philippines were to follow a trend closer to projection B, about 25 million births would have to be omitted in the next 27 years. This estimate of birth omission was calculated as a difference between "maximum" fertility and an assumed reason- able declining fertility trend. These calculations are presented in Tables 2 through 6. As indicated in Table 2, in order to accomplish the fertility re- duction illustrated by projection B, the number of continuous contraceptors  ANNEX 1 Page 9 of 18 per year 1/ would have to increase from 19% of all married women in 1974 to 36% in 1985. Of this number, about 50-60% would be using the services of the program. Tables 3 and 4 present the detailed calculations of continuous contraceptors from 1974 to 1985. 23. The level of clinic activity in family planning has been estimated assuming that a proportion of contraceptive users varying from 40% in 1974 to 50% in 1991 and subsequent years will be practicing family planning effectively without using the program services, i.e., will be buying contraceptives through commercial outlets and consulting private physicians. This is a reasonable assumption taking into account that in 1971/72 approximately 30% of the con- traceptive pills used were sold through commercial channels 2/. On the basis of this assumption, it is shown in Table 5 that in 1974 the national family planning program would need to recruit 528,000 new acceptors. During the years between 1975 and 1980 the annual recruitment would have to increase from 681,000 to 715,600 and by 1985 it should reach to 1 million (12% of all married women). Estimation of the recruitment level to achieve projection B indicates that by the end of the century the program would be recruiting 1.4 million acceptors per year. However, these estimates of new acceptors are based on certain conservative assumptiohs of continuation rates for women already in the program (see footnote 3, Tab:.e 2), If in the future these continuation rates could be improved, the implication would be a need for less new acceptors per year. 29. In 1975, when according to these estimates 16% of all married women in the Philippines would need to be practicing effective contraception throughout the year, program clinics should be prepared to service 1,185,700 clients and to recruit 681,800 new acceptors. Unless there are substantial changes in the mixture of methods, the level of clinic work would be at 2.3 million by 1985. 30. In the short run (say about 2 to 3 years) there is a fair chance that the target numbers for the program, outlined in Tables 5 and 6, may be achieved with reasonably moderate strengthening in the organization, staffing and facilities of the family planning delivery system, face-to-face motivation and education and communications activities. However, the long-term capacity needs of the program to reach clients and to render clinic services covering the entire country should be a matter of concern which requires serious plan- ning. Careful study of geographical distribution of service facilities will have to be complemented by imaginative and effective approaches to increase the adoption of contraceptives by increasingly larger numbers, in a relatively short time. 1/ Continuous contraceptor is defined as a woman effectively protected against pregnancy during the whole year. 2/ Source: Westinghouse Population Center, Part I of the Survey of Global Patterns on Contraceptive Distribution in the Private Sector in Selected Developing Countries, Columbia, Maryland, 1972.  ANNEX 1 Page 10 of 18 31. For the next two to thiree years the present facilities available to the family planning program will be sufficient to handle the volume of clients and acceptors to meet the targets of fertility decline, provided that: (a) these clinics serve adequate catchment areas and (b) they function effectively with at least three half day sessions a week and service an average of 12 patients per session. The number of clinies estimated as needed for 1974 (2,300 clinics) was already in operation in 1973; however, average performance of these clinics would have to improve in order to recruit and retain the stated number of fam- ily planning clients in the future. At present, many clinics are operating at a low level of performance and there are frequent overlaps in catchment areas among many of them. By 1975, the number of effectively operating clinics would need to increase to 1,580. 32. A first indication is that the present rural health units of the Ministry of Health would be sufficient for the next three years to carry out the program with the indicated targets if the performance of their family planning services is made more effective in terms of new clients and follow up of old clients. However, careful planning for extension of the RHU network, commesurate to personnel availability and public response to the program will have to start immediately, in preparation of future needs.  ANNEX 1 Page 11 of 18 was already in operation in 1973; however, average performance of these clinics would hive to improve in order to recruit and retain the stated nuzaber of famr ily planning clients in the future. At present, many clinics are operating at a low level of performance and there are frequent overlaps in catchment areas among many of them. 32. A first indication is that the present rural health units of the Ministry of Health would be sufficient for the next three years to carry out the program with the indicated targets if the performance of their family planning services is made more effective in terms of new clients and follow up of old clients. However, careful planning for extension of the RHU network, commesurate to personnel availability and public response to the program will have to start immediately, in preparation of future needs.  ANNEX 1 Page 12 of 16 :1: PHILIPPINES POPULATION PROJECTIONS BASED ON ASSUKPTIONS OF (A) CONSTANTLY HIGH FERTILITY AND (B) MODERATELY FAST FERTILITY DECLINE 1970-2000 -Population ProJections (in millions) (July 1) Birth Rate Death Rate Rate of Natural (Constant (Moderately per 1,000 per 1,000 increase (,) Year Fertility) fast decline) A B A B A B 1970* 36.8 42.5 12.5 3.0 1971* 38.0 hl.5 12.5 2.9 1972* 39.2 4o.3 12.3 2.8 1973* 4W0.4 39.8 11.8 2.8 1974 41.7 41.2 40.7 38.1 10.9 8.7 3.0 2.6 1975 43.0 4j2.3 4o.9 37.1 9.8 8.4 3.1 2.5 1976 44.4 43.3 41.0 35.9 8.7 8.2 3.2 2.5 1977 45.9 441.4 41.1 33.2 8.6 8.1 3.2 2.5 1978 47.4 4l5.6 41.3 33.1 8.4 7.9 3.3 2.5 1979 49.0 46.7 41.4 33.0 8.2 7.8 3.3 2.5 1980 50.7 47.9 41.5 32.9 8.1 7.7 3.3 2.5 1985 60.1 54.4 42.2 32.6 7.5 7.3 3.5 2.5 1990 71.6 61.8 42.4 31.0 7.0 6.9 3.5 2.5 1995 85.5 70.1 41.7 30.0 6.5 6.7 3.5 2.b 2000 101.9 78.9 40.9 28.9 6.1 6.5 3.5 2.2 * Actual Rates  Table 2: TIilThIS hiaT WOULD BE 0i'TTED IF P-iDiCTIGN P WJ&tE RIdLIZED ISTEAD OF P.OJECTI0O; , Wormen Continuous Contraceptors Continuous Continuous Births During Year V Of Which Contraceptors Contraceptors Lew Ormtted A of Married 50%1-6c; wwh Contributed Ey Contribute,- by Acceptors Year Total flurmber Women Program 2 Program in 1969-73 Program fror 19?1, on /In Froram 1974 271,8G0 1,037,200 19.3 652,320 388,300 388,300 528,000 1975 352,0oo 1,L408,000 21.0 8144,800 213,500 503,920 681,8oo 1976 382,900 1,531,600 25.2 918,960 118,800 652,200 533,500 1977 1,15,500 1,662,o00 26.1 997,200 63,900 667,6&o 659,100 1978 L5C,10G 1,800,1;00 27.6 1,080,2L0 35,300 757,070 646,300 1979 h86,800 1,907,200 28.8 1,168,320 18,700 800,220 736,200 1980 525,800 2,103,200 30.0 1,261,920 7,900 904,130 715,600 1981 567,100 2,268,10o0 31.2 1,361,0o0 4,400 966,330 789,1400 1982 611,000 2,hhh,000 32.4 1,466,Loo - 1,052,360 828,100 1983 657,800 2,631,200 33.7 1,578,720 - 11140,350 876,700 1984 707,600 2,830,400 34.9 1,698,240 - 1,218,310 959,900 1985 4/ 760,100 3,0141,600 36.1 1,824,960 - 1,321,510 1,006,900 go ! 1/ Estimated on the basis of fertility rates prevalent without any contraception (250 per 1000 women 15-149 years as ,maximum" fertility) applied to the number of births to be averted. 2/ It is assumed that 40% of the contraception practice required to avert births will be done outside the program and that by 1987 that proportion will increase to reach 50% by 1991. 3/ Calculated in Tables 3 and 4 on the basis of: (a) new acceptors per year during 1969-1972; (b) continuous program clients following the function e Bt where e = 2.718282, natural logarithm base, B = drop-out rate, t = years; (c) continuous program clients declining with increasingly improved continuation rates through time, (1974-75, LO%; 1976-78, 45%3 1979-84, 50%; 1985-89, 55%; 1990 on, 60%); (d) new acceptors were assumed to enter linearly to the program during the year, each contributing 6 months of effective contraception during year. 14/ The level of new acceptors from 1985 on would have to continue at around 1 million women per year up to 1995, increasing slowly thereafter to reach 1.4 million by the year 2000. v 0  Table 3t CONTINUOUS OONTRACEPTORS 1/ CONTRIBUTED BY PROGRAMS IN 1969-73 Continuous Users fram AoeDtors in 1969/70 1970/71 1271/72 197"2/73 New Acceptors in Program 89,200 204,000 343,800 440,800 Continuous users in 1971 49,060 1972 26,760 112,200 1973 15,164 61,200 189,090 1974 8,028 34,680 103,140 242,440 388,288 1975 4,460 18,360 58,446 132,240 213,506 1976 2,676 10,200 30,942 74,936 118,754 1977 892 6,120 17,190 39,672 63,874 1978 892 2,040 10,314 22,040 35,286 1979 2,040 3,438 13,224 18,702 3,438 4,408 7,846 4,408 4s4O8 v/ Obtained as followst .60 (Women needed to be CYP contributed by CYP contributed by New Accep- continuous contra- - contraceptors con- - contraceptors in tors 6 ceptors in year) tinuing from 1969-73 program in 1974 on months each x- New acceptors during year 0 cr  Table 4: ESTIMATED CONTINUOUS USERS FOLLOWING A NEGATIVE EXPONENTIAL FUNCTION FROM THE YEAR OF ACCEPTANCE Continuous Continuous users remaining from acceptors in year: users in year 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1974 - - - - - - - - - - - 1975 290,1420 - _ _ _ _ _ _ _ _ 1976 158,400 375,000 - - - _ _ _ _ _ _ 1977 89,770 20h,530 309,440 - - - - - _ _ _ _ 1978 47,520 115,900 176,060 382,290 - - - - - - _ 1979 26,400 61,360 101,370 217,510 374,880 - - - - _ - 1980 15,840 34,100 58,690 125,230 213,290 449,080 - - - - - 1981 5,280 20,450 32,010 72,500 122,800 272,390 436,500 1982 5,280 6,820 213140 39,550 71,100 161,960 264s760 481,550 - - - _ 1983 - 6,820 10,670 26,360 38,780 103,070 157,1430 292,090 505,130 - - 1984 _ - 5,330 13,180 25,850 58,900 100,180 173,670 306,390 534s810 - 1985 _ _ 5,330 6,590 12,930 36,810 57,250 110,520 182,180 324s390 585,510 - 1o  Table 5: CONTINUOUS CONTRACEPTOiSR AND NEW ACCEPTORS IN THE PROGRAM. PHILiPPINES 1974-85 Continuous contraceptors New Acceptors Women 15-49 Married Women from previous years In Program ;% of married Nube of married Year Years 15-42 Number women 15-49 4 Number women 15-49 1974 9,143,619 5,644,492 388,300 6.9 528,000 9.3 1975 9 465021 5,865,34B 503,920 8.6 681,800 11.6 1976 9,805,979 6,o74,388 652,200 10.7 533,500 8.8 1977 10,167,002 6,292,054 667,640 10.6 659,100 10.5 1978 10,548,721 6,518,990 757,070 11.6 646,300 9,9 1979 10,951,286 6,756,023 800,220 11.8 736,200 10.9 1980 11,3714502 7,003,904 90M,llo 12.9 715J,600 10.2 1981 11,817,792 7,262,733 966,330 13.3 789J4oo 10.9 1982 12,280,660 7,532,714 1,052,360 14.0 828,100 11.0 1983 12,761,752 7J814J,913 1,1140350 14.6 876,700 11.2 1984 13,256,846 89U0,1448 1,218,310 15.0 959,900 11.8 1985 13,754,157 8,419,086 1,321,510 15.7 1,006,900 12.0 1/ See Table 2 col. 3, for percent of total continuous contraceptors (both within and outside the program3 required to the stated achieve fertility decline. 0' PhI  Table 6: ACTIVE CLIENTS DURING YEAR CLINIC VISITS, SESSIONS AMID NUMBER OF FAMIIL PLANNING CLINICS Active clients Number of clinic Number of ses- Number of family Year during ar_visits e year sions Yer year pla